Disasters : Mental Health Context and Responses [1 ed.] 9781443893244, 9781443889445

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Disasters

Disasters: Mental Health Context and Responses Edited by

George N. Christodoulou Juan E. Mezzich Nikos G. Christodoulou and Dusica Lecic-Tosevski

Disasters: Mental Health Context and Responses Edited by George N. Christodoulou, Juan E. Mezzich, Nikos G. Christodoulou and Dusica Lecic-Tosevski This book was first published in 2016 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2016 by George Christodoulou, Juan E. Mezzich, Nikos G. Christodoulou, Dusica Lecic-Tosevski and contributors All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-4438-8944-X ISBN (13): 978-1-4438-8944-5 Image Credits: Concept and design of Disasters Cover, Preface, Natural Disasters, Man-Made Disasters, Economic Disasters © Electra Christodoulou, 1 October 2015 All intellectual design property rights reserved by © Electra Christodoulou, [email protected] Original photograph for Man-Made Disasters is from Creative Commons. All other photographs originally by © Dimitra Stasinopoulou, [email protected]

CONTENTS

Preface ....................................................................................................... ix George Christodoulou, Juan Mezzich, Nikos Christodoulou, Dusica Lecic-Tosevski Natural Disasters Disaster Psychiatry in Greece: Mental Disorders and Psychological Distress associated with Earthquakes .......................................................... 3 E. Oikonomou, Th. Paparrigopoulos, C. Soldatos, G. Christodoulou The Dynamics of Psychosocial Interventions in Natural Disasters: Experiences from Turkey .......................................................................... 17 P. Gökalp, H. S. Kalkan Disasters: An Indian Experience ............................................................... 25 S. Sharma Managing Disasters: Pakistani Experience ................................................ 37 A. Javed Person-centered Global Perspectives and Latin American Experience on Disaster Response ................................................................................. 47 J. Mezzich, N. Morales Soto Women’s Mental Health in Disaster Psychiatry ........................................ 57 U. Niaz Psychological Effects on Military Personnel Assigned to Humanitarian Assistance and Disaster Response Missions.............................................. 69 J. West, J. Morganstein General Principles in the Psychosocial Management of Damaged People in Disasters ................................................................................................ 83 M. Benyakar, C. Collazo

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Lessons for Mental Health Education Learned from the 1999 Marmara Earthquake ................................................................................................. 97 B. Coskun Neurobiology of PTSD ............................................................................ 111 P. Pervanidou, G. Chrousos Human –Made (or Man-Made) Disasters War and the Mental Health of Civilians: What Did We Learn So Far From Lebanon? ........................................................................................ 125 E. Karam, J. Fayyad, C. Farhat, L. Itani, Z. Mneimneh, A. Karam, G. Karam Conflict Situations and Mental Health Care in Developing Countries .... 151 R. S. Murthy Crises and Disasters: Mental Health Context and Responses: Syria ....... 173 M. Mobayed, M. Abou-Saleh Psychopathological Consequences of the Chernobyl Disaster: Long-Term Observation, Treatment and Rehabilitation of the Clean-Up Workers Cohort............................................................. 189 V. Krasnov, V. Kryukov, I. Emelianova, E. Samedova, I. Ryzhova Neglected Factors in Addressing Violence as a Man-Made Disaster ...... 203 D. Baron, Th. Wenzel, H. Kienzler Resilience and Vulnerability in Coping with Terrorism and Political Violence................................................................................................... 215 Z. Zemishlany Public Health and International Law: An Interdisciplinary Challenge in the Case of Man-Made Disasters ......................................................... 223 Th. Wenzel, R. Izquierdo, S. Parmentier The Spiral of Trauma and its Consequences ........................................... 237 D. Lecic-Tosevski, B. Pejuskovic, O. Vukovic

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Economic Disasters The Impact of Economic Crises on Health: An Overview ...................... 251 G. Rachiotis Individual and Systemic Mental Health Effects of Economic Crises and their Associated Measures ................................................................ 265 N. Christodoulou Mental Health Repercussions of the Economic Disaster in Greece......... 279 M. Economou, L. E. Peppou, K. Souliotis Suicidality and the Current Economic Crisis in Europe .......................... 289 E. Tsitsipa, K. Fountoulakis Criminality and Suicide at the Onset and during the Financial Crisis in Greece.................................................................................................. 297 G. Tsouvelas, V. Kontaxakis, Th. Papaslanis, O. Giotakos The Coverage of Suicides by the Mass Media during the Recent Greek Economic Crisis ............................................................................ 309 I. Malogiannis, K. Efthimiou Farmers’ Suicide in India: Sociological Disaster or Unrecognized Psychopathology? .................................................................................... 319 R. A. Kallivayalil, P. K. Gupta, A. Tripathi Catastrophe in Theater as the Point of Reversal: The Cases of The Cherry Orchard, Blasted and Kiev ............................................... 333 S. Krasanakis Appendix I ............................................................................................... 341 Appendix II.............................................................................................. 343 Appendix III ............................................................................................ 347

Disasters have been with us since time immemorial and they will continue to be our companions in life. We can prevent some of them, mitigate the effects of others and tolerate the rest. We have to adjust our lives to their threat and to their actual occurrence and learn how to live with them. Disasters have a serious impact on mental health, ranging from “normal” or even “beneficial” to psychopathological (either of general nature such as onset or exacerbations of pre-existing psychopathology or of specific nature such as acute stress reaction or PTSD). Victimization of those affected is yet another unwanted consequence that should be avoided if we do not want chronicity to develop. The psychological effect of a disaster is greatly influenced by the meaning ascribed to the traumatic event. This meaning to a great degree determines whether individual behaviours will be “dysfunctional” or “adaptive” and explains why human-made disasters have greater psychopathological impact than natural disasters. It is not only the directly traumatized persons that are psychologically affected by a disaster. Rescue teams, police, paramedics, hospital personnel, ambulance drivers, by-passers, cleaners of the site of a disaster, even people watching a disaster on TV may be affected. The families of traumatized people are also likely to be adversely affected and may need help. Issues such as early predictors of psychopathology following a disaster, efficacy and risk of available therapeutic methods (e.g. the controversial issue of debriefing), the importance of risk and protective factors, the effectiveness and cost-effectiveness of preventive programmes, the effectiveness and cost of organizing mental health services for disasters and the paradoxically positive effects of disasters for some people are all important areas where further research may reveal important information. At a personal but also at a social level the response to disasters of every kind is associated with certain personal and social qualities that should be reinforced before, during and after a disaster. Resilience and solidarity are the most important among them: resilience at a personal level and solidarity at a social level. The prioritization that the mental health aspects of disasters deserve is an issue of great importance. As is the case with other areas in health provision, mental health is not given the priority it deserves in terms of

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funding and attention. It is paradoxical that although vulnerable people in the community and mentally ill patients are more at risk than other people during periods of economic crises, yet it is very often mental health services that are curtailed more severely during these periods. It is disheartening that this attitude is adopted not only by government officials but also by the public. The aim of this volume is to throw light on some important aspects of disasters. The volume has three inter-related but distinct parts: 1. Natural Disasters 2. Human-made (or Man-made) Disasters 3. Economic Disasters The addition of Economic Disasters to the classical categorization of disasters into Natural and Human-made arises from the recent catastrophic developments in the world economy. Are these disasters not human-made? In essence yes, although other factors may also contribute. Yet, the nature of even the two classical categories is also not clearly defined. There is certainly a human contribution to natural disasters and the situation becomes even more complex when the above two or even three categories of disasters co-occur – a not so rare phenomenon. The Natural Disasters section of the volume incorporates contributions related to disasters of this kind that have occurred in various parts of the world: Earthquakes in Greece and Turkey (Oikonomou et al., Gökalp and Kalkan) droughts, floods, cyclones and earthquakes in India (Sharma) and earthquakes and floods in Pakistan (Javed) are some paradigms. These disasters are differentiated with reference to two basic parameters, namely the nature of the disaster and the population affected by it. The interaction of these two parameters (with the additional contribution of other factors) produces a great variety of manifestations and management possibilities. The person-centred perspective in disasters is covered by Mezzich and Morales who also deal with the Latin American experience in disaster response. Special reference is made to the effect of natural disasters on women (Niaz) and to military personnel assigned to humanitarian assistance (West and Morgenstein).

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Benyakar and Collazo examine the general principles in the psychosocial management of damaged people in disasters and Coskun deals with the opportunity but also the need to study disasters from an educational perspective. Lastly, Pervanidou and Chrousos deal with the neurobiology of one of the major clinical consequences of natural disasters, post-traumatic stress disorder. The Human-made Disasters section of the volume is comprised of chapters pertaining to the mental health of civilians in war (Karam et al.), mental health care during conflict situations in developing countries (Murthy), the mental health consequences of the dramatic conflict situation in Syria (Mobayed and Abou-Saleh) and the mental health of clean-up workers following the Chernobyl disaster (Krasnov et al.). Baron et al. highlight neglected factors in addressing violence as a manmade disaster, Zemishlany addresses the issue of resilience and vulnerability in coping with terrorism and political violence and Wenzel et al. deal with public health and international law in man-made disasters. Lastly, Lecic-Tosevski et al. deal with the intrapsychic and diachronic trans-generational consequences of the trauma produced by human-made disasters. The third part of the volume pertains to the mental health consequences of a disaster that has appeared with great and persistent magnitude in the last few years, the Economic Disaster. This disaster is responsible for the production of psychopathology de novo, for relapses of pre-existing psychopathology and for a deleterious effect on the well-being and the quality of life of the populations that are affected by it. In some cases (such as Greece recently) the economic disaster is associated with the catastrophic consequences of man-made disasters occurring elsewhere but resulting in waves of refugees that further impact on the psychosocial condition of both the refugees and the citizens of the host country. Parenthetically, the way in which Europe will respond to the ongoing refugee crisis represents one of the greatest ethical challenges of our century. The impact of economic crises on health in general is examined by Rachiotis, a vista of economic disasters from an individual and systemic

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perspective is provided by Nikos Christodoulou, their impact on mental health is addressed by Economou et al., the suicidality associated with economic disasters is examined by Tsitsipa and Fountoulakis, criminality and suicidality at the onset and during the financial crisis in Greece are dealt with by Tsouvelas et al., and Malogiannis and Efthimiou deal with the coverage of suicide by the mass media during the recent Greek economic crisis. The suicide of farmers in India is examined from a sociological perspective by Kallivayalil and alternative explanations for this morbid phenomenon are discussed. Lastly, viewing disasters in an artistic context, Krasanakis deals with catastrophe in theatre from a psychoanalytic perspective. We want to thank all the distinguished authors who have contributed to this volume. We feel confident that their contributions will be greatly appreciated by the readership. We would also like to thank Ms Helen Gretsa and Ms Androniki Gatzelaki of the Hellenic Psychiatric Association for their expert administrative and secretarial contribution, Ms Electra Christodoulou for the beautiful cover design of the book and for the designs of the preface and of the part pages separating the chapters and Ms Dimitra Stasinopoulou who has kindly offered to us two of the photographs that are included in this volume. We hope that this volume will promote our knowledge and awareness of disasters of every kind and will increase our preparedness to prevent or at least mitigate their serious and often incapacitating psychosocial effects. We also hope that our book will stimulate further research, broader and more case-specific dissemination of information and more appropriate, holistic and person-centred management of people affected by them.

George Christodoulou Juan Mezzich Nikos Christodoulou Dusica Lecic-Tosevski

DISASTER PSYCHIATRY IN GREECE: MENTAL DISORDERS AND PSYCHOLOGICAL DISTRESS ASSOCIATED WITH EARTHQUAKES ELINA OIKONOMOU 1ST DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF ATHENS MEDICAL SCHOOL

THOMAS PAPARRIGOPOULOS 1ST DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF ATHENS MEDICAL SCHOOL

CONSTANTIN SOLDATOS MENTAL HEALTH CARE UNIT, EVGENIDION HOSPITAL, UNIVERSITY OF ATHENS

GEORGE N. CHRISTODOULOU UNIVERSITY OF ATHENS MEDICAL SCHOOL, HELLENIC PSYCHIATRIC ASSOCIATION, WORLD FEDERATION FOR MENTAL HEALTH, ATHENS, GREECE

Abstract Natural disasters are fairly common events and their incidence is increasing over time. The consequences of natural disasters vary around the globe, depending on the region and its economic development. According to the data collected in the Emergency events Database (EMDAT), earthquakes have claimed an average of 27,000 lives per year since 1990 and clearly have had serious psychological, economic and social consequences on the affected communities. Earthquakes constitute a common type of natural disaster in Greece due to its high seismic activity. Several epidemiological studies have been conducted over the past 30 years focusing on the prevalence of psychological reactions and mental disorders among populations exposed to earthquakes in Greece. The

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common finding of these studies is the detection of acute stress reactions, post-traumatic stress disorder, anxiety and depressive symptoms. The prevalence of mental disorders and the psychological symptoms following exposure to the most destructive earthquakes in Greece are reported and a paradigm of intervention is provided.

Introduction Natural disasters occur worldwide every day and there is growing concern that exposure to natural disasters is inevitably increasing globally (GridArendal, 2012). A substantial body of literature has been accumulated during the past decades addressing their devastating consequences on the mental health of large populations and their psychosocial implications as well (Norris et al., 2002). Emotional distress and post-traumatic symptoms occur frequently either during the immediate or during the later postimpact phases in response to various disasters (Riddle et al., 2007). In the present contribution the psychological impact concerning the five major destructive earthquakes that took place in Greece during the last sixty years is reviewed.

Overview of epidemiological data Since 1988, the Centre for Research on the Epidemiology of Disasters (CRED) at the Catholic University of Louvain, Belgium has been maintaining an Emergency Events Database (EM-DAT) with the support of the UN, the World Health Organization (WHO) and the Belgian government, with its primary goal being to enhance regional, local and national capacity to prepare for and respond to disaster events. EM-DAT provides standardized data on disaster occurrence around the world. The overwhelming majority of people affected or killed by natural disasters reside in developing countries, particularly in the Asia-Pacific region (Cavallo, 2009). Epidemiological data show that 96% of the people killed and 99% of the people affected by natural disasters over the period 1970–2008 were in the Asia-Pacific region, Latin America and the Caribbean, and Africa (Cavallo, 2009). As far as Greece is concerned, available data on the EM-DAT country profile from 1900–2015 show that earthquakes, extreme temperature conditions, storms with flooding and wildfires have taken place, with 2001

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deaths reported and 1,006,860 people affected in total (i.e., the sum of injured, homeless and people requiring immediate assistance during a period of emergency, including displaced or evacuated people). Countries with greatest earthquake occurrence and consequences: 1980–2009 Country

China Indonesia Iran Turkey Japan Afghanistan United States Peru Greece Pakistan

No. of earthquakes 94 74 62 34 31 25 23 22 20 20

No. killed

89,852 178,742 74,020 20,495 5,753 9,175 145 1,095 244 74,278

No. affected (millions) 86.5 8.4 1.8 5.9 0.8 0.5 0.1 1.3 0.3 6.5

Economic damage (billions US$) 88.6 11.3 10.4 22.8 145.7 0.03 38.6 0.9 6.7 5.2

More than 1.4 million earthquakes per year take place around the planet, approximately averaging 4,000 per day. Earthquakes have claimed an average of 27,000 lives a year since 1990 and they were responsible for 29% of natural disaster-related deaths in the last 30 years (Cred Crunch Issue, 2010). Earthquakes are considered to be among the most devastating natural disasters because they are unexpected and can cause massive destruction. Their consequences vary around the globe depending on the region and its economic development (see table below) (Cred Crunch Issue, 2010).

Earthquakes in Greece since 1950 Greece is characterized by a high level of seismic activity. Since 1950 five destructive earthquakes have hit Greece. On 7 September 1999, an earthquake measuring 5.9 on the Richter scale hit the city of Athens and the larger metropolitan area. The most heavily damaged area lay within a radius of 12 km from the epicentre. The main earthquake was followed by a series of aftershocks of a smaller magnitude

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that lasted for a couple of weeks. The earthquake caused 152 deaths, 700 injuries and left approximately 40,000 families homeless (www.emdat.be). On 15 June 1995, a 6.1 Richter earthquake hit the city of Egion in the northern Peloponnese. Numerous houses were destroyed, 26 people were reported dead and 20,000 had to relocate for several weeks (www. emdat.be). On 13 September 1986, a 5.9 Richter earthquake struck the city of Kalamata in the southern Peloponnese. Material damage was extensive within the city limits, as well as in the nearby villages; twenty-four people lost their lives and 330 more were injured (1/4 of them required hospitalization). Many aftershocks followed, the strongest (5.4 Richter) occurring two days later with its epicentre within the town limits. This aftershock caused 37 more injuries and further damage to the already weakened buildings. Approximately 3,150 buildings were destroyed and 10,000 people were left homeless (www.emdat.be). On 20 June 1978, the city of Thessaloniki was hit by an earthquake with a magnitude of 6.4 on the Richter scale. The death toll was 50 people and another 600,000 were affected (www.emdat.be). On 12 August 1953, a 7.2 Richter earthquake took place in the islands of Cephallonia and Zakynthos. Approximately 455 deaths and 4,400 injuries were recorded, and 35,440 people were left homeless. More than 70% of the buildings on the island of Cephallonia were destroyed (www. emdat.be).

Mental disorders and psychological impact of earthquakes Several epidemiological studies have been carried out exploring the psychological consequences of natural disasters. The people affected are at increased risk of developing acute stress reactions, post-traumatic stress disorder (PTSD), anxiety disorders, depression, and substance use disorders that can last for years following the natural disaster (Norris et al., 2002). It is reported that PTSD may be observed in 32–80% of the adult and in 26–95% of the child population following an earthquake (Kolaitis et al., 2003). In most cases, PTSD coexists with one or more mental disorders and with poorer physical health (Foa et al., 2006). The rates of PTSD appear to be much higher in developing countries (Bonanno et al., 2010). Although psychopathology may be long-lasting, studies investigating long-term outcomes after an earthquake are rare (Bland et al.,

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2005). In a study of 526 survivors of the 1999 earthquake that hit Turkey, the rates of PTSD and depression four years after the disaster were 25% and 11% respectively (Kilic et al., 2006). The strongest predictors of PTSD are the intensity of fear during the earthquake, previous exposure to traumatic events, female gender, younger age, being married, and the loss of kin (Kilic et al., 2006). In general, women report higher levels of distress following earthquakes but may achieve more positive outcomes compared to men (Fergusson et al., 2015). The literature examining resilience and post traumatic growth has suggested that some individuals exposed to traumatic events may experience long-term positive consequences in terms of personal growth, improved interpersonal relationships and increased community cohesion (Peterson et al., 2008). A number of epidemiological studies have been carried out over the past three decades in Greece focusing on the prevalence of psychological reactions and psychiatric disorders in populations exposed to earthquakes. Following the earthquake that hit the Athens metropolitan area in 1999 a study was conducted in 102 help-seekers (Christodoulou et al. 2005, Soldatos et al. 2006). Psychopathological symptoms during a three-week period after the earthquake were reported and the subjects were assessed based on a checklist of socio-demographic variables and a semi-structured interview for the detection of acute stress reaction (ASR) and PTSD using the ICD-10 diagnostic criteria. The study showed that 85.3% of the subjects fulfilled the ICD-10 diagnostic criteria for ASR (30 for a mild, 29 for a moderate and 28 for a severe reaction) and 43% for PTSD. Almost all subjects diagnosed with PTSD had suffered ASR initially, and ASR was found to be the only significant predictor for PTSD. Accelerated heart rate and feelings of derealization within the first 48 hours following the earthquake appeared to be the principal factors associated with the development of early PTSD. A limitation of the study was the lack of a long-term follow up and the use of a non-random sample of subjects seeking help at a special psychological support unit. Christodoulou et al. (2003) pointed out that the early reactions to a major traumatic event consist primarily of “non-specific” symptoms of stress response and autonomic hyperarousal symptoms rather than dissociative symptoms, a finding corroborating other studies (Marshall et al. 1999). In a study by Livanou et al. (2005), 157 survivors of the 1999 Athens earthquake were assessed by the Traumatic Stress Symptom Checklist four

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years after the earthquake. A substantial proportion of the survivors experienced symptoms of PTSD and depression. Approximately 22% of the survivors reported moderate or severe subjective distress and 15% marked interference with social, occupational and personal adjustment due to their symptoms. The intensity of fear during the earthquake and participation in rescue operations were related to greater psychological distress. This study showed that earthquakes of a relatively low magnitude and few casualties can lead to long-lasting psychological effects in some survivors. Giannopoulou et al. (2006) in their study six months after the 1999 Athens earthquake included 2,037 children, aged 9–17 years. Girls reported significantly more PTSD, anxiety and depressive symptoms than boys. Also, younger children reported significantly more PTSD and anxiety symptoms than older children. The severity of PTSD symptoms was most strongly predicted by greater perceived threat during the earthquake, whereas depression was most strongly predicted by the level of postearthquake adversity. In a school-based study by Roussos et al. (2005), one of the largest postearthquake screenings of children and adolescents after a disaster, 1,937 students, aged 9–18 years, were assessed three months after the 1999 earthquake in two differentially affected cities in the Greater Athens Area, one at the epicentre and another 10 km away from the epicentre. The estimated rates for PTSD and depression for both cities combined were 4.5% and 13.9% respectively. Prior disaster studies have found the rates of depression to be similar to or lower than the rates of PTSD, although in survivors with lower levels of traumatic exposure the rates of depression have exceeded the rates of PTSD (Goenjian et al., 2001). In the Roussos et al. study (2005), the strongest predictor of the severity of PTSD reactions was depression (explaining 27% of the variance), followed by the severity of subjective earthquake-related experiences. A significant minority of students in each city, mainly boys, reported having vengeful thoughts after the earthquake. In a follow-up study conducted by Goenjian et al. (2011) in 511 adolescents 32 months after the 1999 Athens earthquake, PTSD scores had considerably subsided, as also reported in previous studies, but 8.8% were still experiencing moderate to severe levels of symptoms and 13.6% met criteria for depression. This study showed that repeat screening is recommended after a natural disaster to identify adolescents who continue to experience symptoms.

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Kolaitis et al. (2003) assessed 115 children attending two elementary schools located at the epicentre of the 1999 earthquake six months after the disaster. A control group of non-exposed children to the earthquake was used for comparison of psychopathology. The study showed a high rate of severe to mild PTSD symptoms (78%) among children exposed to the earthquake. Severe or moderate PTSD symptoms were associated with high levels of depression. Those who were most likely to be affected were children alone at the time of the earthquake and children who, or whose families were either injured or had homes damaged. In another study by Groome et al. (2004) 178 children from three districts of Athens were assessed five months after the 1999 Athens earthquake. PTSD and anxiety symptoms were significantly related to proximity to the epicentre, exposure to threat and female gender; these results are in agreement with previous studies. In the region closest to the epicentre, the younger children reported the highest PTSD and anxiety symptoms, but in the group furthest away from the epicentre, the older children reported the highest PTSD and anxiety scores, reflecting age differences in sensitivity to direct or indirect experience of the earthquake. In a study by Psarros et al. (2013) PTSD was detected in 42.3% of a sample of 97 randomly chosen victims one month after an earthquake of 6.1 on the Richter scale that hit the city of Egion (Peloponnese, Greece) in 1995. The prevalence of PTSD was similar to the prevalence reported by other authors in previous epidemiological studies. In terms of general psychopathology, the most significant factors associated with the early development of PTSD were high anxiety levels, compulsive symptoms and symptoms of phobic anxiety. These findings are in agreement with the high prevalence of panic disorder, social phobia and specific phobias that have been reported in the literature (Onder et al., 2006). Acute stress reaction (ASR) was diagnosed in 70% of a sample of 91 subjects immediately following the 1995 earthquake in Egion; in the majority of the subjects ASR persisted beyond the initial 48 hours following the earthquake, due to continued aftershocks (Bergiannaki et al., 2003). People with a protracted ASR reported significantly more severe material damage and disruption of their social network, had a history of medical illness, and had higher trait anxiety levels. The persistence of ASR related positively to the fear of death at the time of the earthquake and the levels of pre-existing anxiety.

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Papadatos et al. (1990) conducted a study on a randomly selected sample of subjects divided into three groups that consisted of 205 adults, 172 high school students and 69 outpatients from the Kalamata General Hospital with minor pathological problems or on regular check-up, two weeks following the 1986 Kalamata earthquake. It was shown that the majority of the subjects exhibited a significant degree of anxiety, depression and psychosomatic symptoms; students adjusted better to the negative impact of the earthquake compared with the other groups. Lazaratou et al. (2008) reported on the psychological impact of the 1953 Cephallonia earthquake in a sample of 121 survivors, fifty years after the event. In this retrospective study it was shown that the majority of the victims (78%) acknowledged a strong overall impact of the earthquake on their lives with the experiencing of intense recollection of the event at anniversaries; the most frequent symptom during the first six months following the earthquake was persistent remembering or reliving of the event. Women and young adults at the time of the earthquake were at greater risk of psychological distress compared to men. Studies on the long term effects of natural disasters show that approximately one third of the survivors are still suffering from PTSD one to three decades after the catastrophic event (Green et al., 1992). Finally, Hartocolis (1955) was the first to assess the psychological consequences of earthquakes in Greece in a study following the 1953 earthquake on the island of Cephallonia. In his study most people reported fear of dying and many psychopathological symptoms.

A Paradigm of Crisis Management An example of a contribution to the management of a crisis due to a disaster is presented here. Within the first three days following the Athens 1999 earthquake, many psychological support agencies of the public and private sector in the Athens area were mobilized to help. We will describe here the interventions carried out by the Athens University Department of Psychiatry, at that time under the chairmanship of Prof. George Christodoulou (Christodoulou et al. 2005). The special service for psychological support of earthquake victims of the department formed three psychosocial support units, as follows:

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Two units posted within the most severely hit regions One unit centrally located at Eginition Hospital (main facility of the Department of Psychiatry in the downtown Athens area) A telephone helpline unit

These units were staffed by mental health professionals of the University Department who volunteered to serve in this capacity and the telephone helpline unit was staffed by psychiatric trainees under supervision. The scope of the units was to provide information, reassurance and relief from the traumatic experience. The goal was not only prevention of posttraumatic stress disorder (PTSD) but also management of acute stress reactions, depression and other maladaptive psychological and behavioural reactions, as well as simply aiding management of grief, an adaptive response to the disaster. Supportive psychotherapy and pharmacotherapy with anxiolytics and antidepressants were mainly administered. Exacerbations and relapses of psychotic conditions were managed with medication and support. Particular emphasis was attached to fostering resilience, a basic concept in prevention and mental health promotion. Ventilation of feelings was encouraged but this did not take the form of abreactions such as debriefing, in view of evidence indicating that this technique does not help very much and may even have a negative effect, unless applied in selected cases. On the contrary, elementary training in coping skills, as well as provision of information on the expected stress response, traumatic reminders and normal versus abnormal functioning were implemented. In selected cases, anxiety reduction techniques to decrease physiological arousal were utilized. Follow-up was carried out as appropriate by the staff of the Outpatients’ Department of Eginition Hospital. We believe that the above scheme had a positive effect as an emergency intervention and possibly in the long run as well.

Conclusions Earthquakes are a common type of natural disaster with devastating psychological, social and economic consequences. In Greece, earthquakes are a frequent phenomenon due to the geological structure of the region and its high levels of seismic activity (Christodoulou, 2002). Five destructive earthquakes have hit the country since 1950. There has been an

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increase in the number of epidemiological studies over the past 30 years pertaining to the psychological impact of earthquakes in Greece. Most reports were on the 1999 Athens earthquake and were conducted both on adult and children/adolescent populations. The large majority of survivors in all studies were found to have developed depression, anxiety, acute stress reaction and PTSD. Identifying highly symptomatic individuals with history of previous exposure to traumatic events should be a priority for health care professionals and psychological support staff in order to undertake the appropriate intervention. Several studies have reported on the prevalence of chronic psychological symptoms after exposure to earthquakes (Bland et al., 2005; Onder et al., 2006), confirming the need for long-term psychosocial care of survivors. Given the high prevalence of psychopathology in both adults and children following an earthquake, actions should be taken to manage their aftermath and specialized mental health services should be available for survivors of natural disasters both in the short and long term.

References Bergiannaki JD, Psarros C, Varsou E, Paparrigopoulos Th, Soldatos CR. Protracted acute stress reaction following an earthquake. Acta Psychiatr Scand 107: 18-24, 2003 Bland S, Valoroso L, Stranges S, Strazzullo P, Farinaro E, Trevisan M. Long-term follow up of psychological distress following earthquake experiences among working Italian males: a cross-sectional analysis. J Nerv Ment Dis 193(6): 420-423, 2005 Bonanno GA, Brewin CR, Kaniasty K, Greca AML. Weighing the costs of disaster. Psychol Sci Public Interest. 11:1-49, 2010 Cavallo E, Noy I. The economics of natural disasters. A survey. Interamerican Development Bank, December 2009. Christodoulou GN, Paparrigopoulos T, Soldatos CR. Acute stress reaction among victims of the 1999 Athens earthquake: help seekers’ profile. Research Report. World Psychiatry 2:1 50-53, 2003 Christodoulou GN, Paparrigopoulos TJ, Soldatos CR. The experience of the Athens Earthquake. In: Disasters and Mental Health (Lopez-Ibor JJ, Christodoulou G, Maj M, Sartorius N, Okasha A, eds), Wiley, England, 2005 Cred Crunch, Issue No.20, Disaster Data: A Balanced Perspective. www.cred.be, Centre for Research on the Epidemiology of Disasters (online), April 2010

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Fergusson DM, Boden JM, Horwood LJ, Mulder RT. Perceptions of distress and positive consequences following exposure to a major disaster amongst a well-studied cohort. Australian & New Zealand Journal of Psychiatry 49(4); 351-359, 2015 Foa EB, Stein DJ, McFarlane AC. Symptomatology and psychopathology of mental health problems after disaster. J Clin Psychiatry. 67:15-25, 2006 Giannopoulou I, Strouthos M, Smith P, Dikaiakou A, Galanopoulou V, Yule W. Post-traumatic stress reactions of children and adolescents exposed to the Athens 1999 earthquake. European Psychiatry 21:160166, 2006 Goenjian AK, Molina L, Steinberg AM, Fairbanks LA, Alvarez ML, Goenjian HA, Pynoos RS. Posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch. Am J Psychiatry 158:788-794, 2001 Goenjian AK, Roussos A, Steinberg AM, Sotiropoulou C, Walling D, Kakaki M, Karagianni S. Longitudinal study of PTSD, depression, and quality of life among adolescents after the Parnitha earthquake. Journal of Affective Disorders 133:509-515, 2011 Green BL, Lindy JD, Grace MC, Leonard AC. Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample. J Nerv Ment Dis. 180:760-766, 1992 GRID- Arendal. Trends in natural disasters (online). Arendal, Norway, 2012 Groome D, Soureti A. Post-traumatic stress disorder and anxiety symptoms in children exposed to the 1999 Greek earthquake. British Journal of Psychology 95:387-397, 2004 Hartocolis P. Psychologie du tremblement de terre. Unpublished thesis, Universite de Lausanne, 1955 Kilic C, Aydin I, Taskintuna N et al. Predictors of psychological distress in survivors of the 1999 earthquakes in Turkey: effects of relocation after the disaster. Acta Psychiatr Scand 114: 194-202, 2006 Kolaitis G, Kotsopoulos J, Tsiantis J, Haritaki S, Rigizou F, Zacharaki L, Riga E, Augoustatou A, Bimbou A, Kanari N, Liakopoulou M, Katerelos P. Posttraumatic stress reactions among children following the Athens earthquake of September 1999. European Child & Adolescent Psychiatry 12:273-280, 2003 Lazaratou H, Paparrigopoulos T, Galanos G, Psarros C, Dikeos D, Soldatos CR. The psychological impact of a catastrophic earthquake. A retrospective study 50 years after the event. J Nerv Ment Dis 196:340344, 2008

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Disaster Psychiatry in Greece

Livanou M, Kasvikis Y, Basoglu M, Mytskidou P, Sotiropoulou V, Spanea E, Mitsopoulou T, Voutsa N. Earthquake-related psychological distress and associated factors 4 years after the Parnitha earthquake in Greece. European Psychiatry 20: 137–144, 2005 Marshall R, Spitzer R, Liebowitz M. Review and critique of the new DSM-IV diagnosis of acute stress disorder. Am J Psychiatry 156: 1677-85, 1999 Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 Disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry 65 (3): 207-239, 2002 Onder E, Tural U, Aker T, Kilic C, Erdogan S. Prevalence of psychiatric disorders three years after the 1999 earthquake in Turkey: Marmara Earthquake Survey (MES). Soc Psychiatry Psychiatr Epidemiol 41:868-874, 2006 Papadatos Y, Nikou K, Potamianos G. Evaluation of psychiatric morbidity following an earthquake. The International Journal of Social Psychiatry 36; 2:131-136, 1990 Peterson C, Park N, Pole N, D’Andrea W, Seligman MEP. Strengths of character and posttraumatic growth. Journal of Traumatic Stress 21(2): 214-217, 2008 Psarros C, Paparrigopoulos T, Varsou E, Kostaras P, Marinaki U, Daskalopoulou E, Bergiannaki JD. Psychopathological characteristics of ICD-10 diagnosed subjects with posttraumatic stress disorder one month following a destructive earthquake. J Trauma Stress Disor Treat 2:4, 2013 Riddle JR, Smith TC, Smith B, Corbeil TE, Engel CC, Wells TS, Hoge CW, Adkins J, Zamorski M, Blazer DG. Millennium cohort: the 20012003 baseline prevalence of mental disorders in the U.S military. J Clin Epidemiol 60 (2): 192-201, 2007 Roussos A, Goenjian AK, Steinberg AM, Sotiropoulou C, Kakaki M, Kabakos C, Karagianni S, Manouras V. Posttraumatic stress and depressive reactions among children and adolescents after the 1999 earthquake in Ano Liosia, Greece. Am J Psychiatry 162:530-537, 2005 Soldatos CR, Paparrigopoulos T, Pappa DA, Christodoulou GN. Early post-traumatic stress disorder in relation to acute stress reaction: An ICD-10 study among help seekers following an earthquake. Psychiatry Research 143: 245-253, 2006 The International Disaster Database, www.emdat.be (online).

E. Oikonomou, Th. Paparrigopoulos, C. Soldatos, G. Christodoulou

Corresponding author: Elina Oikonomou, MD 1st Department of Psychiatry of Athens University Eginition Hospital, 72–74 Vas. Sofias, 11528 Athens, Greece, E-mail: [email protected]

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THE DYNAMICS OF PSYCHOSOCIAL INTERVENTIONS IN NATURAL DISASTERS: EXPERIENCES FROM TURKEY PEYKAN G. GÖKALP, HIRA SELMA KALKAN SECTION ON TRAUMA AND DISASTER PSYCHIATRY PSYCHIATRIC ASSOCIATION OF TURKEY

Abstract A disaster disrupts normal living conditions and causes enormous suffering for the affected community. If sufficient preventive measures are taken, the situation may be an emergency but not a disaster. Humanitarian aid and support in the post-disaster period is considered a duty for the international community, since no society/country is immune from experiencing a disaster or conflict and everyone will take their turn in giving and receiving help. The basic principles of humanitarian aid – impartiality, neutrality and independence – are the sine qua nons of ethical conduct in serving the needs of survivors. Although aid efforts originate from principles of solidarity among people, under certain conditions, social, political, economic and military influences may undermine the outcome of efforts made by humanitarian organizations. In this paper, social and psychological dynamics within and between the survivor community and the rescue and aid staff will be discussed with special focus on two large earthquakes (Marmara, 1999 and Van, 2011) that took place in Turkey.

Introduction Disasters cause significant losses for the individual and the community and to nature. Even though natural disasters are defined as those which originate from natural causes such as earthquakes, floods, volcanic eruptions and hurricanes, in most of them a human hand can be found. In

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The Dynamics of Psychosocial Interventions in Natural Disasters

some of these disasters, the situation may be unpredicted but foreseeable, as with hurricanes, some earthquakes or floods. The number of deaths reported in underdeveloped regions is much larger than in developed ones and this implies the influence of the multifaceted preparedness of the community (Steinberg, 2000). The definition of a disaster, according to the World Health Organization, is “an occurrence disrupting the normal conditions of existence and causing a level of suffering that exceeds the capacity of adjustment of the affected community” (WHO/EHA, 2002). Therefore, with sufficient preventive measures and preparedness, the situation is an emergency but not a disaster. Disasters that affect the whole community cause a disruption to social and economic functions. In this paper, social and psychological dynamics within and between the survivor community and the rescue and aid staff will be discussed, with special focus on two large earthquakes (Marmara, 1999 and Van, 2011) that took place in Turkey.

Marmara 1999 and Van 2011 Earthquakes The north-western part of Turkey, the Marmara region, was struck by an earthquake of 7.4 on the Richter scale on 17 August 1999. The area was the most populated area of Turkey, with many of the country’s important industrial facilities. Eighteen thousand people were killed, approximately 50,000 were injured and many were left homeless and lost relatives. In the early period after the quake, voluntary rescue staff and medical personnel under the umbrella of the Turkish Medical Association were in the disaster area within hours, especially from Istanbul where the majority of the health and rescue workforce is located. In spite of heroic efforts and donations both from national and international communities, the institutional and state organizational capacity was not sufficient in the early period. Mental health professionals were well organized under the leadership of the Turkish Psychologists Association and the Psychiatric Association of Turkey, with the support of Universities. The Marmara earthquake was a very significant experience regarding the insufficiencies and lack of a national organization that could manage the volunteers and government officers from the earliest period to the recovery phase.

Peykan G. Gökalp, Hira Selma Kalkan

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Van is one of the eastern cities in Turkey, covering a large area and with a population of approximately one million. The earthquake struck Van with a magnitude of 7.1 on 23 October 2011 and on 9 November 2011, with a magnitude of 5.7. The earthquake killed 604 and injured 4,152 people. Furthermore, around 60,000 became homeless. The state institutions and non-governmental volunteer organizations were much more organized compared to the Marmara earthquake. An umbrella organization was founded in 2006 for disaster psychosocial services named APHB (Association for Disaster Psychosocial Services) that included the Turkish Psychologists’ Association, Psychiatric Association of Turkey, Turkish Red Crescent, Associations of Social Workers and Counsellors. Later, in 2009, AFAD (Disasters and Emergency Situations Management Directorate) was founded and organized countrywide across cities through connection to city governors.

Insights into the Settings for Support and Help-Seeking Behaviour Humanitarian aid and action is linked with the service provision of humanitarian organizations in temporary disaster and conflict situations. The basic principles of humanitarian aid are impartiality, neutrality and independence. At this point, the concept of humanitarian space comes to the fore to define the environment “where humanitarians can work without hindrance and follow the humanitarian principles of neutrality, impartiality and humanity (Hilhorst and Jansen, 2010). Humanitarian space has both physical and metaphorical dimensions. The physical settings include refugee camps, camps for disaster survivors, spaces where healthcare is provided for those in need of aid and certain grounds or vehicles to which people are transferred for greater safety. Humanitarian space is also a place where help providers are able to work without danger of attack. Unfortunately, many humanitarian spaces become either militarized under certain conditions or may be used for political reasons. The United Nations and its components, Red Cross/Red Crescent organizations, and the NGO Codes of Conduct all work under the basic principles of impartiality, neutrality and independence. Humanitarian assistance also mobilizes and urges authorities and official bodies to fulfil their responsibilities under ethical and humane conditions. During post-disaster periods, aid

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The Dynamics of Psychosocial Interventions in Natural Disasters

organizations have to negotiate and conduct diplomacy with official bodies and survivors of disasters. The Codes of Conduct for the Red Cross and Red Crescent emphasize the principles of accountability, participation, partnership, vulnerability reduction and respect for culture and/or professional standards. Therefore, during the humanitarian encounter between the aid providers and seekers, the aid providers in particular have to take certain points into consideration: aid recipients are generally vulnerable, but they are also labelled as helpless and passive (code of conduct in disaster relief, 1994). The protection of disaster survivors from further hazards is the main objective of aid. This involves the provision of food, shelter, healthcare, sanitation and water. If the period to return to normal life lasts longer, opportunities for education, vocational activities and protection of the vulnerable such as children, the elderly, and former physical and psychiatric patients should be implemented. There are examples of clashes between International NGOs (INGO) and states or governments of disaster-struck countries. During the 2004 Indian Ocean Tsunami, it was reported that the INGOs were accused of promoting the aspirations of Western countries rather than helping the locals (Hilhorst and Jansen, 2010). These disagreements may make the disaster survivors feel distrust and undermine the help that they would normally get from available resources. The Sphere Project was founded in 1997, by a group of humanitarian NGOs and the Red Cross and Red Crescent. The core beliefs are that disaster or conflict survivors have a right to live with dignity, and therefore a right to assistance. Humanitarian aid is not just the charity of merciful people, but it is the right of the people who have faced a disaster or a war. This conceptualization will balance the power inequalities in humanitarian spaces, and will enable aid providers to include the affected population more in the support processes, decision making mechanisms and dissemination of aid (5).

Notes from the Van Disaster Area The Van earthquakes took place in October and November 2011. It was winter time and providing warm shelter to the survivors was not easy, despite the efforts of international and national governmental and nongovernmental humanitarian organizations. The area with a mainly Kurdish

Peykan G. Gökalp, Hira Selma Kalkan

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population of low socio-economic status had difficulties in feeling secure after the disaster. They were reluctant to trust those who came from abroad or from other larger cities in Turkey. They were also unsure about the equity of the distribution of aid from official staff. We health care staff (physicians, nurses and health technicians) and mental health professionals were in the disaster area after just a few hours. We were able to communicate with members of the psychiatric community who lived and worked in Van and the surrounding towns. From these officers and members of the Section on Trauma and Disaster Psychiatry of the Psychiatric Association of Turkey, we were able to receive information about the conditions and needs. Colleagues from nearby cities reached the area and took over the responsibilities of the psychiatrists who were themselves disaster survivors and who had to look after the safety of their families. An online logbook was started by the members of the section to disseminate knowledge about the situation as effectively and quickly as possible. After the first post-disaster period, rescue efforts were organized and the wounded were transferred to neighbouring cities. Shelter was not adequate with camp tents, heating being by heaters in the tents producing several fires that caused losses of life and possessions. Loss was everywhere: people had lost their houses, family members, relatives, friends and belongings. When a survivor was able to get one blanket, he would ask for another, because he did not feel secure enough. The same was true of food. People had difficulty in trusting officials, aid personnel or even their relatives. They felt that the distribution of aid was not fair; there were always those who were privileged. Because of the low level of education, people were ready to believe in rumours that made them more distrustful. They also faced discrimination from different actors in the humanitarian space (Rabalais et al., 2002; Koniasty et al., 2000). It was not easy for the mental health professionals to work and establish a trustful relationship with people who faced contradictory attitudes from some official staff. Volunteering health care professionals were organized for 10 day periods to handle possible burn-out and secondary traumatization. Children ran after healthcare/mental health staff to cuddle on their laps, because these staff had fresh energy at the beginning of their shifts, to play with children and engage in activities. Volunteer mental health teams conducted preventive psychiatric surveys in tent camps with vulnerable

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The Dynamics of Psychosocial Interventions in Natural Disasters

parts of the population. Local women’s organizations made important contributions for women who had to survive by themselves, because the cultural climate and the power struggle in the area meant it was not easy for widowed or single women to survive in the camps. Women participated actively in informal meetings in the tents with mostly female aid volunteers. Men were more reluctant to speak in a group at first but later they started to speak out about their fear, doubt, anger and hopelessness. Survivors demanded work, housing, goods, support and sometimes money from volunteers, and when they heard that the volunteers “were not here for that”, they were disappointed or angry. It was difficult for the volunteers to contain those intense feelings, especially of those who had lost a child or another close one. Demandingness is a common feature of disaster survivors: they have lost the ground from beneath them and without it they cannot stand firm, they cannot be. Therefore, the survivors have to test those who have come to help, who are strong, prosperous, healthy, to find out whether they really care for the disaster stricken population. Babies need a stable environment (mothering) and the mother or mother substitute has to adjust herself to the needs of the baby, who cannot take care and soothe him/herself. Survivors may feel as if they have been born on the day they are saved from the rubble. Until they feel safe and strong again, they have to be looked after and provided for. The members of the aid staff have to understand these dynamics, to put limits on the survivors’ demands as well as on their own feelings of omnipotence, and try to protect themselves from burnout (Danisman et al. 2012). A last word from a survivor to a colleague in Van: “Buildings have fallen down but humanity has not, that’s our comfort.”

References Steinberg T. The Acts of God: The Unnatural History of Disasters in America. Oxford University Press, New York, 2000 WHO/EHA (Emergency Humanitarian Action). Disasters and Emergencies. Definitions. Training Package. Pan African Emergency Training Centre, Addis Ababa, 2002 Hilhorst D, Jansen BJ. Humanitarian Space as Arena: A Perspective on the Everyday Politics of Aid. Development and Change; 41(6): 1117– 1139, 2010

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Code of Conduct for the Red Cross and Red Crescent Movement and NGOs in disaster relief (1994). http://www.ifrc.org/en/publications-and-reports/code-of-conduct www.spherehandbook.org Rabalais AE, Ruggiero KJ, Scotti JR. Multicultural issues in the response of children to disasters. In “Helping Children Cope with Disasters and Terrorism”. AM La Greca, WK Silverman (eds), American Psychological Association, Washington DC, 2002 Koniasty K, Norris FH. Help Seeking Comfort and Receiving Social Support: The Role of Ethnicity and Context of Need. American Journal of Community Psychology, 28(4):545, 2000 Danúman IG, Ylmaz B, Aker AT. Support Staff in Traumatic Events. in AT Aker. Approach to Psychological Trauma in Primary Health Care. Psychiatric Association of Turkey Publications, Ankara, 2012 pp 51-57 (in Turkish) Corresponding author: Peykan Gökalp, MD Professor of Psychiatry Section on Psychological Trauma and Disaster Psychiatry, Psychiatric Association of Turkey E-mail: [email protected]

DISASTERS: AN INDIAN EXPERIENCE SHRIDHAR SHARMA NATIONAL ACADEMY OF MEDICAL SCIENCES, DELHI, INDIA

Abstract All disasters hurt people. They kill, injure and cause psychological and social trauma. Due to its geography and topography, India has faced serious large-scale natural disasters such as droughts, cyclones and earthquakes. The available statistics also show that the number of disasters per year is increasing but additionally that the number of people affected and killed is also rising. The last century has added a new ecological dimension to the definition of a disaster. We now have newer humanmade disasters on our hands which include chemical and nuclear catastrophes, oil spills and air, water and soil pollution. Health and mental health consequences of disasters are accepted phenomena all over the globe. Developing countries have been facing the brunt more than developed ones because they have less physical and financial resources. India, as the second most populated country with 1.2 billion inhabitants suffers a large share of all types of disasters. The present paper will focus on different types of disasters with special reference to India.

Introduction Disasters are ubiquitous and are a regular occurrence throughout the world. But most large-scale disasters occur in the geographical region between the Tropics of Cancer and Capricorn which encompasses most of the developing nations. Due to its geography and topography, India has faced serious large-scale natural disasters such as droughts, floods, cyclones and earthquakes. The available statistics also show that not only

Disasters: An Indian Experience

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the number of disasters per year is increasing but also the number of people affected and killed. Distressing as they may be, the rising human and material loss caused by such disasters calls for immediate response from both national and global support (National Disaster Management in India, http://www.ndma.gov.in/; WHO, 1997)

Major Disasters in Known History of India No.

Name of Event

Year

Fatalities

1.

Bengal Earthquake

1737

300,000

2.

Bengal Cyclone

1864

60,000

3.

The Great Famine of Southern India

1876– 1878

5.5 million

4.

Maharashtra Cyclone

1882

100,000

5.

The Great Indian famine

1896– 1897

1.25 million to 10 million

6.

Kangra earthquake

1905

20,000

7.

Bihar Earthquake

1934

6,000

8.

Bengal Cyclone

1970

500,000 (including Pakistan & Bangladesh)

9.

Drought

1972

200 million people affected

10.

Andhra Pradesh Cyclone

1977

10,000

11.

Bhopal Gas Tragedy

1984

3,000 deaths in first 24 hours

12.

Latur Earthquake

1993

7,928 dead and 30,000 injured

13.

Orissa Super Cyclone

1999

10,000

Shridhar Sharma

14.

Gujarat Earthquake

2001

25,000

15.

Indian Ocean Tsunami

2004

10,749 deaths; 5,640 persons reported missing

16.

Kashmir Earthquake

2005

86,000 deaths (including Kashmir & Pakistan)

17.

Kedarnath Flood & Avalanche

2013

Over 1,000 deaths and thousands reported missing

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Nature of Disasters Disasters may be classified as either natural or human-made. The following chart describes the different characteristics of natural and human-made disasters. Blame is a characteristic that differs significantly for natural and human-made disasters.

Broad Categories of Disasters Natural Major Earthquake Flood Drought

Human-made Major Ethnic Conflict Terrorism Stampede

Minor Heat & cold wave Landslides Avalanche Tornadoes

Fire Chemicals/ Toxins Rail accidents Ship and Aeroplane Accidents

It is virtually impossible to prevent most disasters. Nevertheless, we can forestall or alleviate many of their worst effects by anticipating them and by being prepared. The greatest numbers of disasters occur in those countries that are already most adversely affected by ill-health and poor economic conditions. The following characteristics of disasters will give a clear idea about their predictability and lethality:

Disasters: An Indian Experience

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Natural disasters Earthquakes India has a high risk of Earthquakes. More than 58 per cent of India’s land area is under threat of moderate to severe seismic hazard. During the last 20 years, India has experienced 10 major earthquakes that have resulted in more than 35,000 deaths. Of the earthquake-prone areas, 12% are prone to very severe earthquakes, 18% to severe earthquakes and 25% to potentially damaging earthquakes. The major quakes occur in the Andaman and Nicobar Islands, Kutch, Himachal and the north-eastern part of India. The Himalayan regions are particularly prone to earthquakes. The number of casualties and the degree of damage caused by earthquakes has increased markedly due to faulty urban development planning. A major earthquake in an urban area ranks as the largest potential natural disaster in highly seismic parts of the world. Magnitudes of damage due to the Earthquake in Gujarat in 2001 will provide some insight into the havoc an earthquake can cause. x x x x x

x x x x

Villages affected: 7,904 Population affected: 15.9 million Deaths: approx. 25,000 People injured: 160,000 Houses fully destroyed: a) 187,000 (Brick & Cement) b) 167,000 (Mud houses) c) 10,600 ( Huts) Collapse of many schools/hospital buildings Disruption of water, electricity and telephones Destruction of roads and bridges Estimated economic loss: Rs. 212,620 million, approx. US$ 3,429 million

There was no prior warning and the widespread impact caused major loss of both life and physical structures. The integration of epidemiological studies with those of other disciplines such as engineering is essential for improved understanding of the injuries that follow earthquakes to minimize such damage in the future.

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Floods In India about 30 million people are affected annually. Floods in the Indo– Gangetic–Brahmaputra plains are an annual feature. On average, a few hundred lives are lost, millions are rendered homeless and several hectares of crops are damaged every year. Nearly 75% of the total rainfall occurs over a short monsoon season (June–September). Forty million hectares, or 12% of Indian land, is considered prone to floods. Floods are a perennial phenomenon in at least 5 north-eastern states – Assam, Bihar, Orissa, Uttar Pradesh and West Bengal. On account of climate change, floods have also occurred in recent years in areas that were not normally floodprone. In 2006, drought-prone parts of Rajasthan Desert also experienced floods.

Droughts Drought is another recurrent phenomenon in India which results in widespread adverse impact on vulnerable people’s livelihoods and young children’s nutrition status. About 50 million people are affected annually by drought. Of approximately 90 million hectares of rain-fed areas, about 40 million hectares are prone to scanty or no rain. Although a slow onset emergency, and to an extent predictable, drought has caused severe nutritional problems in the affected areas, though deaths due to famine are now not seen.

Cyclones About 8% of the land is vulnerable to cyclones of which coastal areas experience two or three tropical cyclones of varying intensity each year. Cyclonic activities on the east coast are more severe than on the west coast. The Indian continent is considered to be the part of the world worst affected by cyclones, as a result of low-depth ocean bed topography and coastal configuration. The principal threats from a cyclone are in the form of gales and strong winds, torrential rain and high tidal waves/storm surges. More cyclones occur in the Bay of Bengal than in the Arabian Sea and the ratio is approximately 4:1, on analysis of the frequency of cyclones on the east and west coasts of India.

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Disasters: An Indian Experience

Tsunami The December 2004 Indian Ocean earthquake and tsunami had a huge impact on all the countries in South Asia including India. The number of people reported killed in India was 10,749 and 5,640 were reported missing. Many were later declared dead (Nambi et al., 2007). The impact of a tsunami is like hit and run accident. Successive crests can arrive at intervals of 10 to 45 minutes and wreak destruction for several hours. Areas of greater risk are coastal areas which are less than 50 feet above sea level. Interestingly the five aboriginal tribes’ inhabitations in the Andaman and Nicobar islands emerged unscathed from the Tsunami. The people of those tribes had a sense of impending danger from biological warning signals, from the cry of birds and changes in the behavioural patterns of marine animals (Aldrich, 2010; Telford et al., 2007).

Land Slides In the hilly terrain of India, mainly in the Himalayas and North East India, landslides occur frequently during the rainy season and often strike life and property and occupy a position of major concern. One of the worst tragedies took place at Malpa, Uttarkhand (UP) on 11 and 17 August 1998 when nearly 380 people were killed when massive landslides washed away the entire village.

Avalanches Recent climate changes have had a significant impact on high mountain glacial environments resulting in major avalanches. Avalanches are fast, river-like flows of snow or ice descending from the mountain tops. Avalanches are very damaging and cause huge loss of life and property. In the Himalayas, avalanches are common. In June 2013, there was a combination of heavy rainfall, avalanches and landslides in Uttarakhand, in the Kedar Nath region, which devastated the whole area with the loss of a large number of human lives and damage to the houses, roads and bridges. There was a vast loss of livestock and property too (Kedanath Disaster, http://chimalaya.org/2013/30/kedarnath-disaster-facts-and-plausiblecauses/).

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Industrial Disasters Small industrial disasters are quite common but usually their impact is small. A major industrial disaster took place in Bhopal in December 1984 where more than 3,000 people died in the first 24 hours due to inhalation of Methyl Isocynate (MIC) and the lungs were one of the most commonly affected organs. In addition, other organs were also affected. Further, pregnancy loss and birth defects in the newly born were also found (Samarth et al., 2013; Mishra, 2012; De, 2012; Lorin et al., 1986)

Railway Accidents India has the largest network of railways in the world and one million passengers travel each day. Both minor and major railway accidents are not uncommon causing both death and disability to thousands of passengers each year. The characteristics of those involved in such accidents are quite different from those affected by earthquakes and floods. The victims are from many different parts of India, but it is easy to reach the sites of such disasters by railway track (Kumar, 2012).

Impact of Disaster Disasters produce several types of trauma. These include: x x x x x x x x x x

Water and power disruption Roads and communications broken Disorganization of families due to collapse of houses Death Starvation Disease Disability Distress Dislocation Unemployment

We must always remember that the target population is primarily normal in all disasters and people do not disintegrate in response to disaster suddenly but respond to active interest and concern shown. We should always be innovative in offering help and abandon the traditional approach of institutional care but develop outreach procedures to help

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Disasters: An Indian Experience

victims and fit programmes to specific communities in order to have them accepted. Traumatized individuals are resistant to seeking treatment, so treatment must be taken to the survivors. It has been reported that in victims of flood, earthquakes and hurricanes there was increased prevalence of PTSD. Depression and anxiety are other conditions which need essential mental health support after severe disasters. Morbidity in severe disasters represents a cluster of diseases involving more than one target organ, hence multiple-member health teams are needed. Community as a resource plays an important role. There is need for joint preparation to meet the challenges of disaster but the goal is to develop a single function team. It is always helpful to use joint training and a multi-disciplinary service model during the training period.

Hope: India Can Deal with Disasters India has enough experience in dealing with natural disasters. The lessons that we have learnt from floods, droughts, earthquakes, the Bhopal gas tragedy, tsunami and other disasters have helped us effect a paradigm shift in our approach to disaster management proceeding from the conviction that development cannot be sustainable unless disaster mitigation is built into the development process at all levels. As a part of a strategic plan, it was felt necessary to build a national hub in the form of a National Disaster Management Institute/Centres at both central and state level. This will improve knowledge-sharing and learning and help to create a critical mass of institutions, trainers and trained professionals. Every calamity presents an opportunity to equip the people to face with greater confidence and competence similar challenges in the future. Disasters disrupt progress and destroy the results of years of developmental efforts, often pushing nations back in their quest for progress by several decades. Thus, the efficient reduction of disaster risks, as opposed to mere response to disasters, has received increased attention. With a vision to build a safe and disaster-resilient India, the government has adopted a holistic, proactive, multi-hazard oriented and technology driven strategy by promoting a culture of prevention, mitigation,

Shridhar Sharma

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preparedness, recovery and response (Pruthi et al., 2013; National Disaster Management in India http://www.ndma.gov.in/; Kar, 2010)

Speed and Direction are Key Issues in Every Disaster The key issues are quick assessment and immediate response, including quick planning coordination and quick execution. There are always diverse scenarios in different disasters. The key elements include health sector readiness and empowerment of survivors. There should be enough provision of relief to caregivers. For this provision of relief, material readiness is necessary. Mitigation of the damage from disasters should be addressed and there should be improved media coverage to avoid public panic.

Psychological Impact of Disasters After a disaster, the psychological reactions among members of a community may vary and usually they will change over time. Therefore, post-disaster psychological interventions should be flexible and be based on an ongoing assessment of needs. Psychological reactions to disaster will also depend on actions taken in the pre-disaster phase. The predisaster phase is the period of time prior to disasters in which all planning and training activities take place. The rehabilitation phase is the period during which the population works to return their lives as closely as possible to the pre-disaster situation. During this period, action is taken to re-establish normal activity as much as possible. This period begins after the disaster impacts and may last from several hours up to three or four weeks. The reconstruction phase is a longer period during which the population rebuilds personal skills, social support and leadership. This phase overlaps with the rehabilitation phase (Jackson et al., 1999). Mental health departments and other health sector agencies must prepare messages that a population, living under stressed conditions, will find easy to understand. The ministry should authorize and supervise the release of these messages through radio, television, press and newsletters. They must have a specific content and style. As we know, disasters constitute stressful and traumatic experiences. However, vulnerability to such experiences as well as to more chronic stressors is determined by a variety of factors including gender, race and ethnicity.

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Disasters: An Indian Experience

Disaster events differ in generating different stresses for their victims and are influenced by a) social support system, b) cumulative stresses and c) victims’ coping capacity. The guiding principle of mental health management is to listen to the victim’s distress. By assessing the problems, goals can be set for providing service and groups can be targeted for assistance. Besides understanding and strengthening communities’ preparedness, selfreliance in disaster management is the most economic and fruitful way to improve effectiveness and minimize disaster trauma. Knowledge, training and education are the basic first aid and rescue methods. Every disaster presents an opportunity to face with greater confidence and competence similar challenges in the future. It is virtually impossible to prevent most natural disasters. Nevertheless we can forestall or alleviate many of their worst effects by anticipating and by being prepared to face them. Disaster response is a collective responsibility requiring coordinated responses from various agencies and all sections of the society.

References Aldrich DP. Separate and unequal: post-tsunami aid distribution in Southern India. Soc Sci Q; 91(5), 1369-89, 2010. De S. Retrospective analysis of lung function abnormalities of Bhopal gas tragedy affected population. Indian J Med Res. 135,193-200, 2012. Jackson G, Cook CG. Disaster Mental Health: Crisis counseling Programs for the Rural Community. Substance Abuse and Mental Health Services Administration, Washington DC, 1999 Kar N. Indian research on disaster and mental health. Indian J Psychiatry. 52(S1), S286-90, 2010. Kedarnath Disaster: Facts and Plausible Causes. http://chimalaya.org/2013/30/kedarnath-disaster-facts-and-plausiblecauses/ Kumar V, Suryawanshi P, Dharap SB. et al. The great Indian invisible railroad disaster. Prehosp Disaster Med. 27(2), 216, 2012. Lorin HG, Kulling PE. The Bhopal tragedy: what has Swedish disaster medicine planning learned from it? J. Emerg. Med. 4(4), 311-6, 1986.

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Mishra PK. A pragmatic & transnational approach of human biomonitoring to methyl isocyanate exposure in Bhopal. Indian J. Med. Res. 135(4), 479-84, 2012. Nambi S, Desai NG, Shah S. Mental health morbidity and service needs in tsunami affected population in coastal Tamil Nadu. Indian J Psychiatry. 49, S2-3, 2007. National Disaster Management in India http://www.ndma.gov.in/ Pruthi S, Aggarwal A, Goel A. Disaster management in India: a road ahead. Prehosp Disaster Med. 28(1), 82, 2013. Samarth RM, Gandhi P, Maudar KK. A retrospective review of cytogenetic studies on methyl isocyanate with special reference to the Bhopal gas tragedy: is the next generation also at risk? Int. J. Occup. Med. Environ. Health. 26(3), 324-36, 2013. Telford J, Cosgrave J. The international humanitarian system and the 2004 Indian Ocean earthquake and tsunamis. Disasters. 31(1), 1-28, 2007. WHO (1997) Earthquakes and Peoples Health – Proceeding of a WHO Symposium, Kobe 27-30 Jan. Centre for Health Development, Kobe, 1999.

Corresponding Author: Shridhar Sharma, MD, DPM, FRCPsych, FRANZcp, FAMS Emeritus Professor, National Academy of Medical Sciences D-127, Preet Vihar, Delhi-110092, India E-mail: [email protected]

MANAGING DISASTERS: PAKISTANI EXPERIENCE MUHAMMAD AFZAL JAVED WORLD PSYCHIATRIC ASSOCIATION PAKISTAN PSYCHIATRIC RESEARCH CENTRE, FOUNTAIN HOUSE, LAHORE, PAKISTAN,

Abstract Pakistan, like many South Asian countries, holds a highly vulnerable position for both natural and man-made disasters. The country has been hit by massive disasters in recent years. A devastating earthquake which measured 7.6 on the Richter scale brought large scale destruction in areas located in both Kashmir and North West Pakistan on 8 October 2005. Because of this earthquake more than four million people were affected in one way or another. The psychological trauma for the survivors was even bigger than these figures might suggest. Similarly 2010 and 2011 witnessed the impact of massive floods that hit the whole country in a big way. This again affected the victims of the flood in many areas of day to day functioning including psychosocial adversities. Continuous and ongoing war and terrorism in the region are furthermore increasing the trauma and stress on the mental health of the people tremendously. Unfortunately, mental health services are scarce in the country and with about 300 psychiatrists and very few psychologists and allied mental health professionals, it has always been very difficult to cope with such tragedies. This paper gives details of the impact of these disasters and the efforts being put in place to cope with the continuous and long lasting impact of these disasters. It is argued that there should be ongoing measures for disaster management especially in low income countries where mental health services still require a lot of attention by professionals and policy makers.

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Disasters are sudden and unfortunate adverse events that cause great damage, destruction and loss that could leave detrimental effects on the day-to-day living of the affected populations. Disasters may strike rapidly, can occur anywhere and affect people indiscriminately. Disasters are not new phenomena in our history as such events have always co-existed with civilisations. There have long been attempts to define what a disaster is. The term can be traced to earlier times, especially in earlier French literature where the word “desastre” was used combining the two words “des” meaning bad and “aster” meaning star, thus referring to bad or evil star. The United Nations, while defining disaster as “a serious disruption of the functioning of a community or a society causing wide spread material, economic and environmental losses which exceed the ability of the affected community and society to cope and use its own resources”, places an important emphasis on implementation of the international strategy for disaster reduction (UNISDR, 2015). Recent advancement in scientific knowledge has helped us to understand many of the underlying causes and the impact of disasters in a more systematic and methodical way. Similarly, with improvement in communication and the world becoming a global village, news and information about any increases in loss of life, property and other unmanageable effects of disasters do get more attention in the media, with calls for help and support for the victims of disasters from almost all over the world. This awareness has certainly increased a general alertness and understanding both of different dimensions of disasters and of the need to prepare for possible threats that could be prevented for predisposed and vulnerable communities, places and populations. It is important to note that professional, non-professional and state organisations have all become more attentive to meaningful planning to reduce the risks from such hazards and have also become more attentive to minimizing the adversities associated with different types of disasters. Disasters can be natural or man-made but one thing is common to either type: that these may make life challenging due to the associated catastrophe, losses and frightful living. There may be many reasons for the occurrence of disasters but the vulnerability of the affected population and the severity of the hazard intensify the consequences of such adverse events. Natural disasters include earthquakes, floods, drought and landslides, the last especially prevalent in mountainous areas. Nature’s most destructive disasters can be hydrological (floods being the most common disasters

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accounting for around 55% of total reported natural disasters), meteorological (storms and hurricanes accounting for around 26% of disasters) and geophysical (earthquakes and volcanoes that could account for around 5% of total disasters). Whereas human-induced or man-made disasters may involve wars, fighting, acts of terrorism and violence, civil unrest, fires and post-disaster migration or internal displacement of groups of people, these could have a severe impact similarly to natural disasters and their damaging effects could even be manifold for a number of associated risks. That Asia, the largest continent of the world, already suffers from a number of socio-economic problems unfortunately adds more vulnerability to both man-made and natural disasters. It certainly requires considerable efforts to deal with such adversities (WCDR, 2005). According to a recent review by the UN Economic and Social Commission on natural disasters for Asia and the Pacific regions (ESCAP) more than half of the world’s 226 natural disasters during 2013–14occurred in the Asia and Pacific region. In addition to a large number of human losses, economic losses owing to natural disasters in 2014 also remained high, amounting to some $59.6 billion. This report also emphasized that during post-disaster periods, lack of economic resilience leads to further concerns over the detrimental effects of such disasters in the affected countries (EM Data, 2015). Disasters can also affect several aspects of an economy, ranging from long-term growth rates to natural resource prices, and may have an important weakening influence on socio-economic conditions. In fact, economic losses increase rapidly, especially in low-income countries that have less capacity to absorb and recover from such losses due to disasters (Skidmore and Toya, 2002; Khan, 2005). Health hazards may account for long-term consequences as disasters could have major direct health impacts causing injury and loss of life. Similarly, indirect and deferred health impacts such as the diverse health consequences of livelihood and population displacement may also result in additional suffering of victims to a great extent. Disturbances in ecosystem mediated health impacts alter infectious diseases and further increase the risks of many physical and public health problems. Global climate change could add significantly to the spectrum of environmental health hazards with its influence on the physical and mental health of affected populations and indeed could lead to loss of livelihood and create further tensions with major psychosocial consequences. Looking at post-disaster well-being, mental health emerges as an important area requiring attention from health professionals. It has been

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observed that psychiatric morbidity increases among the most vulnerable groups of survivors, particularly among children, women and older adults. These problems far exceed in the developing world those found following disasters in developed countries. Following the Asian Tsunami of 2005, the World Health Organization estimated that around 20% to 40% of affected people suffered from short lasting mild psychological distress and another 30% to 50% experienced moderate to severe psychological distress. Disasters also lead to loss of life with its associated grief, bereavement, damage to property and most of all loss of living places. The burden of mental health and psychosocial problems for those exposed to traumatic events in low- and middle-income countries is substantial and studies from many Asian countries on disaster areas have shown a consistent long-lasting impact on personal, family and community life and both mental health problems and psychological disturbances (Desai et al., 2004; Datar et al., 2011; Purgato et al., 2014). It is unfortunate that Pakistan holds a highly vulnerable position for both natural and man-made disasters. The effects may vary according to the nature of the threat and may show long-lasting consequences in many spheres of life. Pakistan also lies in a geological belt that suffers from frequent earthquakes. The earthquakes that occur along the Himalayan Mountains and Hindu Kush ranges in the north, Kohe Suleiman range in the west and Makran Fold that lies along the sea coast certainly increase the vulnerability to long-lasting damage. It has been reported that the occurrence of such earthquakes is normally associated with changes in the Indian plate, thus resulting in continuous pressures on the Eurasian landmass. Looking specifically at natural disasters, Pakistan has historically suffered from a number of earthquakes. In 1935 an earthquake of about 6.5 on the Richter scale rocked the city of Quetta leaving around forty thousand people dead. Similarly, during the latter half of the last century approximately six thousand people were killed due to earthquakes in various northern areas and the Kashmir region. There was a significant earthquake that again affected a large number of people in 2004 in the Northern Province but the 2005 earthquake was the worst natural disaster that this nation has experienced in recent history. This earthquake took the lives of around ninety thousand people injuring around two hundred thousand. This earthquake also affected the Indian part of Kashmir, as well as some adjacent areas of Afghanistan. The Pakistani government’s official death toll as of December 2005 stood at

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around 87,000 although it was estimated that the death toll could have reached over one hundred thousand. Similarly, around two hundred thousand were injured and over 3.5 million rendered homeless. According to the official figures 19,000 children died in the earthquake, mostly due to widespread collapses of school buildings. The earthquake affected more than five hundred thousand families and in addition to the loss of around 250,000 farm animals, more than five hundred thousand large animals required immediate shelter from the harsh winter that followed the earthquake. It was also estimated that more than eight hundred thousand buildings were either destroyed or damaged beyond repair. Those who were seriously injured but alive were in fear in the weeks following the earthquake that there could be another earthquake as there were a number of aftershocks. In addition to the impact on much other infrastructure, educational institutions were among the worst affected. It was reported that around one thousand teachers died, about seven thousand students were amongst the dead and a large number of school and institutional buildings were seriously damaged and many of the buildings that survived were non-repairable. Reports on the 2005 earthquake’s effect on nation’s health showed a large number of people being left with mental health problems in the affected parts of the country (NDMA, 2008; Rana and Ali, 2006). As disasters have a significant link to mental wellbeing it was observed that people with mild psychological distress were very high in number soon after the earthquake in Pakistan. Similarly many people became chronically ill either with moderate or severe psychological distress during the postearthquake period and were in need of specialist services (Rana et al., 2006; Makhdoom and Javed, 2006). This earthquake also increased the problem of internal migration and resulted in the displacement of a huge number of people from their native homes. This certainly emerged as a big challenge and also a severe burden on the country’s failing economy. Looking at some of the damage in 2005, the World Bank and the Asian development bank estimated that around 3.5 billion US dollars would be required for re-building and for rehabilitating the earthquake victims including internally displaced persons (IDPs). Tsunami and cyclones are other forms of natural disaster that also hit the long coast line of Pakistan very often. There have been a number of reports describing earthquakes of high Richter scales triggering a tsunamilike effects along the Pakistani coast. Similarly, hazardous cyclones

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frequently affect long tracts of the coastal districts causing wide-spread loss of life, property and belongings to thousands of people. Floods, another type of natural disaster, have also caused considerable damage to life and property in Pakistan. Despite a number of preventive measures, the damaging effect has continued to grow over the last several years. The 2011 and 2012 floods again had a very damaging effect not only regarding the death toll or personal injuries but also regarding the loss and damage of property. These floods caused around 2000 deaths and a large agricultural area of around 2.5 million acres was severely affected. Similarly, drought, that has become a regular occurrence in many rural parts of the country, leads to outbreaks of many diseases and severe public health hazards, increasing the vulnerability of the general public living in drought-affected areas. Unfortunately, Pakistan is also suffering at the hands of many man-made disasters including war, terrorism, violence and increased insurgency. War in Afghanistan has had a very significant effect on the economy and the political situation in the country. In addition to the hazards of on-going war, around two million Afghans have fled due to the military fighting and many of them have still not returned home. The devastating floods that began at the end of 2004 also displaced millions and the total impact was estimated to be even larger than the 2004 tsunami. Continuous war on terrorism has hit Pakistan very badly and has been a major source of unwanted and hazardous impacts on day to day living (Rana et al., 2010). Over the last few decades, Pakistan has been fighting an all-out war against the Taliban and like-minded militant groups, mostly in the north-west stretch of the country known as Khyber-Pakhtunkhwa (KPK), which extends into the border region with Afghanistan. While the world has lauded the sacrifices made by Pakistani troops and the general public for their commendable efforts in the anti-terror struggle, the nation has also received allegations of harbouring and aiding terrorists. Reports estimate that more than fifty thousand people including army, police, and civilians have lost their lives in the war on terror along with billions of rupees being lost in this on-going fighting (Musharraf, 2006). Unlike natural disasters, this is an on-going problem that continues with further risks (Asfa and Ahmad, 2012; Javaid, 2014). In addition to a long list of war-related adversities, there is a growing literature showing concern about the mental health consequences of

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terrorism (Murthy and Lakshminarayyana, 2006). The scene in Pakistan is also not different from many other war-affected areas and in fact the whole nation is paying a big price in increased mortality and morbidity due to terrorism-related activities (Nizami et al., 2014; Rana et al., 2010) Another war-related threat is a growing concern with depleted uranium. This has received less attention despite its grave consequences (European Committee on Radiation Risk, 2010). Depleted uranium, also known as spent nuclear fuel in armour-piercing shells and bullets, is considered one of the very dangerous hazards of present day wars (Al Ani and Baker, 2009). Once these shells hit their targets, as much as 40% of the uranium is released in the form of tiny particles in the area of the explosion and can then remain there for years, easily entering the human blood stream where it then lodges itself in lymph glands and attacks DNA causing, in turn, serious birth defects in the next generations. This particular aspect has not been studied fully and is still neglected in research in the Afghan and Pakistani areas where there has been a continuous war for more than two decades with a lot of use of such munitions. Looking at disaster management strategies, a number of initiatives and plans have been started in Pakistan. However, there are some ground realities that make many of these efforts limited in actual practice. Economic problems, shortage of infrastructure, lack of health and social service facilities and ongoing stresses related to the threats posed by insurgency, terrorism and violence continue affecting the overall disaster management strategies. However, despite these limitations, recent disasters (both natural and man-made) have seen a growing interest in looking at the management of disasters both in the short and long terms. The Pakistani government has formulated a disaster management policy and in addition to revisiting annual development plans, the establishment of the Natural Disaster Management Authority (NDMA, 2006) has been a very welcome response. The purpose behind its establishment was to change national responses to emergency situations and to look at different aspects, including preparedness and recovery aspects of trauma and disasters. Also, the NDMA supervises provisional disaster management authorities and district disaster management authorities. The NDMA has been given the responsibility of co-ordinating risk management efforts at the national level along with implementing risk management strategies, mapping hazards, developing guidelines and ensuring the establishment of disaster management and emergency operational centres at provincial, district and grass-roots levels.

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Government agencies have not been alone in their efforts as a lot has also been done by non- government organisations and self-help groups in Pakistan. The principles of unity, the spirit of gathering from what has been left, and indigenous methods of coping with a strong hope and resilience have been the salient features of these remarkable contributions. Similarly, professional organisations including the World Association for Psychosocial Rehabilitation (WAPR), the World Psychiatric Association (WPA), the Asian Federation of Psychiatric Associations (AFPA) and South Asian Forums (SAF) with the help of local professional bodies, including the Pakistan Psychiatric Society, the Pakistan Psychiatric Research Centre (PPRS) and Fountain House have been very active in initiating and supporting the victims of disasters. It is a pity that Pakistan regrettably remains very vulnerable to experiencing an increased number of natural and man-made disasters. There remains a strong liability for on-going health and non-health related costs and despite the efforts by the government and non-government organisations, a lot still needs to be done. As reported by WHO, the mental health consequences of disasters have not been fully addressed by those in the field of disaster preparedness or service delivery (Saxena et al., 2006), and it is therefore of utmost importance that policy makers understand the impact of disasters, evaluate the risks of irreversible damage to natural systems and threats to the survival of mankind, and allay suffering with utmost urgency. Whereas natural disasters such as earthquakes, floods and hurricanes, and manmade disasters including wars and floods take a heavy toll on health systems, it is bad luck that most of the affected populations live in developing countries where the capacity to take care of such problems is extremely limited. There is no doubt that over the last many decades Pakistan has witnessed the damaging effects of disasters but many such adversities have also raised some optimism and hope as well. People are becoming more resilient and are trying to live with hope. Certainly, overcoming the effects of disasters is a long process. Man-made disasters can be minimized or at least efforts can be made to help those who are vulnerable and exposed to these hazards. The fact remains that Pakistan has to continue fighting against terrorism and will always be in dire need of some organized plans for disaster management. There is thus a need for a consolidated policy to tackle emergency situations and also to develop strategies looking at preventive aspects. For a country like Pakistan where many pressing issues such as poverty, political unrest, war on terrorism, violence and security concerns are among the top priorities, disaster management also requires

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urgent and appropriate attention. It is true that most of the onus lies upon the government to revisit its policies and to strengthen institutions to tackle such challenges but a strong commitment is equally required to ensure that the services are used appropriately, adequately and in full capacity. It is also high time that non-government organisations and voluntary groups should also be encouraged to be a part of the state’s coordinated efforts.

References Al Ani A-H and Baker J. Uranium in Iraq. The poisonous legacy of the Iraq Wars. Vandenplas Publishing, Florida, 2009 Asfa R and Ahmad M. Impact of Terrorism on Global Security in 2011: A Pakistani Perspective. Berkeley Journal of Social Sciences, 2, 1-9, 2012 Datar A, Jenny L, Sebastian L & Chad S. The Impact of Natural Disasters on Child Health and Investments in Rural India. Santa Monica, CA: RAND Corporation, 2011. http://www.rand.org/pubs/working_papers/WR886 Desai NG, Gupta DK, Srivastava RK. Prevalence pattern and predictors of mental health morbidity following an intermediate disaster in an urban slum in Delhi: a modified Cohort study. Ind. J. Psychiatry, 46: 39-51, 2004 EM-DAT: The OFDA/CRED International Disaster Database, www.cred.be/emdat, Université Catholique de Louvain, Brussels, Belgium. European Committee on Radiation Risk Uranium and Health: The Health Effects of Exposure to Uranium and Uranium Weapons Fallout, 2010. Documents of the ECRR 2010 No 2. www.euradcom.org Javaid U. War on terror: Pakistan’s apprehensions. African Journal of Political Science and International Relations, 5, 125-131, 2014 Available online at http://www.academicjournals.org/ajpsir Kahn ME. The death toll from natural disasters: the role of income. Geography and institutions. The Review of Economics and Statistics, 87: 271–284, 2005 Makhdoom MA and Javed A. Earthquake in Pakistan and Kashmir: suggested plan for psychological trauma relief work. International Psychiatry 3, 1, 16-17, 2006 Murthy RS, Lakshminarayyana R. Mental health consequences of war: a brief review of research findings. World Psychiatry 5, 25-30, 2006

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Musharraf P. In the Line of Fire: A Memoir. Simon & Schuster UK Ltd, London, 2006 National Disaster Management Authority (NDMA). National Strategy for Disaster Management, 2006 http://www.ndma.gov.pk/new/ —. NDMA annual report 2007–2008. Govt of Pakistan, Islamabad, 2008 Nizami AT, Rana MH, Hassan TM. and Minhas FA. Terrorism in Pakistan: A Behavioral Sciences Perspective. Behav. Sci. Law 32: 335–346, 2014 Purgato M, Gross AL, Jordans M, TVM de Jong, Barbui C and Tol W. Psychosocial interventions for children exposed to traumatic events in low- and middle-income countries: study protocol of an individual patient data meta-analysis. Systematic Reviews. 3:34, 2014 Rana MH, Ali S and Yusufi B. Mental Health and Psychosocial Relief of Earthquake Survivors – Activities and Interventions. Pakistan Armed Forces Medical Journal 56: 441-449, 2006 Rana MH. and Ali, S. Mental Health Care: An Integral Part of Disaster Management. Pakistan Armed Forces Medical Journal, 56: 327-332, 2006 Rana MH, Alexander DA. and Jan A. Terrorism: the Pakistani perspectives. Pakistan Armed Forces Med J. 60: 289-99, 2010 Saxena S, van Ommeren M, Saraceno B. Mental health assistance to populations affected by disasters: World Health Organization’s role. International Review of Psychiatry 18, 199–204, 2006 Skidmore M. and Toya H. Do Natural Disasters Promote Long-Run Growth? Economic Inquiry 40: 664–687, 2002 UNISDR Terminology of Disaster Risk Reduction, UNISDR, 2015 http://www.unisdr.org/eng/library/lib-terminology-eng%20home.htm www.unisdr.org/hfa World Conference on Disaster Reduction. WCDR. A review of Disaster Management Policies and Systems in Pakistan, Islamabad, 2005 www.unisdr.org/wcdr

Corresponding Author: Muhammad Afzal Javed, MD Chairman, Pakistan Psychiatric Research Center, Fountain House, Lahore Secretary for Sections, World Psychiatric Association President, World Association of Psychosocial Rehabilitation E-mail: [email protected]

GLOBAL PERSPECTIVES AND LATIN AMERICAN EXPERIENCE ON PERSON-CENTRED DISASTER RESPONSE JUAN E. MEZZICH ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI, NEW YORK, USA

NELSON R. MORALES SOTO SAN MARCOS NATIONAL UNIVERSITY, LIMA, PERU

Abstract Both natural and man-made disasters are becoming substantial and not infrequent challenges in today’s world. The need for more creative and effective responses to them is increasingly apparent. Among such proposals are public health and clinical policies conceived by the World Health Organization and the World Psychiatric Association. Also illustrative are action plans and institutional activities developed by the World Psychiatric Association to respond to disasters in a person centred manner. At the regional level, substantial efforts are emerging to organize a Latin American Network of Person Centered Medicine. Within this framework, explorations are presented on incipient person centred indicators of disaster responses. The plan is to be able to build on them to construct more effective disaster responses articulating science and humanism.

Introduction Global perspectives on disaster responses are explored first in terms of collaborative efforts of the World Health Organization and the World Psychiatric Association. Then, plans and activities of the World Psychiatric Association to address disaster response under the aegis of a Program on Psychiatry for the Person and in collaboration with several

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institutional structures are considered. In the last section, Latin American perspectives and experience on person centred medicine are outlined. Within this framework, person centred medicine indicators are explored in a sample of the Latin American literature on disasters. Prospects for building on such indicators within the ongoing process of developing person centred medicine regionally are considered.

World Health Organization and World Psychiatric Association Collaboration on Disaster Response Recommendations on the roles of psychiatrists and other health professionals in the aftermath of disasters have appeared in recent times (Mezzich and Saraceno, 2007). Efforts have been made to draw the attention of psychiatrists across the world and members of the international health community at large to WPA-WHO Joint Statements on the Role of Psychiatrists in Disasters Response. Massive disasters have been taking place with increasing frequency over recent years and are challenging the world community to understand better such phenomena and their natural and man-made causes as well as their general health and psychosocial consequences on the affected populations. The need to respond thoughtfully and effectively to disasters is the responsibility of all concerned at local, national and international levels. In regard to the psychosocial impact of massive disasters, the WHO Department of Mental Health and Substance Abuse and the WPA, among other institutions, have developed, through their various structures, relevant procedures, educational aides and service on site. It is recognized that psychiatrists have an appropriate role to play within coordinated disasters response efforts. The optimization of such a role is the concern of the World Psychiatric Association (WPA), which has established an Institutional Program on Disasters Response to work in conjunction with its Section on Disasters and Mental Health and several local Disasters Task Forces. The WHO is also contributing to this endeavour as part of its broad public mental health responsibilities. Illustrative of their collaborative efforts in this area, the WPA and the WHO prepared a Joint Statement on the Role of Psychiatrists in Disasters Response as presented below. It is consistent with a hope to enhance the effectiveness of overall efforts in this increasingly important domain.

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WPA-WHO 2006 Joint Statement on the Role of Psychiatrists in Disasters Response The WPA and the WHO drew in 2006 the attention of the international community of psychiatrists to the needs of people affected by disasters, the key actions to be potentially taken by psychiatrists, and the value of their collaboration with public health agencies. This statement was consistent with an Inter-Agency Standing Committee (IASC) Guidance on Mental Health and Psychosocial Support in Emergency Settings, to which the WPA contributed. The IASC, established by the UN General Assembly, is the highest-level humanitarian forum for coordination, policy development and decision-making. Emergency situations can have devastating psychological and social effects on individuals, families, communities and societies and tend to be associated with elevated rates of a broad range of mental disorders among affected populations. Moreover, disasters can severely disrupt social structures and ongoing formal and informal care of persons with preexisting disorders. Because disasters are associated with numerous types of social and mental health problems, it is not surprising that psychiatrists and aid agencies offering help often offer diverse and numerous types of responses. This help is usually offered at a time when normal health and social services are either overwhelmed or have stopped working altogether. To avoid chaos and to increase the chance of populations receiving the best possible support, it is important (a) to set priorities regarding how to respond to the disaster and (b) to coordinate all mental health and psychosocial support responses across sectors with agencies and professionals from diverse backgrounds. Psychiatric societies at national and local levels must help in stimulating and organizing psychiatrists’ contributions. To facilitate and guide these contributions, the WPA has developed structures such as an Institutional Program on Disaster Response, a scientific Section on Disasters and Mental Health and disaster specific local task forces, which are producing educational resources in various languages as well as training and service protocols (Mezzich, 2006). Interaction and coordination of local psychiatric societies and pertinent WPA structures with corresponding governmental and intergovernmental organizations is strongly recommended. Attention should also be given to WHO publications on this matter.

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Priority activities by psychiatrists working in the acute phase of a disaster (i.e., when daily mortality is elevated above baseline) include: – Working together with all aid agencies to establish broad-based mental health and psychosocial support with maximal participation of assisted communities. In large scale disasters many psychosocial support activities are organized by aid agencies that work in the “protection”, “social sector” or “health sector”. Consulting affected populations and coordination among sectors is essential to facilitate optimal support. – Maintaining access to care for people with acute and serious mental disorders in the community. Psychiatrists play a major role in training and supervising primary health care (PHC) workers to care for people with severe mental disorders in fixed or emergency PHC clinics in disasters. Most people with severe mental disorders in a disaster will have a pre-existing disorder, but there will also be people who have severe disaster-induced mood and anxiety disorders, including severe presentations of acute stress reaction/posttraumatic stress disorder, and there will be numerous presentations of severe medically unexplained somatic complaints. – Protecting and caring for people with severe mental disorders and other mental and neurological disabilities living in institutions. People living in institutions are among the most vulnerable people in society, and they are especially at risk in emergencies, where they are at risk of being left without care and without protection from the effects of the disaster. Psychiatrists play a key role to ensure ongoing care and protection. – Advocating with aid workers in other sectors to address the social determinants of mental health, e.g., advocating that shelter is organized in such a manner that displaced families and communities can live together to maintain social cohesiveness; advocating that areas around toilets in camps are well-lit so as to avoid sexual violence against women; advocating for family tracing to avoid child separations; advocating that adults and adolescents become involved in concrete, purposeful, common interest activities to avoid passivity; advocating that all health workers treat their patients with dignity. After the acute disaster, psychiatrists play a major role in the (re)building of community mental health services to address the increased prevalence of mental disorders in affected populations. To maximize population coverage, traumafocused care may be best integrated into general health and mental health services. These services could have a dual function – routine

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in normal times and disasters intervention in emergency periods. Disasters not only provide tragedy but also unprecedented impetus and opportunities to enhance personal and community resilience and perspectives and also to strengthen the overall mental health system.

WPA Policies and Actions on Disaster Response As previously mentioned, massive natural disasters are becoming increasingly frequent, directly affecting many areas of the world and indirectly humanity as a whole. The WPA, embodying 130 national psychiatric societies, over 180,000 psychiatrists, and over 64 scientific sections, has felt consistently concerned to respond with solidarity in each case to the suffering of the directly involved psychiatric societies, individual colleagues and the populations they serve. Responses based on the WPA constitution and particular expertise and resources must focus on assisting member societies and related health professional groups to fulfil their responsibilities in helping local populations and organizations to deal with the psychosocial consequences of disasters. This would often involve educational efforts based on adequate situational assessments and carefully prepared and culturally informed health actions. These activities would be promoted by engaging and assisting competent and committed local member societies and groups organizationally and financially to carry out assessments and action programmes in coordination with national and international efforts, including those of the World Health Organization (WHO).

Involved WPA Structures The work of WPA on disaster response has been operationalized through the following WPA structures: -

The WPA Executive Committee, for policy formulation and monitoring. The Institutional Program on Disasters and Mental Health, for broad operational coordination. The Scientific Section on Disasters, for the development of academic resources. Other relevant contributors of academic materials include the Sections on Developing Countries, Emergency Psychiatry, Rural Psychiatry, and Women’s Mental Health among others.

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-

Appointed local task forces (incorporating Zonal Representatives, Member Societies and other local groups), for basic situational assessment and the preparation of strong and budgeted protocols. At various times, these task forces have included the following: a) A WPA South Asian Tsunami Task Force, b) A WPA InterSectional Task Force on Katrina and related North American Hurricanes, and c) A WPA Task Force on the Kashmir Earthquake.

The functioning of the above listed central and local structures is overseen by the WPA President.

WPA Disasters Fund A significant structure to help with the implementation of the above policies is the WPA Disasters Fund. The involved funds come from the central WPA budget, member society donations and unrestricted grants from foundations and industry. They have been used for planning meetings, for the development of operational packages by the WPA Disasters Section, for initial assessment of disaster related psychosocial training needs, and to prepare strong protocols for specific projects and for training programmes.

An Illustrative Field Meeting A field meeting with key WPA central and local leaders on disasters was held on 3 December 2005 within the framework of the International Conference of the South Asian Association for Regional Cooperation (SAARC) in Agra, India. This meeting reviewed emerging WPA policy and plans on disasters response, emphasizing the need for proactive communication with governments, the WHO and Member Societies when a disaster occurs (readiness) as well as ensuring preparedness for disaster response. Also suggested was the formation of national sections on disasters within Member Societies linked to the WPA Disasters Section and the establishment of a database of disaster leaders, experts, resources, and experiences to be accessible through the WPA website. A preliminary evaluation of the South Asian Tsunami Task Force documented the limitations of psychosocial responses overall and the critical role of psychiatrists in acute care and rehabilitation efforts. It was reported that the WPA assigned funds for training programmes in Sri

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Lanka and Indonesia were put to good use, with a further specification in process. Concerning the Task Force on the Kashmir Earthquake, it was proposed that its membership include the presidents of the Pakistani and Indian Psychiatric Societies. An Advisory Group was recommended to include the other WPA Zonal Representatives and Member Societies in WPA Region IV.

Latin American Experience with Disaster Response The region of Latin America has a propensity to natural disasters. Illustrative are the relatively recent earthquakes in Haiti and Chile. They call for greater efforts to understand them and to address them more effectively (Organizacion Panamericana de la Salud, 2015). An exploration was conducted on a sample of Latin American experience with disasters and responses to them. The objective was to identify indicators of person centred medicine patterns. The core person centred medicine concepts to be explored were: ethical commitment, holistic framework, cultural sensitivity, relational matrix at multiple levels, individualized clinical care, establishing common ground among clinicians, patients and families for shared diagnosis and decision-making, people-centred organization of health services, and person-centred health education and research (Mezzich, Kirisci, and Salloum, 2014). The available literature in English and Spanish was reviewed. The impact of disasters in Latin American countries was largely obtained from the data of the Pan American Health Organization, the Disaster Documentation Center, the Economic Commission for Latin America and the Caribbean, and the Center for Research on the Epidemiology of Disasters published in the last 50 years, a period for which knowledge of these events in the region is systematized. The results of the exploration are presented in Table 1. Several studies and reports revealed the presence of Person Centred Medicine indicators. Such indicators, however, were rather incipient, and either direct or indirect as noted in this table. Conspiring against greater clarity in the exploration is the nature of the disaster literature examined, most of it oriented to particular institutional goals, predominantly economical, physical structure-related and social, rather than health or medically oriented.

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Table 1. Person Centred Medicine indicators on disaster response reviewed in the literature Person Centred Medicine principles Ethical commitment

Holistic framework Cultural sensitivity

Relational matrix at multiple levels Individualized clinical care Establishing common ground among clinicians, patients and families towards shared diagnosis and decision making. People-centred health services organization

Person-centred health education and research

Direct indication of the principle Morales Soto & Ronceros, in press UN Women, 2015 UN Women, 2015; Morales Soto & Ronceros, in press.

Indirect indication of the principle Morales Soto, 2009; Zapata, 2010

Zapata, 2010

CETRI, 2015 Morales Soto & Ronceros, in press Morales Soto & Ronceros, in press

OPS/OMS, 2015; UN, 2014; UNISDR, 2013; CETRI, 2015

Morales Soto & Ronceros, in press

Nevertheless, the presence of the above noted Person Centred Medicine indicators represents a beachhead for gradually building innovative person centred medicine responses to future disasters, articulating science and humanism in such enterprise. The potential for this is affirmed by the current process of systematic development of person centred medicine efforts in the region, based on Latin American perspectives and experience (Wagner et al, 2015) and the recently established Latin American Network on Person Centered Medicine.

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Colophon When a major disaster strikes, often with enormous mental health consequences to individuals and communities, the increasingly small world in which we live must come together in partnership. A reflection of disaster-response efforts at the global level are the presented activities of the World Health Organization and the World Psychiatric Association. The innovativeness and effectiveness of such responses are likely to advance in a person centred manner on the basis of the ongoing process of development of person centred psychiatry (Mezzich, 2007; Christodoulou et al. 2008) and person centred medicine (Mezzich et al. 2009; Miles and Mezzich, 2011). Likewise, the presented analysis of Latin American experience with disaster response is stimulating and said experience should grow in solidity in the disaster response field as the ongoing Latin American developments in person centred medicine unfold (Wagner et al, 2014).

References CETRI. Haiti: Del desastre humanitario al desastre social. http://www.cetri.be/Haiti-del-desastre-humanitario-al?lang=fr, login: 23 September 2015. Christodoulou G, Fulford B, Mezzich JE: Psychiatry for the Person and its Conceptual Bases. International Psychiatry, 5: 1-3, 2008. Mezzich JE: WPA and Disaster Response: New Policies and Actions. World Psychiatry, 5: 1-4, 2006. —. Psychiatry for the Person: Articulating Medicine’s Science and Humanism. World Psychiatry, 6: 65-67, 2007. Mezzich JE, Saraceno B: The WPA-WHO Joint Statement on the Role of Psychiatrists in Disaster Response. World Psychiatry, 6: 1-2, 2007. Mezzich JE, Snaedal J, van Weel C, Heath I: The International Network for Person-centered Medicine: Background and First Steps. World Medical Journal, 55: 104-107, 2009. Miles A, Mezzich JE: Advancing the global communication of scholarship and research for personalized healthcare: The International Journal of Person Centered Medicine. International Journal of Person Centered Medicine 1: 1-5, 2011. Morales Soto NR, Ronceros. Evaluacion e intervencion de vulnerabilidad familiar y de vivienda en Lima por estudiantes de medicina. Anales de la Facultad de Medicina, San Fernando, Universidad Nacional Mayor de San Marcos, in press.

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Morales Soto NR. Hitos en la ultima centuria. Volume 14: Emergencias y Desastres. In: Academia Peruana de Salud “Historia de la Salud en el Peru”. Codice Ediciones SAC, Lima, 2009. OPS/OMS. ¿Por que un Programa para Desastres? http://www.eird.org/wikies/images/Area-Preparativos-OPS.PDF. Login date: 21 September 2015. Organizacion Panamericana de Salud, OPS/OMS. Centro de Investigacion sobre Epidemiologia de los Desastres. http://www.paho.org/disasters/newsletter/index.php?option=com_cont ent&view=article&id=456%3Acred-provides-valuable-information-onthe-impact-of-disasters&catid=214%3Aissue-115-april-2011-newtools&Itemid=285&lang=es, acceso 14enero2015. UN. Third World UN Conference on Disaster Risk Reduction. Preparatory Committee. Geneva, 17 and 18 November 2014. Item 5: Considerations on the framework for disaster risk reduction after 2015. http://www.wcdrr.org/uploads/1419084.pdf. UNISDR. Framework for disaster risk reduction after 2015 (HFA2) Report of the consultations on the 2013 Global Platform for October 2013. http://www.preventionweb.net/files/35070_gordysp.pdf. UN WOMEN. Disaster risk reduction. Statement by UN Women on the occasion of World Humanitarian Day, 19 August 2015. http://www.unwomen.org/es/what-we-do/humanitarian-action/disasterrisk-reduction Wagner P, Perales A, Armas R, Codas O, de los Santos R, Elio-Calvo D, Mendoza-Vega J, Arce M, Calderón JL, Llosa L, Saavedra J, Ugarte O, Vildózola H, Mezzich JE. Latin American Bases and Perspectives on Person Centered Medicine and Health. International Journal of Person Centered Medicine 4: 220-227, 2014 Zapata A. La onda sismica del 2007 en el Estado peruano. In: Martin Tanaka (Editor). El Estado, Viejo Desconocido. Visiones del Estado en el Peru. Instituto de Estudios Peruanos, Lima, 2010.

Corresponding author: Juan E. Mezzich, MD, PhD Professor of Psychiatry Icahn School of Medicine at Mount Sinai, New York, USA Editor in Chief, International Journal of Person Centered Medicine Founding President, International College of Person Centered Medicine Former President, World Psychiatric Association E-mail: [email protected]

WOMEN’S MENTAL HEALTH IN DISASTER PSYCHIATRY UNAIZA NIAZ SECTION ON WOMEN’S MENTAL HEALTH, WORLD PSYCHIATRIC ASSOCIATION AND WORLD FEDERATION FOR MENTAL HEALTH, KARACHI, PAKISTAN

Abstract Disasters, whether natural or man-made, bring substantial mental health consequences at the individual and community level. The past century has evidenced that more than 85% of major conflicts were in poor countries. Women are disproportionately affected by disasters, and their special needs have recently begun to be understood and considered in disasterrelated planning, management and rehabilitation. Existing research data suggests that there is a pattern of gender differentiation at all levels of the disaster process: exposure to risk, risk perception, preparedness, response, physical impact, psychological impact, recovery and reconstruction. Studies on the relationship between gender and outcome following disasters indicate that this gender pattern of incidence persists and that comparatively more symptoms are reported in women and girls. High rates of psychological problems in women are associated with higher numbers of traumatic events experienced by them. Pre-existing structures and social conditions increase women’s vulnerability to being victimized during and after disasters. For instance, the worst sufferers in the Pakistan earthquake of 2005 were the uneducated, single, widowed and elderly women in camps. Feminists working in relief agencies after the 2004 tsunami have identified several factors including sex differences in physical strength that increase women’s vulnerability to being victimized. The context and settings may be different however; women from developed countries are also vulnerable to suffering from mental and physical health consequences of these conflicts and wars. For instance it was reported that more than 160,500 American female soldiers have served in Iraq, Afghanistan and

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the Middle East. About 450 women have been reported to have been wounded in Iraq, and 71 have died. Ironically, despite the equal risks women are taking, they are still being treated as inferior soldiers and sex toys by many of their male colleagues. This situation suggests that some effective measures need to be taken at all levels as well as expansion of existing community services in order to support women during and after disasters. Disaster psychiatry is one of the fastest growing subjects in the field of mental health in the twenty-first century. An extensive literature on the psychological impacts of natural and man-made disasters and catastrophes has grown rapidly over recent years. And disasters are now well recognized as leading to serious mental health consequences for survivors. Unlike other disciplines, which have come more recently to the study of disasters, psychiatry has concerned itself with disasters’ impacts on victims and their psychosocial rehabilitation. Lindemann’s landmark study (1944) published an observation of the psychological aftermath of the Coconut Grove nightclub fire in Boston. Since then several reports and research studies have documented psychiatric disorders in the survivors of disasters. It has been widely recognized that for more than two decades the Eastern and Mediterranean regions have been most affected, where 80% of the population is either in conflict situations or war zones (Gosh et al, 2004). And for the last twenty years, emergence of new conflict zones in the third world has raised concerns for their catastrophic effects on the mental health of these countries’ populations and their women in particular. The mental health component of disaster response is a vital subject of study, as trauma is associated with a substantial and long-lasting psychological burden, both at individual and community levels. The psychopathologies associated with disaster are also pervasive, varying from several different types of post-traumatic stress and anxiety disorders, through acute variations of grief-associated depression, brief psychotic episodes, adjustment disorders and psychosomatic disorder, and through alcohol abuse and dependence to less documented interpersonal violence. Although the appearance of post-disaster psychological symptoms in adults varies, the incidence of psychopathology in women and children is considerably high after disasters (Niaz and Hasan, unpublished data). Since 11 September 2001, disaster preparedness and response has developed into a distinct subspecialty in medicine, and the paramount health care initiative worldwide. Women are disproportionately affected by disasters, and their special needs have recently begun to be understood and considered in disaster-related planning, management and rehabilitation.

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Gender, a major risk factor in disasters In disaster situations genders are clearly affected differently. Research data suggest that there is a pattern of gender differentiation at all levels of the disaster process: exposure to risk, risk perception, preparedness, response, physical impact, psychological impact, recovery and reconstruction. Due to social norms and their interaction with biological factors, women, particularly girls, may face increased risk to adverse health effects and violence. They are often unable to access assistance safely and/or to make their needs known. Women are vulnerable to disasters due to their socially constructed roles. Women have less access to resources such as social networks which effect their transportation, information, skills (including literacy), control over land and other economic resources, personal mobility, secure housing and employment, freedom from violence and control over decision-making that are essential in disaster preparedness and rehabilitation. Additionally, women are not sufficiently included in community consultation and decision-making processes, resulting in the non-recognition of some of their basic needs (for instance, separate toilets close to their camps, availability of sanitary napkins, and various gynaecological and obvious obstetric needs) (Enarson, 2000). Gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society; and their susceptibility and exposure to specific mental health risks, stress and adversity. Women are thus victims of the gendered division of labour. They are overrepresented in the agriculture industry, self-employment and the informal economy, in under-paid jobs with little security and no benefits such as healthcare or union representation. The informal and agricultural sectors are usually the most impacted by natural disasters, thus women become over-represented among the unemployed following a disaster. Also, as women are primarily responsible for domestic duties such as childcare and care for the elderly or disabled, they do not have the liberty of migrating to safer places or looking for work following a disaster (Norris et al, 2002). Men, on the contrary, often migrate, leaving behind very large numbers of female-headed households. This failure to recognize the real situation of women’s double jeopardy – of being productive financially and to be reproducing and rearing the future generations – explains why women’s visibility in society remains low and attention to their needs remains woefully inadequate. Because housing is often destroyed in the disaster,

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many families are forced to relocate to shelters. Inadequate facilities for simple daily tasks such as cooking mean that women’s domestic burden increases at the same time as their economic burden. When women’s economic resources are taken away, their bargaining position in the household is adversely affected. Numerous studies have shown an increase in levels of domestic and sexual violence following disasters (Richard, 1999; Belle and Doucet, 2003). The mental health impact of long-term, cumulative psychosocial adversity has not been adequately investigated. Hence the resulting economic and social policies cause sudden, disruptive and severe changes to income, employment and social capital in women. These factors cannot be controlled or avoided, resulting in significant increases in gender inequality and the rate of common mental health disorders. Hence in adversities such as disasters, whether man-made or natural, women’s vulnerability increases manifoldly.

Underlying dynamics in women in disasters Vulnerability factors within the victim operate in complex ways. Psychodynamic psychiatrists and psychologists have attempted to relate the distress of victims of disasters to several important psychological constructs. Disasters allow psychologists to perceive the operation of trauma on emotional functioning, a process which mental health practitioners as far back as Freud have been involved in understanding. Stress research is a central and crucial explanatory factor in many fields of psychology, especially community psychology, which considers stress the central ingredient to the formation of psychopathology (e.g., Albee, 1997; Dohrenwend, 1998). Depression, anxiety, somatic symptoms and high rates of co-morbidity are significantly related to gender dynamics. “These psycho-social connections are drastically severed or disrupted, in disasters” Niaz and Hasan (unpublished). Women in the refugee camps and IDP rehabilitation centres often appear and feel bewildered and non-functional; their social support systems and psychological/spiritual anchors are absent, disrupted or destroyed. Besides the concurrent risk factors such as gender-based roles, stressors and negative life experiences and prevailing traumatic events continue to add damage to distress. Thus, reconnecting and rebuilding severed links in the dynamic apparatus in adverse situations is crucial. In the female gender

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this is innate dynamic factor, related to the nurturing instinct, is clearly enhanced and reactivated in crisis. Protection and survival, is a basic psychodynamic factor and strength in the female gender. These traits of innate resilience play an active role in emergency situations and must be positively harnessed for the purpose of rehabilitation and planning in crises situations (Niaz and Hasan, unpublished)

Women suffer more psychological distress than men in disasters Gender differences occur particularly in the rates of common mental disorders – depression, anxiety and somatic complaints. These disorders, in which women predominate, affect approximately one in three people in the community and constitute a serious public health problem. Studies on the relationship between gender and outcome following disasters indicate this gender pattern of incidence persists and that comparatively more symptoms are reported in women and girls. However, this bias towards female gender may be due to the types of the symptoms and disorders studied by researchers. For example, PTSD, anxiety or depression, which are most commonly researched after disaster, are generally more prevalent in women in the general population (Kessler et al., 1994; WHO, 2005). In most of the systematic research studies, high rates of symptoms were associated with higher numbers of traumatic events experienced, and women clearly had higher rates of symptoms than men (WHO report 2001). More than 85% of the major conflicts since the second world war have been in poor countries... During the 1990s the poorest countries of the world became saturated with arms, with brokers often supplying both sides of a conflict... Between 1986 and 1996, a major proportion of those dying as a result of armed conflicts were civilians, particularly women and children... Huge differences in the health of mothers and children exist between the poor countries undergoing conflict and the predominantly rich countries exporting arms to them (Southhall and O’ Hare, 2007).

For over four decades, the Middle East has been in turmoil, in a situation of overt inter-nation armed conflicts as well as long-term low intensity conflicts. Every day the media bring the horrors of ongoing “war” situations in Iraq, Palestine, Israel, Syria and Lebanon. There was a horrendous impact on women from the 1975–90 civil wars in Lebanon – the lengthiest and bloodiest in its recent history. War has been documented to be a more potent oppressor of women than of men (Shehadeh, 1999).

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The plight of women in Iraq and Syria is of growing concern, with everincreasing reports of murders, rapes and kidnappings, as well as general intimidation and oppression (Madi-Skaff, 2006; Synder, 2003). Mental Health professionals must recognize how different the Iraq war is for women compared to any other American war in history. More than 160,500 American female soldiers have served in Iraq, Afghanistan and the Middle East since the war began in 2003 (Gulf war, Iraq war, Afghani war etc), which is approximately one in seven soldiers. Women make up 15 percent of active duty forces, four times more than in the 1991 Gulf War. About 450 women have been reported to have been wounded in Iraq, and 71 have died. These figures clearly indicate more female casualties and deaths than in the Korean, Vietnam and first Gulf Wars combined. And women are fighting in ground combat as there is no choice. This is a war with no front lines or safe zones, no hiding from incoming mortars or car and roadside bombs, and not enough soldiers. As a result, women are coming home with missing limbs, mutilating wounds and severe trauma, just like men. The core of the whole issue is that societies have failed to accept women as equal partners at the realistic and intellectual levels. Insufficient equality of women and men in important spheres of daily life has added to the stress in women. This brings out the point raised earlier of non-acceptance of women in their new roles. Ironically, despite the equal risks women are taking, they are still being treated as inferior soldiers and sex toys by many of their male colleagues. Benedict (2007) describes this situation in detail. Norris et al. (2002) point out that the risk factors in adults include: severe exposure to the disaster, especially injury, threat to life and extreme loss; living in a highly disrupted or traumatized community; female gender; age in the middle years of 40 to 60; little previous experience relevant to coping with the disaster; ethnic minority group membership; poverty or low socioeconomic status; the presence of children in the home; psychiatric history; secondary stress; and weak or deteriorating psychosocial resources. Disasters are seldom gender-neutral. In the 1995 Kobe, Japan earthquake, 1.5 times more women died than men; in the Southeast Asia tsunami of 2004, the death rate for women across the region was three to four times that of men on average. The gender, class and race dimension of each disaster needs particular description. Feminists working in relief agencies, for example, identified several factors that describe the gender skew in the 2004 tsunami deaths. In some cases, sex differences in physical strength

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clearly made a difference to the ability of survivors to climb, cling or run to a safe place (Gender and Disaster source book, 2005). The Oxfam report on the Asian tsunami (2005) states emphatically that “disasters, however ‘natural,’ are intensely discriminatory. Wherever they hit, pre-existing structures and social conditions determine that some members of the community will be less affected while others will pay a higher price. Among the differences that determine how people are affected by such disasters is that of gender”. Reports of rapes in the middle of the New Orleans disaster and during the tsunami disaster are well documented. Several research studies reported that women that had survived unimaginable tragedy and stress had also been raped. Even in conditions of extreme human suffering, no disaster experts assured women that rape-support teams were included in the rescue teams and there were no discussions about the medical and psychological resources that women needed. There is no gender breakdown of the victims of the tsunami; it devastated the lives of millions of people in Asia, regardless of sex, age, colour or income. But its long-term effects are expected to hit women particularly hard. International Labour Organisation’s research shows that disasters tend to sharpen existing inequalities (Gender mainstreaming during disaster, 2007). The Pakistan Earthquake in 2005 killed 70,000 people, mostly school children and women, rendering about four million homeless. The Earthquake occurred in the early hours of the morning. Many women in rural areas had left home to cut grass as fodder for their animals. Many of them died as a result of rocks and boulders falling on them. For women in urban areas a different set of patriarchal rules are applicable; there are reports that many women would not easily leave their homes, due to the cultural norms of purdah. In certain areas of the north west frontier province of Pakistan, women would not leave their homes to the relative safety of streets, despite the violent shaking of buildings and concrete walls tumbling down and trapping them inside. This disaster has left many women and children disabled. There were no facilities to help them in their helpless conditions. Women suffered domestic violence and health problems, besides being overburdened by domestic responsibilities. In many cases, disabled women were lying helpless in camps or hospitals and their husbands had either abandoned them or remarried to help them share their workload! Women in the rural culture of Pakistan are not accustomed to talking to strangers; hence this behaviour has caused many hurdles in getting them

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the much needed help, medical, social or financial. The United Nations estimated that over 40,000 women in the quake-hit region in Pakistan in 2005 were pregnant. The author documented her observations in several articles and in her book The Day the Mountains Moved: Pakistan Earthquake, 2005 (Niaz, 2007). They are often shy to come forward with their problems, and the relief workers had to make special efforts to reach these women. In camps, where there was a lack of women health care workers, women by and large have been reported not to have accessed medical care. The wash rooms provided at the tent villages were considered inadequate and women were reported going back to the damaged buildings or nearby open areas rather than using the camp facilities. There were reports that women had not taken a bath even after a month of delivering a child. Their physical and emotional state of health was directly affected; the issue of lack of sanitation for these women is just one facet of the enormous difficulties faced by them. In a country like Pakistan, where women, in general, are largely absent from public life, especially in positions of leadership, the issue of women’s access to relief efforts is much more dire in rural and remote areas. The lack of women in the relief effort teams had vastly impacted the direction of relief work, as would be expected. The few women involved in the relief operations felt this gap immensely, as fewer women-survivors of the earthquake could be reached directly. In the mountainous terrain it takes a whole day to just reach one or two villages. Communities even in one village are scattered and not easily accessible. (Niaz, 2007, pp 140-144).

Research studies conducted on the women survivors of the Pakistan earthquake are supportive of the severe psycho-social effects on high-risk vulnerable women. Niaz (2007) reports that in the Pakistan earthquake of 2005, the worst sufferers were the uneducated, single, widowed and elderly women in camps; they had to suffer unbearable heat in tin sheet shelters, in sizzling summer heat and they had minimal basic food and inadequate milk for children. These women’s relatives were themselves struggling to rehabilitate themselves and could not be bothered to help these women.

Gender-based violence in disasters The chaos and disorder that follow natural and man-made catastrophes leave women and girls vulnerable to violence and sexual abuse. Poor socio-economic standing means they may not be able to get the relief aid and resources they need or voice their needs when decisions are made

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about their future. At the same time, lack of skills and work experience put women and girls at special risk of trafficking, prostitution, debt bondage and other kinds of exploitation. Gender-influenced post-disaster outcomes in many research samples indicate that the effects had a wide range of outcomes, but one of the strongest effects was Post-Traumatic Stress Disorder (PTSD) for which women’s rates often exceeded men’s by a ratio of 2:1. The effects of gender were marked in the groups that came from traditional cultures and in the context of severe exposure (Gender mainstreaming, 2007). The high prevalence of sexual violence to which women are exposed and the correspondingly high rate of PTSD following such violence render women the largest single group of people affected by this disorder.

Conclusions The greatest challenge mental health professionals face presently is to handle trauma in various forms, as in the prevailing situation, where there is not even a remote possibility of individualized or collective support or therapy. In these situations the only feasible solution is a quick rehabilitation and re-organization of the fractured society at all levels. The support systems need to be strengthened as early as possible. In the developing countries, some simple steps can help women survivors go a long way to relieve their distress and remorse in disasters. Simple tasks such as registering land in the name of women, facilitating women in opening bank accounts in their own names, or depositing their relief cheques in their accounts, for instance, were found to be extremely useful in the Pakistan earthquake of 2005. Frustration, anger, sense of deprivation and helplessness are all negative emotions common in post-disaster survivors. These damaging and disruptive emotions can be channelled and transformed into positive energies and constructive activities. The good health of women is well documented to have a positive impact on the general health of all members of a society. Training primary care physicians, nurses and other health workers in the recognition and appropriate referral and/or treatment of mental illness is central to community services. Mainstreaming a gender perspective will possibly build on the interests of many women professionals who have entered the field of mental health care as psychiatrists, psychiatric nurses, counsellors and social workers.

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References Albee GP. Speak no evil. American Psychologist, 52, 1143-1144. 1997. Belle D, Doucet J. Poverty, inequality, and discrimination as sources of depression among U.S. women. Psychology of Women Quarterly, 27 (2), 101-113. 2003. Benedict H. The Private war of women soldiers, Salon, Wednesday, March 7, 2007. Dohrenwend BP. Adversity, stress and psychopathology. Oxford, England: Oxford University Press. 1998 Enarson E. Gender and Natural Disasters, IPCRR Working Paper no.1. International Labour Organization, Sept 2000 Gender and Disaster Sourcebook, Gender and Disaster Network: More information is available in the gender section of www.unisdr.org, www.disasterwatch.net, www.huairou.org, www.groots.org and www.sspindia.org, 2005. Gender Mainstreaming During Disasters: The Case of the Tsunami in India. Oxfam International, September, 2007 Ghosh N, Mohit A, Murthy RS. Mental health promotion in post-conflict countries. J R Soc Promot Health. 124(6):268-70. 2004. Janoff-Bulman, R. The aftermath of victimization: Rebuilding shattered assumptions. In C.R. Figley (Ed.), Trauma and its wake: the study and treatment of post-traumatic stress disorder. New York, Brunner/Mazel, 1985 Kessler RC, Sonnega A, Bromet E, Hughes M, Christopher BN. Posttraumatic stress disorder in the National Co morbidity Survey. Archives of general psychiatry 52: 1048-1060. 1995. Kessler R, Sonnega A, Bromet E. Posttraumatic stress disorder in the National Co-morbidity Survey. Archives of General Psychiatry, 52, 1048-1060. 1995. Lindemann E. Symptomatology and management of acute grief. American Journal of Psychiatry, 101:1141–1148, 1994. Madi-Skaff J. Conflicts in the Middle East: Impact on Women's Mental Health" Forum - Mental Health Consequences of War, World Psychiatry, 5(1), 12-22, 2006. Niaz U. Introduction, Gender Perspectives in Psycho-trauma, The Pakistan Earthquake, 2005: The Day The Mountains Moved. Ed, Unaiza Niaz, Published by Sama Books, Karachi, Pakistan, Hard Cover ISNB-060-8784-52-7, 2007 Niaz U, Hassan ZM. Psychodynamics of Interconnectedness in Women play a crucial role in developing Resilience in Crises Situations

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(Unpublished data, part of continuing research project on Women – enduring gender) Niaz U. Pakistan Earthquake, 2005. The Day The Mountains Moved. International Perspectives in Handling Psycho trauma. Published by Sama Books Karachi, Pakistan, 2007, pp 140-144 Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part 1. An empirical review of the empirical literature, 1981-2001. Psychiatry, 65, 207-239. 2002 Overton Lisa Rose-Anne. Flirting with Disaster: Gendered Impacts of Women’s Access to Land and Housing in Post-Tsunami Sri Lanka. BA Dissertation, Middlesex University, 2014 www.sciencedirect.com/science/article/pii/s2212567114009332 Richard HR. Global Problems and the Culture of Capitalism. Allyn and Bacon, Boston, Mass. 1999, p. 354 Shehadeh LR (editor). Women and war in Lebanon, University Press of Florida, 1st Edition, 1999 Snyder U. In the Face of War, Medscape Ob/Gyn & Women’s Health, From the Editor. 2003 Southall D, O’Hare B. Empty Arms: The Effect of the Arms Trade on Mothers and Children. Child Advocacy International, Newcastle under Lyme, Staffordshire, UK, 2007 WHO, Department of Gender, Women and Health (GWH), 2005 http://www.who.int/gender/other_health/disasters/en/ World Report on Violence and Health, World Health Organization (WHO), On the Brink of Possible War: Reflections, WHO, 2010 World Health Report, Collective Violence, World Report on violence and Health, chapter 8, 2001

Corresponding Author: Unaiza Niaz, MD Professor of Psychiatry Chair, Section on Women’s Mental Health, World Psychiatric Association Advisory Board Member, International Association of Women’s Mental Health Vice President for Eastern Mediterranean Region & Board Member, World Federation for Mental Health Pakistan E-mail: [email protected]

PSYCHOLOGICAL EFFECTS ON MILITARY PERSONNEL ASSIGNED TO HUMANITARIAN ASSISTANCE AND DISASTER RESPONSE MISSIONS JAMES C. WEST, JOSHUA C. MORGANSTEIN UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES BETHESDA, MD, USA

Abstract Humanitarian operations frequently employ military personnel. This chapter discusses typical roles of military personnel and the psychological effects of humanitarian deployment on military personnel. Expectable responses include distress reactions, health risk behaviours and mental illness. Anticipating the strengths and vulnerabilities of this population of first responders leads to emphasis on proper preparation, monitoring and recovery practices to mitigate stress and minimize the likelihood of prolonged impairment or illness. Specific examples of promising evidence-informed practices illustrate effective preparation, monitoring, and recovery of personnel. Disclaimer: The opinions expressed are those of the authors and do not represent the official views of the United States Department of Defence or Uniformed Services University.

Introduction International humanitarian assistance increasingly involves military forces. By virtue of their emphasis on readiness and training, military units can rapidly respond to needs both domestically and around the world. Humanitarian assistance takes many forms, from planned medical

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assistance and development missions to disaster relief. In keeping with the overall theme of this volume, this chapter will focus on military personnel involved in disaster response. Military forces in this context will include active duty combat and support forces, national defence forces and national guard forces. On 29 August 2005 Hurricane Katrina came ashore on the United States Gulf Coast devastating the region. Within one week of the catastrophe, over 26,000 National Guard troops from across the United States were engaged in disaster relief efforts in the states of Louisiana and Mississippi (Davis et al., 2007). These troops performed search and rescue, engineering and infrastructure repair, and security operations in affected areas. On 11 March 2011 a 9.0 magnitude earthquake struck the island of Honshu, Japan producing a massive tsunami that inundated the east coast of the island. The Fukushima nuclear power plant suffered crippling damage to its nuclear reactors and release of radioactivity into the environment. The military response included Japanese Self-Defence Forces, United States military forces and a host of Pacific nation military forces. Within three days of the earthquake 50,000 United States military personnel were providing humanitarian assistance. In all, over 91 countries provided support to Japan (Ford et al., 2011). The following chapter will discuss the use of military forces in humanitarian assistance operations. As there is relatively little research available on military personnel as first responders, it will necessarily be an interpolation between existing information on civilian first responders and military combat and operational stress control practices. While many of the examples draw from United States experiences and practices, the conclusions and recommendations are presumably applicable to military forces from any nation involved in humanitarian response.

Roles of Military Personnel in Humanitarian Assistance Operations With established command and control structures military units are ideally suited to rapidly responding in disasters and other humanitarian crises. Military personnel train for work in austere environments and are used to adjusting missions as situations change. Military units assume a variety of roles in humanitarian assistance missions depending on training and

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specialization. Training and experience in specific roles can serve to buffer against psychological trauma, but in some cases lack of this may leave individuals and units more vulnerable. Units with basic military training assume a range of responsibilities in response to humanitarian crises. The large manpower pools of infantry units and naval vessels readily lend themselves to the distribution of food, water and other immediate humanitarian aid needs. Combat units may also aid in search and rescue and debris clearing operations. Such units can expect to be trained “just in time” on the specifics of their mission, and will typically work outside of their primary military role. As such they represent a potential high-risk pool for psychological trauma. In some circumstances military units may be detailed to serve as security forces. Such assignments are typically constrained by laws of the nation requiring assistance. Depending on the level of internal security existing within a nation prior to the need for humanitarian response, local security forces may be degraded or non-existent. Specialized units are most likely to fulfil roles aligned to their training. Aviation units are a core component of search and rescue and medical evacuation efforts. Aviation units are also ideal for rapid deployment of food, water, and shelter resources. Medical units can swiftly deploy to provide acute medical and surgical care alongside or in lieu of host nation medical capability. Medical units also bring public health monitoring and intervention capacity. Military construction teams can mobilize heavy equipment to clear debris, repair roads and quickly build or repair vital structures. Disaster response roles closely aligned with the primary missions of military units will presumably leave them relatively inoculated against the psychological stresses of humanitarian deployment.

Potential Psychological Responses to Operations An understanding of the mental health effects of humanitarian missions on military personnel is largely informed by the current disaster literature. Research on first responders and aid workers helps to inform on the experiences of those charged with providing services and support to affected individuals in the aftermath of a disaster event. While those responding and providing services demonstrate a similar pattern of psychological and behavioural response to the victims they are assisting, unique exposures that occur in the process of providing assistance as well as the inability to address self-care needs often impact the mental health of

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these personnel (Benedek et al., 2007). Exposure to human suffering, extremes of poverty, human remains, impact of resource scarcity and unique cultural variables also affect those responding to humanitarian crises (Holloway et al., 2010). Following exposure to disaster events, affected individuals can demonstrate distress responses, engage in health risk behaviours, and experience symptoms of formal mental health disorders.

In the immediate aftermath of a disaster, distress responses predominate. Individuals feel a sense of vulnerability and engage in blaming, scapegoating and expressions of anger at government and other leaders perceived as responsible. These emotions may be exacerbated for responders who were not psychologically prepared for the damage and suffering caused by a disaster event. Demoralization and a loss of faith may also occur. Many individuals will experience insomnia, irritability and feelings of distractibility (Mellman et al., 1995). Following the Gander Newfoundland crash in 1985, assistance workers reported increased rates of sleep disturbance and distractibility which was worst for those with lower social support (Bartone et al., 1989). Some individuals will present

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to healthcare settings with physical symptoms as a manifestation of psychological distress (Rundell et al., 1996). Symptoms such as headache, dizziness, nausea, fatigue and weakness are common in the wake of a disaster even when an identifiable physical disorder cannot be found (Ford, 1997). These are normal reactions to an extraordinary event. Leaders must plan for the presence of these distress responses in both disaster victims and those providing response and relief efforts and ensure adequate resources to respond to individuals with these symptoms in a timely and supportive manner. In addition to distress responses, an increase in health risk behaviours is common following disasters. Increased use of alcohol, caffeine and tobacco are common coping mechanisms and generally represent selfmedicating of distress symptoms (Osofsky et al., 2011). Following disasters, intimate partner violence and overall levels of violence commonly increase, with women being most prone to victimization (Harville et al., 2011). Some individuals will develop psychiatric disorders following a disaster. The most widely studied is Post-traumatic Stress Disorder (PTSD) (Ursano et al., 2010). Approximately 10–20% of those exposed to a traumatic event will develop full criteria for PTSD, though many more individuals will experience less severe levels of these symptoms, which can persist and be problematic over time (Goldmann et al., 2014). Following the earthquake and resultant disasters in 2011, first responders from the Japanese Self-Defence Force who were exposed to human remains experienced significantly higher symptoms of post-traumatic stress (Dobashi et al., 2014). Factors such as living in close proximity to a disaster have also been associated with post-traumatic stress in responders (van Kamp et al., 2006). The course of PTSD varies, with some individuals presenting with symptoms long after the initial incident (See Figure 2). Post-traumatic stress disorder is not the only trauma related disorder, nor perhaps the most common (Fullerton et al., 1997). Responders exposed to disaster are at increased risk for depression (Cardozo et al., 2012), generalized anxiety disorder, panic disorder and increased substance use (North et al., 2002). The experience of first responders, just as in the disaster-affected community, does not occur in a vacuum. It is important to interpret their significance in light of other social and interpersonal events, as well as the context of their experiences while responding to a disaster event. Like others who serve in a first responder role, military personnel can

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experience a wide range of distress symptoms, engage in health risk behaviours and may develop mental disorders. Planning and interventions that increase preparedness, decrease exposures, more rapidly identify symptoms warranting treatment and reduce barriers to care can mitigate the impact of disaster exposure during humanitarian operations. Military personnel serving on humanitarian assistance and disaster response missions bring unique strengths and vulnerabilities. Resilience among first responders in general is a common trait, even in the face of severe adversity (Foa et al., 1997). It is a process that evolves with changing disaster circumstances and experiences. Military personnel tend to be self-selected for resilient psychological traits, and military training tends to enhance these. Individual and collective vulnerability to stress reactions, health risk behaviours and mental illness depend on the duration and intensity of exposure to disaster stressors. However, it is important to consider that responding to a humanitarian crisis will be transformative for many involved, enabling more constructive ways of managing adversity and stress (Reissman et al., 2004). Resilient military personnel will rapidly and successfully adapt to adverse environmental, cultural and situational challenges, and subsequently reintegrate into life in their home country or continued military training and operations in a healthy and adaptive fashion.

Preparing Military Personnel to Optimize Resilience in Humanitarian Operations Optimal humanitarian response by military units requires an organizational culture that prioritizes both physical health and psychological well-being. Effective commanders will prepare their units in order to diminish the likelihood that critical personnel refuse to work during a disaster or become incapacitated and incur the cost of rehabilitation and training replacements. Unlike standing civilian disaster response units, such as search and rescue teams, military units do not necessarily train in advance of specific humanitarian missions. Once assigned to humanitarian missions, such training must typically be delivered rapidly during transit to the response location. Preparatory training should include the elements outlined in Table 1 (adapted from Centers for Disease Control, 2013; National Response Team, 2012).

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Table 1. Elements of Pre-deployment Training to Military Response Workers x x x x x x x

Host nation background Nature of the disaster Response organization Anticipated hazards and exposures Protective equipment and decontamination procedures Self-care, Buddy-care Communications

Military personnel providing humanitarian assistance often work extended hours in high-risk environments where alertness and attention to detail are an absolute requirement for safe work practices. Hazards and risks to responders directly relate to the reason for the deployment (e.g., infectious disease outbreak) or can be incidental to the deployment (other endemic diseases, limited host nation medical facilities and physical security hazards). Commanders must consider the risk of psychological effects from exposure to these hazards and plan appropriate measures to mitigate them. An additional preparatory task is appropriate screening of potentially deploying personnel. All should undergo thorough screening for medical and psychiatric conditions that may put them at increased risk of decompensation or injury during deployment or significant disability following deployment. Most militaries comprehensively screen members on entry into the service and periodically during their military service, making this task easier. Most conditions that would otherwise preclude a civilian first responder from humanitarian service would also disqualify them from military service. All personnel should be briefed on expected hazards they can expect to encounter. This includes safety briefings and training and issuance of personal protective equipment. This also includes providing response personnel the opportunity to discuss anticipated psychological stressors.

Managing Stressors in the Operational Environment Organizational policy can prevent or mitigate injuries and illnesses from environmental, occupational and operational threats during humanitarian response, including psychological and traumatic stress. Rapid identification

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of potentially traumatic exposures among response personnel allows for effective intervention. The immediate goal of intervention is to assist individuals and groups whose distress response behaviours may put themselves or the mission at risk. The longer term goal is prevention of persisting traumatic stress symptoms or disability. The United States National Institute for Occupational Safety and Health (NIOSH) recommends a framework for health surveillance of emergency responders, to include psychological health (Centers for Disease Control, 2013; National Response Team, 2012). Although generated for civilian first responders, this comprehensive plan is an excellent example for actions before, during and after deployment of military first responders. During deployment, just-in-time briefings provide information about anticipated exposures, including psychological and emotional hazards from response activities. Units should routinely monitor individual exposures and develop population surveillance data to track patterns of injury and disability. Such a surveillance program also allows for identification of emerging physical and psychological hazards and regular communication of this information back to disaster workers. Doing so not only updates response personnel about evolving risks, it also provides evidence to disaster workers that leadership is monitoring and evaluating hazardous exposures (Reissman et al., 2011). Reliable data on potentially traumatic exposures provides one mechanism to identify at-risk populations among response personnel. There is little research on military personnel assigned to humanitarian missions, but it is reasonable to extrapolate data from other first responders. In Los Angeles, California first responders and their supervisors employ a process of monitoring for exposure to potentially traumatic events called “Anticipate, Plan, Deter” (UC Irvine, 2015). This program uses a self-report checklist for first responders to report the types of exposures they encountered and any symptoms of distress. Such a process can help supervisors identify individuals and units that have encountered situations statistically identified as more likely to promote psychological distress or health risk behaviours. Once identified, supervisors can reach out to affected individuals and groups and apply appropriate psychological first aid interventions. This process was also used following Hurricane Sandy to identify at-risk populations (Schreiber et al., 2014). Managers can also use aggregated triage data for surveillance to monitor populations across assignments.

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Efforts to mitigate negative psychological responses to humanitarian assistance missions should be grounded in the principles of psychological first aid (Hobfoll et al., 2007). Psychological first aid includes elements for establishing a sense of safety, calming, restoring self and community efficacy, promoting connectedness, and instilling hope. Individuals experiencing significant distress symptoms may require more targeted psychotherapeutic intervention. Early trauma-focused intervention has been shown to be effective in mitigating traumatic stress symptoms (Roberts et al., 2009).

Monitoring and Interventions in the Recovery Phase During response efforts, military and other response personnel may be highly focused on mission requirements. Daily operational activities can provide a source of motivation as well as a distraction from stresses encountered in the line of duty. As humanitarian or other mission work demands decline and personnel begin recovery and reintegration, individuals may become more aware of the traumatic stressors to which they were exposed. Following humanitarian and other operations, military personnel and other first responders can also experience boredom and a decreased sense of meaning in performing their routine, non-operational work tasks (Ritchie et al., 2003). Military personnel, particularly those with a limited military support network, can feel that family, friends and other civilians with whom they interact are not able to understand the demands of operational work, both combat and humanitarian in nature. Military personnel may choose to avoid discussing concerns with others, resulting in social isolation that can worsen mental health symptoms. In addition, though much effort has been made to reduce barriers to care for military personnel, stigma regarding the use of mental health services remains an ongoing concern. As a result of these factors, assessment and monitoring in the post-deployment time period are important. Systematic interventions can be used to assess and monitor the mental health of military personnel following a humanitarian mission. The United States Department of Defence utilizes a Post-Deployment Health Assessment and Reassessment process, screening personnel for mental health symptoms before deployment and at specified time intervals following return from a contingency operation, including humanitarian missions (Department of Defence, 2013). This screening assessment includes evaluation of potential environmental exposures and screens for the presence of psychiatric symptoms and health risk behaviours. Personnel

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that have a positive screening on the objective instrument are contacted for additional mental health evaluation. The utility of such assessment and monitoring systems necessitates the use of validated instruments as well as accurate self-reporting, the latter being an ongoing challenge in organizations impacted by stigma. However, the use of population-based interventions may ultimately serve to normalize the reporting of symptoms while identifying affected individuals who might otherwise receive no evaluation or treatment. Military leaders should monitor for signs of worsening distress among personnel returning from contingency operations. Misconduct, domestic violence, substance-related incidents, occupational problems, increased health care utilization and risk-taking behaviour are common indicators that will frequently be observed by first-line supervisors (Osofsky et al., 2011). Identification of these indicators followed by supportive leadership interventions can decrease distress for personnel, reduce stigma, and increase utilization of mental health services when indicated. Team debriefings and after action reports are common interventions used by military leadership in the aftermath of operational activities or potentially traumatic events. They provide military personnel the opportunity to express concerns, receive social support, dispel inaccurate information, enhance knowledge through collective experiences and have their efforts positively reinforced by leadership. When properly utilized, debriefs can improve both individual and team performance (Tannenbaum et al., 2013). The military also utilizes awards and decorations to recognize achievement following contingency operations. The timely and equitable formal acknowledgement of hard work, bravery and sacrifice can have a positive impact on morale. Other interventions or structured programmes may enhance resilience and foster post-traumatic growth. The United States Army began the Comprehensive Soldier and Family Fitness program (CSF2) in 2008 to enhance the resilience of service members and their families with the goal of reducing mental health symptoms and disorder. CSF2 is the largest such programme in the Department of Defence and continues to gather metrics on the efficacy of this intervention (Harms et al., 2013). Kaminsky offered a “resistance, resilience, and recovery” framework to assist mental health in the military humanitarian setting with the process of planning and structuring intervention programmes (Kaminsky et al., 2007). This framework is described as an outcome-driven approach to critical incident and disaster management, addressing protective factors, crisis intervention, and treatment and rehabilitation.

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The transition from contingency operations to routine, garrison work can result in boredom, loss of meaning, and paradoxically increased awareness of underlying traumatic stress. Systematic evaluation of personnel may assist in identifying individuals that may benefit from further mental health assessment and treatment. Informal interventions directed by unit leaders, such as team debriefings, can be used during and following operations to enhance morale and improve performance. The development of outcomes-driven programmes and interventions designed to enhance resilience and decrease adverse mental health outcomes fill a critical role in maintaining the health of military and other responder personnel.

Conclusion Military units can anticipate continued involvement in international humanitarian assistance and disaster response. With their mission-focused organization, large manpower pool and rapid mobility, military units represent a valuable response asset. Military commanders can effectively apply principles of stress management learned from civilian first responders. Such principles include thorough threat assessment and unit preparation for unique stressors encountered in disaster response missions, effective monitoring of exposures and reactions to them during mission execution, and plans for the reintegration of military units back into routine operations after mission completion.

References Bartone, PT, Ursano, RJ, Wright, KM, et al. The impact of a military air disaster on the health of assistance workers. A prospective study. J Nerv Ment Dis. 177, 317-328, 1989. Benedek, DM, Fullerton, C and Ursano, RJ. First responders: mental health consequences of natural and human-made disasters for public health and public safety workers. Annu Rev Public Health. 28, 55-68, 2007. Cardozo, BL, Crawford, CG, Eriksson, C, et al. Psychological distress, depression, anxiety, and burnout among international humanitarian aid workers: A longitudinal study. PLoS ONE. 7, 1-13, 2012. e44948. Centers for Disease Control, NIOSH. Emergency Responder Health Monitoring and Surveillance (ERHMS). http://www.cdc.gov/niosh/topics/erhms/, 2013, (accessed March 18, 2015).

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Davis LE, Rough, J, Cecchine, G, et al. Hurricane Katrina: Lessons for Army Planning and Operations. Santa Monica, CA, RAND Corporation, 2007, pp. 1- 87. Department of Defence Instruction 6490.12,“Mental Health Assessments for Service Members Deployed in Connection with a Contingency Operation,” Department of Defence, Washington D.C., 2013. Dobashi, K, Nagamine, M, Shigemura, J, et al. Psychological effects of disaster relief activities on Japan ground self-defence force personnel following the 2011 great East Japan earthquake. Psychiatry. 77, 190198, 2014. Foa, EB and Meadows, EA. Psychosocial treatments for posttraumatic stress disorder: A critical review. Ann Rev Psychol. 48, 449-480, 1997. Ford, CV. Somatic symptoms, somatization, and traumatic stress: an overview. Nordic Journal of Psychiatry. 51, 5-13, 1997. Ford, L and Provost, C. Japan earthquake: Aid flows in from across the world. The Guardian, US Edition, 14 March 2011, http://www.theguardian.com/global-development/2011/mar/14/japanearthquake-tsunami-aid-relief-world, (accessed 18 Mar 2015). Fullerton CS and Ursano, RJ (eds.). Posttraumatic Stress Disorder: Acute and Long Term Responses to Trauma and Disaster. American Psychiatric Press., Washington, D.C., 1997. Goldmann E and Galea, S. Mental health consequences of disasters. Annu Rev Public Health. 35, 169-183, 2014. Harms, PD, Herian, MN, Krasikova, DV, et al. Report #4: Evaluation of Resilience Training and Mental and Behavioural Outcomes. The Comprehensive Soldier and Family Fitness Program Evaluation. http://csf2.army.mil/supportdocs/TR4.pdf, 2013, (Accessed 15 November 2013). Harville, EW, Taylor, CA, Tesfai, H, et al. Experience of Hurricane Katrina and reported intimated partner violence. Journal of Interpersonal Violence. 26, 833-845, 2011. Hobfoll, SE, Watson, P, Bell, CC, et al. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry. 70, 283-315, 2007. Holloway, J and Everly, GS. Mental health considerations for military humanitarian aid personnel. Int J Emerg Ment Health. 12, 193-198, 2010. Kaminsky MJ, McCabe, OL, Langlieb, AM, et al. An evidence-informed model of human resistance, resilience, and recovery: The Johns Hopkins’ outcomes-driven paradigm for disaster mental health services. Brief Therapy and Crisis Intervention. 7, 1-11, 2007.

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Mellman, TA, Kulick-Bell, R, Ashlock, LE, et al. Sleep events among veterans with combat-related posttraumatic stress disorder. Am Jour Psychiatry. 152, 110-115, 1995. National Response Team (NRT). Emergency Responder Health Monitoring and Surveillance (ERHMS). http://nrt.sraprod.com/ERHMS/, 2012, (accessed 18 March 2015). North, CS, Tivis, L, McMillen, JC, et al. Psychiatric disorders in rescue workers after the Oklahoma City bombing. American Journal of Psychiatry. 159, 857-859, 2002. Osofsky, HJ, Osofsky, JD, Arey, J, et al. Hurricane Katrina’s first responders: the struggle to protect and serve in the aftermath of the disaster. Disaster Med Public Health Prep. 5 (suppl2), S214-S219, 2011. Pfefferbaum, B, Schonfeld, D, Flynn, BW, et al. The H1N1 crisis: a case study of the integration of mental and behavioural health in public health crises. Disaster medicine and public health preparedness. 6, 6771, 2012. Reissman DB, Klomp, RW, Kent, AT, et al. Exploring psychological resilience in the face of terrorism. Psychiatric Annals. 34, 627–632, 2004. Reissman DB, Kowalski-Trakofler, KM, Katz, CL. Public Health Practice and Disaster Resilience: a Framework Integrating Resilience as a Worker Protection Strategy. In: Southwick SM, BT Litz, D Charney, MJ Friedman, eds. Resilience and Mental Health: Challenges Across the Lifespan. Cambridge University Press, Cambridge, 2011, pp. 340358. Ritchie, EC and Mott, RL. Military humanitarian assistance: The Pitfalls and Promises of Good Intentions. In Lounsbury, D and Bellamy, R (Eds.), Military Medical Ethics, Volume 2, Washington, DC: Office of the Surgeon General, Department of the Army, United States of America, 2003, pp. 805-830. Roberts, NP, Kitchiner, NJ, Kenardy, J, et al. Systematic review and metaanalysis of multiple-session early interventions following traumatic events. Am J Psychiatry. 166, 293-301, 2009. Rundell, JF and Ursano, RJ. Psychiatric Responses to Trauma. In: Ursano RJ and Norwood, AE (Eds.). Emotional Aftermath of the Persian Gulf War: Veterans, Families Communities, and Nations. American Psychiatric Press; Washington, DC: 1996. pp. 43-81. Schreiber, MD, Yin, R, Omaish, M and Broderick, JE. Snapshot from Superstorm Sandy: American Red Cross mental health risk

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surveillance in lower New York State. Ann Emer Med 64(1), 59-65, 2014. Tannenbaum, SI and Cerasoli, CP. Do team and individual debriefs enhance performance? A meta-analysis. Hum Factors. 55, 231-245, 2013. University of California, Irvine. Disaster Mental Health Program. http://www.cdms.uci.edu/disaster_mental_health.asp, 2015, (accessed 30 March 2015). Ursano, RJ, Goldenberg, M, Zhang, L, et al. Posttraumatic stress disorder and traumatic stress: from bench to bedside, from war to disaster. Ann N Y Acad Sci. 1208, 72-81, 2010. van Kamp, I, van der Velden, PG, Stellato, RK, et al. Physical and mental health shortly after a disaster: First results from the Enschede firework disaster study. Eur J Public Health. 16, 252-258, 2006.

Corresponding author: Curt West, MD, CDR MC USN Assistant Professor of Psychiatry Assistant Chair, Department of Psychiatry Uniformed Services University of the Health Sciences Scientist, Center for the Study of Traumatic Stress E-mail: [email protected]

GENERAL PRINCIPLES IN THE PSYCHOSOCIAL MANAGEMENT OF DAMAGED PEOPLE IN DISASTERS MOTY BENYAKAR IBEROAMERICAN AND ASIA-PACIFIC ECOBIOETHICS NETWORK FOR EDUCATION, SCIENCE AND TECHNOLOGY, THE UNESCO CHAIR IN BIOETHICS, SECTION ON DISASTER PSYCHIATRY OF THE WPA

CARLOS R. COLLAZO SECTION ON DISASTER PSYCHIATRY OF THE WPA, CHAIR OF PSYCHOPATHOLOGY OF EL SALVADOR UNIVERSITY, BUENOS AIRES, ARGENTINA

Abstract During the last few decades, mental health professionals in ever-increasing numbers have been responding to the needs of citizens after natural or man-made disasters. Their work has increased the awareness of the number and variety of injurious events affecting human mental health and has also highlighted the necessity to find a conceptualization to understand the complex biological, psychological, interpersonal, behavioural and social reactions to disasters. As the United Nations have stated, it is possible to significantly reduce human suffering and economic losses from natural and man-made disasters. This can be achieved by the appropriate use of the scientific and technological advances of recent years coupled with the field experience acquired during wars and catastrophes. Professionals are able to employ well-known knowledge of reactions to trauma and loss such as grieving, stress-reaction processes and coping. But we must bear in mind that all this knowledge is to be used in a way that requires anticipatory planning and preparation in order to be effective and efficient during and after the

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disaster. Professionals must be aware of some paradoxes in psychological assistance during disasters, which are presented in this chapter. Research in this field is extraordinarily difficult; it is plagued with many methodological problems, including difficulty in obtaining adequate controls, getting both pre- and post-disaster measures, and many intervening variables. The clinically trained professionals must face a novel situation that forces them to reconsider not only their understanding of how disruptive events affect the individual but, also, to develop new intervention techniques that usually combine inputs from many disciplines. Special populations such as children, pregnant women, people with disabilities and old persons need special intervention techniques. Different religious and cultural outlooks must also be taken in consideration. The core of mental health interventions in disasters is to deal with the pain of the damaged person while avoiding fixing him/her in the role of victim. This chapter offers a broad approach within which to understand and address mental health problems that ensue from disaster situations caused by nature and/or human will. The characteristics of threatening and disorganizing environments, the psychological suffering they cause, and the challenges increasingly faced by therapists at the meeting point of social and individual factors present a complex and challenging task. How do we deal with the consequences that accompany implosions from the external world into the human psyche? How can we handle a situation that casts therapists and victims into the same psycho-social threat zone? The answers to these questions have conceptual as well as practical implications (Benyakar et al., 2009). How to measure time in post-disaster intervention? In seconds, minutes and hours. Not in days, weeks or months. Shall those affected request a consultation? No!

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Where should the service be provided? Wherever people are: schools, churches, shelters, community centres, etc. Basic axiom of intervention in disasters: We must attend to normal people, who are reacting normally to a very abnormal situation.

Ten Paradoxes in Psychological Assistance in Disasters 1. The pathogenic character of a disruptive situation lies in the situation itself, external to the individual, and not in his/her biological or psychological condition. 2. As assisting and assisted persons are under the same threats, it is especially difficult for the therapists to establish a proper therapeutic distance. 3. Trained teams have to be prepared to act in situations in which the character, time and place of occurrence we cannot anticipate. 4. Almost everyone undergoing a disruptive event is a “damaged person” but not necessarily a patient. The presence of hidden and manifest psychological injuries needs to be checked. 5. In helping “damaged” people we must avoid their victimization. From a psychosocial point of view a “victim” is a person whose subjectivity becomes and remains trapped by a given situation. “Victims” are usually produced by the need of society to guarantee the memory of the “harming event”. This is the result of an unconscious process. As assisting professionals we must help “damaged” people to recover their subjectivity by getting rid of the role of “victims”. Victimization is the main obstacle for rehabilitation (Benyakar, 2003). 6. Post-traumatic Stress Syndrome is the only diagnosis we have for psychic injuries due to disasters, when in disasters the diagnostic spectrum is so broad. We agree that PTSD has opened up the possibility to determine the pathogenic impact of the environment on the psyche allowing us to differentiate circumstantially damaged people from those who present endogenous pathologies (American Psychiatric Association, 1994). Yet, at present, PTSD is a non-specific syndrome placing stress and trauma under the same diagnostic category thus failing to acknowledge the variety of psychic impacts due to disasters (Crocq, 1996; Shalev, 2000). We prefer to refer to the impacts of external events on people’s psyche as “Disorders by Disruption”, a category encompassing various psychological

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manifestations such as stress, traumatic psychic experience (erlebnis), depression, different types of anxiety, etc. Identified by a team of Argentinean, Spanish, Israeli and US researchers, Anxiety by Disruption (AbD) is a new syndrome frequently found in disruptive environments caused by social and/or institutional disintegration or by the presence of a constant threat such as terrorism, or economic disasters. It specifies features included in PTSD more precisely and highlights others not considered in that diagnosis (Benyakar et al., 2002). 7. Although for each physically injured individual during a disaster there are more than 200 psychologically damaged people, the ratio between personnel to assist the former and the latter is 20 to 1 (McFarlane 1989; Ursano et al., 2000; Susser et al. 2002). 8. The disorganizing effects of disasters encompass also those who assist. Among them there exists a tendency to gather in small groups who can even rival each other as if unconsciously acting out the environment’s disorganizing effects and menace. 9. There is a non-proportional relation between economic resources and the amount of human resources in the mental health field. 10. Psychological symptoms are given less attention although they produce very important sequels. These paradoxes lead to the development of 10 key concepts on which psychological assistance during disasters should be based.

Key Concepts Ten W’s 1. Warding off Warding off psychological instability. Despite the unpredictability of disasters, populations can be prepared psychologically in advance to meet their impact (Cohen, 1999). People living under constant threat (especially that of terrorism) show a tendency to develop mechanisms such as denial, which leads to the belief that the menace will never be effective or will not affect them directly. Based on the conviction that strong psychological and physical preparation helps people to accept reality, together with Zohar, Rubinstein and Boaz Tadmor, we have developed the concept of “mental immunity”,

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emphasizing the development of defences so that attacks can be thought of as possible (Benyakar, 2003). Mental immunity means that the individual can: a) Recognize the menace and its characteristics. b) Use psychological capacities to cope with threatening situations. c) Take preventive measures in case the threat becomes a fact. 2. Why Why are mental health professionals necessary during a disaster? They are needed because disruptive situations have the potential to cause traumatic psychic experience (erlebnis) or other pathologies. Therefore, one function of professionals is to serve as a bridge between the disruptive external world and the inner world of each person. As the outer world is perceived as harmful, therapists must present themselves as part of that same world, but in a protective role. In this way they will hopefully prevent permanent damage in the individual’s relation with the outer world. Interventions seek to diminish pain and avoid pathology by allowing elaboration. Another function is to screen for pathological reactions. A third one is to decide what kind of interventions should be carried out. The final function is to provide adequate interventions to actual needs, in the right time and place (Lopez Ibor, 1987). 3. What What is our objective while assisting during a disaster? In a collapsing environment, endangered or actually harmed psychological abilities for processing are the core of our interventions (19–20). It is generally considered that, in such a situation, verbal expression of body sensations and feelings is crucial. There are two concepts to be stressed: a) The recovery of the individual’s subjectivity. b) Maintenance of the ability to elaborate the inner-outer world relationship. Therapists should be fine-tuned to the timing, place and manner of the intervention and highly sensitive to cultural characteristics.

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4. Who Who must intervene to ensure people’s psychological stability? Given that the ratio between available practitioners and people in need of mental health care is so inadequate, the population as a whole must become a resource. Mental health professionals play an important role in recognizing people’s abilities to assume responsibilities (especially among prominent members of the community such as religious leaders, educators, etc.) and in building a network including their own selves as health agents, and coordinating it. 5. Whom Whom should we assist? During disasters, mental health care is usually given to those who demonstrate their needs in a manifest way. Yet we need to be sensitive in order to take notice of those who remain silent, apart or make-believe that nothing has happened to them. Some groups are special targets: children, the elderly, pregnant women, disabled people, etc. and members of the population at risk due to psychological weakness and lesser capacity to deal with threats (Benyakar, 2002). 6. Whose Whose responsibility is at stake? This question concerns individuals and social institutions in two different aspects: a) Their mere presence makes human beings subjectively responsible. Even though we may have no relation at all with the occurrence of external facts, we are still inevitably responsible for our reactions to them. The conflict between fate and necessity is essential to this drama (25–26). b) Communities must have institutions accountable socially and legally for disasters. That is, not only who is “guilty” but who is in charge of administering assistance. A group of political authorities, institutions and other agents as “legitimating recognizers” are essential in providing assistance (Collazo, 1985).

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7. When When must we intervene? Intervention during disasters runs in four stages: Pre-impact phase: actions are directed towards building “mental immunity” in all members of the community so that they will become capable of recognizing the nature and importance of the menace, organizing available resources and acting properly and according to the circumstances. Impact phase: Actions are directed to evaluate the impact of the event on the population and to respond to urgent and acute needs. Immediately after the occurrence of the event: actions are directed to evaluate individual responses and elaborate processes to prevent the installation of pathogenic mechanisms and to respond to emerging pathologies (Crocq et al., 1998). Assistance in the long-term: approximately six months after the event, actions are directed to provide treatment to people that need long-term assistance. Strategies for building “mental immunity” should be reinforced as a preventive measure for the future (Solomon et al., 1991). 8. Where Where do we have to intervene? Frequently, mental health professionals will need to be flexible and create adequate therapeutic milieus even in completely inadequate environments. Any place can become a suitable place for therapy, for example in the open, under the shelter of a tree. 9. Ways In which ways are we going to intervene? Treatments can resort to individual, family or group therapy. Yet professionals must stick to the core of their theoretical frameworks while adapting techniques to the circumstances. Having to be technically flexible, our theoretical frameworks will guide us especially in such confusing circumstances. During disasters, people are not aware of the

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psychic damage they may be suffering. Therefore, they do not demand treatment. This is why we postulate the concept “intervention by presence” instead of “by demand”, which means to be present offering direct care in different places and moments. 10. Wholeness Wholeness means an integrative approach based on the previous nine W’s and on a consistent vista of the problem, its analysis, the ways to intervene and the organization of assistance. The complexity of disasters requires not only the integration of psychiatric and psychological aspects but also knowledge about social, political, economic and cultural processes.

Psychosocial Management People must have access to social and mental health services to reduce mental health morbidity, disability and social problems. Social interventions have secondary psychological effects and vice versa. Standards include the following criteria and indicators: 1. When displacement happens, shelter must be organized with the aim of keeping family members and communities together. 2. To be sensitive on where to locate religious places, schools, water points and sanitation facilities. The design of settlements for displaced people includes recreational and cultural space. Social intervention indicators (Sphere Project, 2004): 1. During the acute disaster phase, the emphasis is on social interventions. 2. People have access to an ongoing, reliable flow of credible information on the disaster and associated relief efforts. 3. Normal cultural and religious events are maintained or reestablished (including grieving rituals conducted by relevant spiritual and religious practitioners). As soon as resources permit, children and adolescents have access to formal or informal schooling and to normal recreational activities. 4. Adults and adolescents are able to participate in concrete, purposeful and common-interest activities, such as emergency relief activities. 5. Isolated persons, such as separated or orphaned children, child combatants, widows and widowers, older people or others without

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their families, have access to activities that facilitate their inclusion in social networks. A structure for psychological interventions is proposed in which there is psychological first aid, care for urgent psychiatric complaints and community-based psychological interventions. 1. Individuals experiencing acute mental distress after exposure to traumatic stressors should have access to psychological first aid at health service facilities and in the community. 2. Care for urgent psychiatric complaints is available through the primary healthcare system. 3. Individuals with pre-existing psychiatric disorders continue to receive relevant treatment, and harmful, sudden discontinuation of medications is avoided. 4. Basic needs of patients in custodial psychiatric hospitals are addressed. 5. If the disaster becomes protracted, plans are initiated to provide a more comprehensive range of community-based psychological interventions for the post-disaster phase.

Interventions focused on family and community Professionals and members of rescue groups are an important aid when disasters are great, but they can’t replace the natural networks of support and help, especially professional trained teams. Family-centred interventions are very important. It is crucial to encourage the support and assistance in the field of family. Families must be helped to talk about what happened to them, their experiences, their losses and their feelings. They should be encouraged to restart most normal activities as soon as possible and to ensure a sense of continuity, despite disruptive events. We must be aware of the fact that the level of homeostatic balance that the family group had managed is altered by the disruptive event and we must help the family to find a new balance to decrease the internal stresses of the group and avoid the emergence of symptoms in its members. Damaged people who are alone should be considered high risk for the development of psychopathology.

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When social networks are severely damaged and can’t keep people in their natural and social environment, it becomes necessary to encourage new community and social activities. Group meetings in which those affected can discuss what happened and the steps to reorganize themselves are important elements to achieve these goals. Also, social rituals such as mourning ceremonies, for expressing solidarity and collective unity, are very useful in these circumstances. Social disorganization and loss of resources will have psychological impacts and, therefore, the potential for development of psychopathology. Mental health specialists should advise the natural leaders of the community and the media on how to proceed to strengthen community ties. At this point conflict may arise between the approach of the specialist and that of political leaders, journalists, etc. (C. Collazo, 1985b). Understanding and alliance with opinion leaders is important. Their attitudes have a huge impact on the community and should be exploited to achieve our goal: preserving mental health and preventing the victimization of people. Special programmes with a coherent and sustainable aim have to be developed. This is what has been done by Dr José Thomé in Argentina who created a way of working with leaders. He named it ERR (in Spanish: Experiencia Relacional Reconstructiva, in English: Relational Reconstructive Experience). This programme was carried out in the Florianopolis disaster. It was used to aid the damaged population, research confirmed (J Thomé, 2014).

“Victims” or “damaged people”? We propose to drop the word “victim” to refer to those who have suffered psychological damage and replace it by “damaged person”. The use of this term does not minimize the essence and the intensity of suffering. We believe that the word “victim” disowns the subjectivity of each person because it ignores its uniqueness and “uses” the person in the sense that the person performs a social function (to preserve the collective memory). Victimization is one of the most dangerous psychological problems, because it is a way of encouraging loss of identity and the development of symptomatology.

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The social role of the “victim” Society needs to keep the community memory of disruptive events that have injured the wellbeing of different groups or to the community as a whole. It is necessary that the directly damaged people and witnesses narrate again and again what happened. This is an essential attitude to avoid the repetition of those kinds of disruptive events. Paradigmatic cases are the survivors of the Nazi genocide (the “living museums”). Their function is to counteract denial of what happened in the Second World War. The real victims are those who are dead, and it is a personal and social function to sustain their memories. This is a different process from that of survivors. Different articles recognize the importance of rejecting the use of the word “victims”, proposing the use of the word “survivors”, but not all survivors are damaged people. That is why we prefer to use the term “damaged people” to emphasize the suffering of particular survivors. One of the functions of victimization is to strengthen the links between the members of the community. This phenomenon, in some cases, appears when the tendency is for confrontations to develop between different groups of society. The place of the victim creates respect, and it becomes a central symbol in the society, giving it special rights. This sounds like a very human attitude on one hand, but on the other it is a way of generating secondary gains that can promote dependence and psychological pathology. Therefore, the “victim” is not the product of the actual damage he or she suffered, but a product of the social process of “victimization” that involves assigning the status of “victim” to persons who have suffered damage, considered by the group to which they belong as an attack on any value that the group wishes to preserve or impose. To sum up, unlike “damaged people”, “victims” are a painful “necessity” of societies because: 1) it is useful as a support to keep the social memory of certain facts; 2) it expiates individual and social guilt; 3) it relieves the agony caused by suffering, because it allows location of the “evil” in the “doer of the damage” and confines its effects to some sector of society that is indicated as the “victim” or “scapegoat”, and 4) it supports group identities, often bringing together individuals by following a “common cause” or “political flag”.

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From the “victimized” person’s side, the process of suffering damage is usually as follows: until the event, the “victimized” saw himself as a normal person who could work, love, play and have friends. From the moment that he suffered the psychic damage, these abilities are affected and he begins to suffer. From his understanding of what happened, his suffering was caused by the external world: something came from outside and harmed him. This is not what happens in other psychological suffering, in which the person feels that the source of suffering is within oneself, and it is related to something that could not be elaborated on (though in personality disorders, the person tends to locate the problem in the environment). Knowing that the damage came from the external world encourages damaged people to claim that either one who inflicted the damage or one who should have avoided it (a group or society in general) should repair, compensate or at least relieve their suffering. An example of this is the compensation mechanism, in which society is considered responsible for all the damages suffered by its members, as this damage has been inflicted on the people that society is supposed to protect. Another aspect that we consider relevant is to point out that when benefits, perks, facilities or special compensation are conferred upon the damaged people, society gives them the possibility to take advantage of a secondary gain produced by being considered a “victim”. In this way, we encourage the damaged people to crystallize themselves in that role for the rest of their life, which means to fit to this definition of “victim” and leave aside the possibility of living a healthy life. This is what makes the decisions about giving and accepting compensation so complex. Professionals must face a novel situation that forces them to reconsider not only their understanding of how disruptive events affect the individual but, also, to develop new intervention techniques that usually combine inputs from many disciplines. The scope of mental health interventions in disasters is to deal with the pain of the damaged person while avoiding fixing him/her in the role of victim.

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References Benyakar M, Collazo C, Fariña JJM. “Prevention, intervention and reconstruction” in Niaz U. (eds) The day the mountains moved, Sama Editorial and Publishing Services, Karachi, 2009, pp 151-157 Benyakar M. Disruption: Collective and Individual Threats. Buenos Aires, Biblos, 2003 Benyakar M, Collazo CR, de Rosa E. Anxiety by disruption, 2002. http://www.psiquiatria.com Benyakar M. Aggression of Life and Violence of Death. The Infant and His Environment. 2002. http://w.w.w.winnicott.net/patron_esp.htm Cohen R. Mental Health for Victims of Disasters. Instructors Guide. PanAmerican Health Organization, Washington, DC, 1999 Collazo C. Psychiatric casualties in Malvinas war: a provisional report. In Pichot P., Berner P., Wolf R., Thau K. (Eds.), Psychiatry: The State of the Art, Vol. 6, pp. 499–503. Plenum Press, New York, 1985 Crocq L. Critique du concept d’etat de stress post-traumatique. Perspectives Psychologiques.vol. XXXV, Nº 5, 1996 Crocq L, Doutheau C, Louville P, Cremniter D. Psychiatrie de catastrophe. Reactions immediates et differees, troubles sequellaires. Paniques et psychopathologie collective. In Encyclopedie Medical-Chirurgicale, Psychiatrie, 37-113-D-10, Elsevier, París, 1998 López Ibor J J. Social reinsertion after catastrophes. The toxic oil syndrome experience. Eur J Psychiatry, 1: 12–19, 1987 McFarlane AC. The treatment of post-traumatic stress disorder. Br J Med Psychol, 18: 354–358, 1989 Shalev AY. Post-traumatic stress disorder: diagnosis, history and life course. In: Nutt D, Davidson J, Zohar J. Editors. Post-traumatic Stress Disorder. Diagnosis, Management and Treatment. Dunitz, London, 2000. p. 1-12 Solomon Z, Laor N, Weiler D, Muller U, Hadar O, Waysman M, Koslowsky M, Benyakar M, Bleich A. The psychological impact of the Gulf War: a study of acute stress in Israeli evacuees. Arch. Gen. Psychiatry, 50: 320–321, 1991 Sphere Project. Humanitarian charter and minimum standards in disaster response. Oxford: Oxfam Publishing, 2004. Susser ES, Susser M. The aftermath of September 11: what’s an epidemiologist to do? Int J Epidemiol, 31: 719–721, 2002 Thome J. Modelo de Intervención en crisis y desastres, basado en la Experiencia Relacional Reconstructiva (ERR). – Intervention Model in crisis and disasters, based on the Relational Reconstructive Experience

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(RRE). University of Salvador, Psychology Department. PhD dissertation, 2014 Ursano RJ, Fullerton C, McCaughey BG. Trauma and Disaster. Cambridge, Cambridge University Press, 2000.

Corresponding Author: Moty Benyakar, MD Professor of Psychiatry President of the Iberoamerican and Co-President of the Asia-Pacific Ecobioethics Network of Education, Science and Technology. President of the Section on Disaster Psychiatry of the WPA International Director of the IBIS Buenos Aires, Argentina E-mail: [email protected]

LESSONS FOR MENTAL HEALTH EDUCATION LEARNED FROM THE 1999 MARMARA EARTHQUAKE BULENT COSKUN KOCAELI UNIVERSITY, ISTANBUL, TURKEY

Abstract In this paper, experiences in utilizing recordings of a major disaster for mental health education purposes are described. The 17 August 1999 Marmara earthquake had a catastrophic effect on Turkey with about 17 thousand deaths and many more injured and displaced. The Psychosocial Solidarity Unit was established by the Kocaeli University soon after the event, and video recordings were made of most of the relief activities. The experiences with use of these videos will be described in six sections: a) an overview of health and mental health services, highlighting deficits; b) views of the environment; c) views of local service providers; d) views of visitors; e) views related to service users; and f) how the videos were used. Breadth of the affected area, lack of preparedness of the healthcare system and lack of coordination were the major problems. Successes and failures in managing the aftermath of the tragedy are discussed with reference to extant literature. Recommendations are presented for future study of major disasters.

Introduction Benjamin et al. (2011) have defined disaster relief as “an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made”. To improve strategies in handling the consequences of all kinds of disasters, people

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should learn from their own experiences and what others have gone through. There are lessons to be learned from almost all disasters (Sederer et al. 2011). Learning is facilitated by access to records of critical incidents during and after disasters, reactions to such events and records of measures to mitigate the negative consequences. These records may be in the form of official documents about the events; communications; observations; or in the form of photographs, video or audio recordings. Video recording of certain public and private sites is currently a routine practice for security reasons. After the Marmara earthquake, which took place in Turkey in 1999 (with about 17 thousand dead and many more injured), in addition to huge amounts of paper documentation of what happened and what kinds of services were implemented, photos and video recordings were made as well, including some by the author, an amateur videographer. Although not originally intended for this purpose when they were made, these recordings became valuable educational resources for training medical staff (as part of in-service training programmes), raising public awareness about disaster preparedness, and educating medical, nursing and social work students, psychiatry residents and students in a Masters programme in psychological trauma. In retrospect, other factors may also have motivated the creation of these videos. They became a kind of message for tomorrow, a tool for evaluation, a type of proof of what people experienced and a reminder of the bitter taste of a certain time, certain people and certain places. Consent was obtained before making recordings and the camera was not hidden (actually the cameras of that period for amateurs were so large that it would not have been easy to hide them even if a hidden recording would have been desired). The recording process was explained as documentation of the situation and as a record of human services for further evaluation. The recordings were edited into short clips of a few minutes each. The same video could thus be presented in different situations depending on context and audience expectations. For example, video clips about the affected setting (buildings, roads, etc.) could be used at meetings with decision makers to draw attention to difficult situations; with service providers during a discussion about how to work with trauma victims or in dangerous conditions; or in educational settings such as in course or at a congress to illustrate disaster management and recreate the atmosphere of the working area.

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Utilization of the Video Recordings The recordings have been grouped into six sections: a) an overview of health and mental health services, highlighting deficits; b) views of the environment; c) views of local service providers; d) views of visitors; e) views related to service users; and f) how the videos were used. There is some overlap between sections and, as explained below, the utilization of the material was not limited to these topics. Any clip could be used for any purpose deemed necessary. Not every important event could be recorded. In addition to the actual recordings, some observations and memories, most of them highly emotional, were used during educational sessions.

A. Health services, strengths and weaknesses Although the title mentions strengths and weaknesses, more emphasis is given to the weaknesses or areas “in need of development,” for in the author’s opinion, they deserve more attention. On the positive side, the Marmara disaster was met by an immediate outpouring of support from local, national and international bodies. Governmental and nongovernmental support was at the highest level but a serious lack of coordination shaded the brightness of all these efforts. A young boy called these supportive approaches “solidarity” during a field visit in the first days of the event. The immediate response of the system and the sincere motivation of people to help were the principle positive factors. The vignette about the young boy above is an example of a situation that could not be recorded (we did not have the video recorder at that early phase), but his words had a great impact on encouraging our studies. It is well known that lack of disaster relief coordination is a world-wide problem (López and Santana, 2011) in all developing areas. As KhoramManesh et al. (2006), put it: “Although disasters and major incidents are difficult to predict, the results can be mitigated through planning, training and coordinated management of available resources.” Related to lack of coordination during disasters, Zoraster (2006) gives examples of problems in leadership and accountability, diverging goals of the responding agencies and weakness in coordination, in sharing his experiences about the South Asia tsunami. Lee and Low (2006) underline the importance of collaboration with local authorities to meet the needs of local governmental and non-governmental agencies. As mentioned above, lack

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of relief coordination has been the major problem in many disasters around the world, and the Marmara earthquake was no exception. Although Turkey is a country in which disasters, including earthquakes, are not infrequent, the responses to such events have almost always been led by the Red Crescent which focuses on sending in first aid material, tents and food to disaster areas. Problems related to coordination were almost always the most common characteristic of organizing the local, regional, national and international contributions. The Marmara earthquake, which affected the largest geographic area on record in Turkey, became a turning point for all disaster relief organizations in the country (Gokalp 2000; Aker, 2006). As a positive outcome of the disaster, there have been several movements for developing and improving disaster preparedness. Twelve years after the Marmara earthquake, a team from Iran, witnessing the Van–Ercis earthquake in 2011, observed that “the extent of damage was relatively limited due to recent national experiences and modernization of infrastructure in Turkey” (Zare and Nazmazar, 2013). However, the authors also criticised the performance of government organizations responding to the event. These observations are consistent with the view of Turkish experts – there has been progress but much improvement is still needed (Aker and Karakilic, 2014). During the early phase of the Marmara disaster, there was duplication of services in some places with relatively less relief in others. Uncontrolled amounts of food were sent to the area causing some to have to be thrown away. Some people asked for or received more food than they could consume. Not only food was collected “to be used later, when needed” but also other material such as tents, blankets and clothing. Fearing they might not receive the necessary material at the right time, some individuals coped by stockpiling supplies for the future. Though less frequent than those who stockpiled supplies for personal use, it was also believed that others may have stockpiled material for later sale. A psychiatrist working in the area would later compare “the influx of more mental health professionals than necessary” and the influx of more “cases of tomatoes and other vegetables” to the area than needed. There were good intentions but almost no coordination.

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In summary, the lack of preparedness of the authorities, the severity of the event and the breadth of the affected area were some of the main obstacles to effective relief efforts. Several photographs and video recordings of the situations mentioned above enriched observations and memories, and were helpful in reviewing the disaster response for educational purposes. Training has been systematically developed to improving preparedness and mitigate the negative effects of future disasters – including establishment of an MSc programme at the Kocaeli University and integrating topics on psychosocial aspects of trauma into the educational curricula in the Psychiatry Department of this University.

B. Environment, buildings, tents, etc. The recordings made of the environment included collapsed buildings, broken cars, offices with cracked walls, and temporary offices in tents for various work places. The Rector of the University established a tent office in the garden of the main university building. Psychiatric interviews took place at chairs and tables under trees. These striking visual materials were used often. Scenes of a disaster may have serious effects even at places far removed from the actual disaster area. Sugiura et al. (2013) found that the prevalence of insomnia increased even in regions at a considerable distance from the epicentre during the east Japan earthquake. The effects of TV broadcasts may have played an important role. Disaster scenes may evoke different feelings in different people at different times and in different settings. We had heard complaints concerning people locked in front of their televisions, moving from one channel to the next to trace rescue efforts, watch interviews with survivors sharing their feelings or authorities offering their experiences. On the other hand, some said they tried to avoid any reminder of the event. The attitudes of the same people might change during different phases of the experienced trauma, either within the disaster area or watching it unfold on TV from a remote area.

C. Service providers, their interventions and interactions Video clips were made of both formal and informal activities and of service provider meetings. In the initial phase, only the staff of the Psychiatry and Child Psychiatry Departments of Kocaeli University were

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present in the area of the disaster. After the first few days other experts (visitors) arrived. Some were brought in by the Ministry of Health and others came as volunteers mostly through national associations of mental health professionals (psychologists, psychiatrists, nurses and social workers). There were international supporters as well. The video recordings about the contributions of these visitors will be discussed in the next section. Here we will focus mainly on local groups. The Psychiatry and Child Psychiatry Departments led the early phase activities. In a few weeks a mobile unit was established – the Psychosocial Solidarity Unit – which would organize visits to different parts of the impacted area to meet and work with other mental health workers including those in the neighbouring provinces (Yalova and Sakarya). Initially staff used their own cars for mobile relief activities, but later a few minibuses provided by an automotive company were used. The Psychiatry Department conducted psychiatric interviews at chairs and tables, serving as outpatient clinics, near the tents where the health professionals were living – working, resting, sleeping. The health personnel were over-involved in their tasks and were not aware of their own fatigue. In one video, two psychiatry residents are seen working on patient files in a tent office (which at night became their tent home). The author asked them for their observations. A bitter smile appears on the face of one of the residents pointing to the inside of the tent as he says “the conditions speak for themselves”. Several planning and assessment meetings of the Psychosocial Solidarity Unit and briefing sessions for the local decision makers (Governor, Mayor, Rector and the Officer of the local army branch) were also recorded. These documents were very helpful in tracing the process and producing educational material about how services were delivered, including both successes and failures. Some details, easily missed during the actual interactions, were recognized while reviewing the videos. One educational aspect of the briefing sessions was in observing the reactions of the decision makers – their gestures while listening and their questions and remarks about the presentations. These materials were especially useful for students in the psychological trauma Masters programme. Another observation about the interactions of the local staff had to do with their interpersonal relationships. Almost all existing conflicts among

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response personnel seemed to be dissolved or wiped out, especially in the immediate aftermath of the event. But after some time, during the normalization process, it became clear that those feelings about previous conflicts had been temporarily frozen, not eradicated, demonstrating once more that catastrophes only temporarily unite people. An anecdote may also be added about an interaction between mental health professionals and the traffic police: One day, one of the minibuses mentioned above was en route to a field visit. At a point where traffic was moving slowly, a traffic policeman saw the name, “Psychosocial Solidarity Unit”, written on fabric in the front of the vehicle and indicated to the staff in it with a smiling face that they, too, needed psychological support. This could have been the usual joke people make to mental health professionals, but it could also be taken seriously for it was not an easy burden that police officers were carrying on their shoulders. We were so involved with the people in the tent cities and the needs of the health personnel that we could not respond to the needs of those police officers, at least in our unit. Takahashi (2014) says, police officers, fire fighters and self-defence forces may all be neglected after disasters – this is something we should keep in mind.

D. Visitors and their interactions There were three types of professionals who visited the disaster area: a) professionals coming to the area to take pictures of interesting incidents or have their pictures taken in front of the tents, b) professionals coming to donate expertise during their limited time, and c) professionals coming to the area after getting in touch with local experts and assessing the needs and potential local capacity. Some of this last group never came to the area but were sensitive to the needs and offered their support by advice or sending necessary equipment. We never met the people who sent in toys for the children or the automotive industry executives who sent minibuses and recruited drivers for months for our mobile services. They avoided the limelight but shared their property and facilities with people in need. During the days immediately following the earthquake, there were interesting observations about the interactions between local personnel and those sent from other provinces by the Ministry of Health. The rapidity with which decisions about duty visits were made produced organizational difficulties. Some visiting health professionals were experienced in

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disaster work and knew what to do. Others were not so lucky. Some health personnel had their own problems back at home, but did not have a chance to discuss this before being dispatched to the earthquake area. These individuals were frustrated with their situation and looked forward to leaving the area as soon as possible. There were other examples of attitudes as well: Some local staff were very friendly toward visiting personnel and did their best to provide comfort to visitors – a symbolic gesture might be serving tea to them. On the other hand, some local staff felt uneasy about the presence of the “guests” and took offense at the slightest comment about local conditions. In such cases visiting professionals would also become frustrated. After observing such interactions (especially about the diverse groups) in the garden of the state hospital one night, the author tried to encourage conversation between the local and visiting groups about the psychosocial difficulties of the patients and their family members. That topic seemed to unite the interests of the different groups, at least for the time observed. Although we lack recordings of interviews with such professionals, the memories are still vivid. The importance of working together with local professionals is also a topic which appears in the literature. Campos-Outcalt (2006) says, “Physician services are most effectively provided in collaboration with, or as part of, an organized local response agency”. Here the critical word seems to be “organized”. In our case none of the partners were organized. In the future, we should be prepared to organize local agencies for visitors who come to work together. During the 2011 earthquake in Van and Ercis, some of these same shortcomings were covered up (Besiroglu, 2014). The literature shows that following major disasters, local human forces are mobilized for psychosocial support – teachers, primary health care workers and emergency department professionals are typically among those mobilized, creating a need for training to improve their skills. In a special programme created in Israel in the aftermath of the war in Lebanon, teachers worked at schools with traumatized children. Children participating in the programme had significantly decreased symptoms when compared with a control group. The authors emphasized the importance of teachers as “valuable cost effective providers for clinically informed interventions after mass trauma and disaster” (Wolmer et al., 2011).

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Well organized programmes for teachers were implemented after the Marmara earthquake by national and international organizers. UNICEF, in collaboration with local officers of the Ministry of National Education, organized an in-service training programme for a group of teachers and psychological counsellors about how to manage student problems after disasters. In another positive outcome of the Marmara disaster, the participants in these programmes later took part in the response to other national disasters. However, apart from the positive aspect of the in-service training having been put to good use later on, there was also an unforgettable negative incident during that programme. A professional visiting from abroad inadvertently insulted the local professionals. His negative attitude was an excellent example of what not to do in situations like this, at any time or place. Invited to give a lecture, the consultant, a supposedly experienced specialist in disaster studies, used overhead transparencies to illustrate his speech, since computer presentations had not yet become popular. The presentation was simultaneously translated from English to Turkish. Probably due to dyslexia, the speaker had difficulty in placing one of the transparencies on the overhead device in the proper position for the text to be read correctly. After several tries he left it as it was, saying that “it would not matter for them at all!” with a condescending attitude. This attitude was far from respectful to the listeners. The video recording of this belittling act was shared with other experts and especially with people in decision making positions at national and international organizations as a reminder to review their criteria in selecting and preparing experts to be sent to disaster areas.

E. Service utilizers, survivors… During the first few days, the author and the team at the Psychiatry and Child Psychiatry Departments of Kocaeli University had intended to observe, to listen and to assist survivors in talking about personal feelings. At that point, most of the victims were occupied with food and shelter issues, not with their losses. Even those facing loss were busy with the physical aspects of their situation rather than the emotional side. After losing hope about rescue efforts, their attention was focused on burying the dead or problems in the hospital – there seemed to be little room for feelings at that moment. Of course, there were occasions in which feelings were very much on the scene. Some received psychiatric help while others postponed it.

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The author and his wife, a child psychiatrist, had paid a field visit to one of the affected areas just a few days after the earthquake. People were spending days and nights in open areas, mainly in the parks, because it was unsafe to enter their houses – even those which did not seem to have serious problems. The adults made conversation while the youngsters played games. The main topic for the adults was the abuse of food that had been brought in with “others” getting more than they needed and throwing it away. The youngsters moved from topic to topic, such as the games they played, or the difficulties they had in sleeping. A week later, the same psychiatrists returned to the area. The youngster who had talked about his sleep difficulties approached the visitors and said he was much better. He said he got well because of the “solidarity” he felt in the environment and the talks he’d had on the previous visit. Following the little boy’s lead, the psychosocial working group was thus named the “Psychosocial Solidarity Unit”. One of the ways to struggle with trauma is to try to search for opportunities in the devastating effects of disasters. It may not be easy for victims to see any opportunities in the early phase of a disaster. But after the shock abates, especially with the help of supportive activities, a broader view of the situation may yield new perspectives for the assessment of the experienced losses and opportunities which can help the recovery process. Local mental health workers were also victims of the disaster with their own personal and familial issues to solve and people looking to them for care. A wonderful example from a couple working on the Kocaeli team had to do with their 10-year old child. Both parents had to work for the Psychosocial Solidarity Unit but they did not have a place to leave their child. Many toys had been sent to hand out to children in the area, following a request from the Child Psychiatry Department. An innovative solution was found in which the child of this couple on the professional team was recruited as a consultant for selecting toys to be disseminated. He was truly an expert in toys and games, much more so than any adult on the team, doing his job very seriously and with great pleasure. Clips showing him separating the toys or suggesting which toy might be suitable for which age child and also taking notes about the dissemination process were very helpful as an example of transforming difficulty into opportunity.

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F. Utilization of videos in education Almost all writing about disaster relief contains some recommendations regarding education for preparedness. Local, national and international measures are suggested (Redwood-Campbell and Abrahams, 2011; Lee and Low, 2006; Jordans, 2012) In our case, as explained earlier, most of the video recordings were used for educational purposes in various settings. Below are some specific examples. Integration into health personnel education The topic “psychological trauma” has already been part of medical school curricula both at preclinical and clinical years. Special programmes on “psychological trauma” A Masters degree programme on psychological trauma was established a few years after the disaster. Its graduates are already in the field contributing to the management of new events and to activities on disaster preparedness. A PhD programme is going to be established in this area in the 2014–2015 academic year. Most of the recordings were considered germane to these courses. The topic of “Leadership” is a good example that was used both for MSc students and medical students. Steinert et al. (2012) have worked on integrating leadership training into medical education and found some positive results, but they are cautious in interpreting their results and suggest that further research is needed to support their findings. Although not rising to the level of a controlled study, our observations about using our experiences, supported by video recordings as concrete evidence, seem to be useful both for medical students and especially for MSc students on topics related to leadership in disaster situations. For the psychological trauma programme, the author is responsible for courses on “communication skills” and “small group interactions”. Verbal and written feedback from current students and graduates who work in the field has been encouraging. In-service training for health personnel Disaster preparedness itself became the title of some in-service training activities or was used as part of other in-service training topics. Just as we have tried to implement such integrated activities, Ruzek et al. (2004), emphasize integration of behavioural health into emergency medicine training related to disaster. Also suggested are training interventions to

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support emergency workers who face acute stress as part of their everyday work (Leblanc et al., 2012) Public awareness training programmes The Community Mental Health Center of Kocaeli University presents public mental health awareness activities mainly on interpersonal and intrafamilial issues once or twice a month (Coskun and Coskun, 2004). During some of those mental health awareness programmes, although the topic might not be directly related to disaster, the importance of preparedness would be mentioned as a component of mental wellbeing. Anniversary meetings can have positive effects on the population both remembering and respecting their losses and also on their future preparedness (Nemeth et al., 2012). Our recordings have been used at our own anniversary meetings each 17 August 17, commemorating the Marmara earthquake.

Recommendations Finally, a few recommendations are provided for future studies dealing with disaster situations. Mankind will never be able to eradicate unexpected events. Not only will natural disasters never disappear, it is unfortunate but realistic that we will be unable to completely stop even man-made disasters. Preparation is what’s needed. * From the perspective of this paper, the educational role of recordings of disasters should be underscored. We can all learn from both our own experiences and the experiences of others. * Coordination of local, national and international activities regarding relief operations is crucial both for improving the capacity of the professionals involved and for mitigating the consequences of disasters. * Integrating the topics related with disaster preparation into formal curricula for all health personnel and also into in-service trainings is a fundamental issue. * All preparations and activities should prioritize a humane approach at all levels.

References Aker T, Karakilic H. [Coordination unit of psychosocial services in disasters and Psychiatric Association of Turkey within the context of

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Ercis Van earthquake] [Chapter in Turkish] in [2011 earthquakes of Van – Ercis] [book in Turkish] Eds: AT Aker, N Aydin, L Besiroglu, F Celik. Psychiatric Association of Turkey, Ankara pp:1-20. Aker AT. [1999 Marmara earthquakes: a review of epidemiologic findings and community mental health policies] [Article in Turkish] Turk Psikiyatri Derg. 17(3):204-12. 2006. Benjamin E, Bassily-Marcus AM, Babu E, Silver L, Martin ML. Principles and practice of disaster relief: lessons from Haiti. Mt Sinai J Med. 78(3):306-18, 2011. Besiroglu, L. [Health personel at disaster situations – experiences from Van Ercis earthquake][Chapter in Turkish] in [2011 earthquakes of Van – Ercis] [book in Turkish] Eds: AT Aker, N Aydin, L Besiroglu, F Celik. Psychiatric Association of Turkey, Ankara pp:65-71, 2014 Campos-Outcalt, D. Disaster medical response: maximizing your effectiveness. J Fam Pract. 55(2):113-5, 2006. Coskun B, Coskun A. Public awareness training program: interpersonal relations and psychosocial well-being awareness in Kocaeli, Turkey. In Mental health promotion: case studies from countries, Eds S Saxena and PJ Garrison, WHO, France, 2004, pp 94 – 96. Gokalp, P. Disaster mental health care: the experiences of Turkey. World Psychiatry 1(3):159-160, 2002. Jordans MJ, Luitel NP, Poudyal B, Tol WA, Komproe IH. Evaluation of a brief training on mental health and psychosocial support in emergencies: a pre- and post-assessment in Nepal. Prehosp Disaster Med. 27(3):235-8. 2012. Khorram-Manesh A, Hedelin A, Ortenwall P. Regional coordination in medical emergencies and major incidents; plan, execute and teach. Scand J Trauma Resusc Emerg Med. 20:17-32, 2009. Leblanc VR, Regehr C, Tavares W, Scott AK, Macdonald R, King K. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med. 27(4):369-74, 2012. Lee VJ, Low E. Coordination and resource maximization during disaster relief efforts. Prehosp Disaster Med. 21(1):8-12, 2006. López Tagle E, Santana Nazarit P. [The 2010 earthquake in Chile: the response of the health system and international cooperation] [Article in Spanish]. Rev Panam Salud Publica. 30(2):160-6, 2011. Nemeth DG, Kuriansky J, Reeder KP, Lewis A, Marceaux K, Whittington T, Olivier TW, May NE, Safier JA. Addressing anniversary reactions of trauma through group process: the Hurricane Katrina anniversary wellness workshops. Int J Group Psychother. 62(1):129-42, 2012.

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Redwood-Campbell, L, Abrahams, J. Primary health care and disasters – the current state of the literature: what we know, gaps and next steps. Prehosp Disaster Med. 26(3):184-91, 2011. Ruzek JI, Young BH, Cordova MJ, Flynn BW. Integration of disaster mental health services with emergency medicine. Prehosp Disaster Med. 19(1):46-53, 2004. Sederer LI, Lanzara CB, Essock SM, Donahue SA, Stone JL, Galea S. Lessons learned from the New York State mental health response to the September 11, 2001 attacks. Psychiatr Serv. 62(9):1085-9, 2011. Steinert Y, Naismith L, Mann K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME Guide No. 19. Med Teach. 34(6):483-503, 2012. Sugiura H, Akahane M, Ohkusa Y, Okabe N, Sano T, Jojima N, Bando H, Imamura T. Prevalence of insomnia among residents of Tokyo and Osaka after the great East Japan earthquake: a prospective study. Interact J Med Res. 18;2(1):e2, 2013. Takahashi, S. [Mental health support for disaster relief personnel] [Article in Japanese]. Seishin Shinkeigaku Zasshi. 116(3):224-30, 2014. Wolmer, L, Hamiel, D, Barchas, JD, Slone, M, Laor, N. Teacher-delivered resilience-focused intervention in schools with traumatized children following the second Lebanon War. J Trauma Stress. 24(3):309-16, 2011. Zaré M, Nazmazar B. Van, Turkey earthquake of 23 October 2011, mw 7.2; an overview on disaster management. Iran J Public Health. 42(2):134-44, 2013. Zoraster RM. Barriers to disaster coordination: health sector coordination in Banda Aceh following the South Asia Tsunami. Prehosp Disaster Med. 21(1):s13-8, 2006.

Corresponding Author: Bulent Coskun, MD Professor of Psychiatry Psikiyatri Anabilim Dali Kocaeli Universitesi Tip Fakültesi Umuttepe 41380 Kocaeli, Turkey E-mail: [email protected]

NEUROBIOLOGY OF PTSD PANAGIOTA PERVANIDOU, GEORGE P. CHROUSOS FIRST DEPARTMENT OF PEDIATRICS, UNIVERSITY OF ATHENS MEDICAL SCHOOL, AGHIA SOPHIA CHILDREN’S HOSPITAL, ATHENS, GREECE

Abstract Post-traumatic Stress Disorder (PTSD) is characterized by dysregulation of the Hypothalamic-Pituitary-Adrenal (HPA) Axis and the Sympathetic Nervous System (SNS). Most studies in individuals with PTSD have demonstrated increased activity of the HPA axis centrally, as evidenced by increased Corticotropin-Releasing-Hormone (CRH) concentrations, and decreased cortisol concentrations in the periphery: saliva, serum, urine and hair. The activity of the sympathetic nervous system has been constantly found increased, as evidenced by high catecholamine concentrations in plasma and urine, in patients with PTSD. Previous trauma history and time since the traumatic event occurred are important determinants of stress responses and HPA axis dysregulation. Longitudinal paediatric data in PTSD development reveal initially elevated cortisol concentrations after the traumatic event that gradually normalize, and, simultaneously, normal peripheral catecholamine concentrations immediately after the trauma that progressively elevate through time. Thus, low cortisol, together with high NE concentrations, may be the end stage of the disorder in adults with chronic PTSD and, at the same time, a biological vulnerability factor for further traumatization and PTSD development.

Introduction The important role of stress reactions and, consequently, stress biology in the pathophysiology of Post-traumatic Stress Disorder (PTSD) is highlighted in the last revision of the Diagnostic and Statistical Manual for Mental Disorders (DSM), where PTSD is no more classified as an anxiety

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disorder, but moved into a new class, the “trauma and stressor-related disorders” (American Psychiatric Association, 2013). Indeed, a large body of evidence supports the crucial role of the stress system in the pathophysiology of PTSD.

Stress System Biology Stress is the state of threatened homeostasis, the complex dynamic equilibrium that all living organisms try to maintain. Normally, homeostasis is constantly challenged by everyday actions of external or internal stressors (Chrousos and Gold, 1992). The magnitude and chronicity of stressors, as well as the perception of stress are important in stress reactions. When any real or perceived stressor exceeds a certain threshold, the adaptive homeostatic systems of the organism are compensatorily activated. These adaptive changes take place both in the central nervous system (CNS) and the periphery. Central actions include facilitation of neural pathways that promote arousal, vigilance and focused attention and, at the same time, inhibition of pathways related to eating, growth and reproduction. In addition, these adaptive changes lead to increased oxygenation and nutrition of the brain, heart and skeletal muscles, all organs essential to the central coordination of the acute stress response and the “fight or flight” reaction (Chrousos, 2009). Centrally, the main mediators of the stress system are the hypothalamic paraventricular nucleus hormones Corticotropin-Releasing-Hormone (CRH) and arginine-vasopressin, the arcuate nucleus proopiomelanocortin-derived peptides Į-melanocyte–stimulating hormone (MSH) and ȕ-endorphin, and the brainstem Norepinephrine (NE) produced in the A1/A2 centres of the Locus Caeruleus (LC) and the central nuclei of the sympathetic nervous system (SNS). In the periphery, the end-effectors of the Hypothalamic– Pituitary–Adrenal Axis (HPA axis) are the glucocorticoids; and those of the sympathetic system are the catecholamines epinephrine and NE (Pervanidou and Chrousos, 2013). In addition to the main components and mediators of the stress system, additional systems and their mediators (neurotransmitters, hormones, cytokines and growth factors) interact with them to regulate homeostasis. The targets of these stress mediators are brain structures and functions

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related to emotion and behaviour, as well as peripheral tissues related to growth, metabolism, reproduction, immunity and cardiovascular function. It is well known today that normally the activation of the stress system by everyday stressors results in adaptive endocrine, metabolic, behavioural and cardiovascular changes that help maintain homeostasis. However, the experience of intense real or perceived stressors, such as accidents, natural disasters, war or terrorism, physical or sexual abuse, bereavement, etc., can lead to excessive and prolonged activation of the stress system or, in a subgroup of individuals, to chronic hypoactivation of this system, with a variety of psychological and biological consequences (Pervanidou and Chrousos, 2013).

Stress System in PTSD The stress system has inevitably been the main focus of the biological research into PTSD. During the last 20 years, a variety of studies in trauma survivors have been published, elucidating the role of the HPA axis and the SNS in PTSD pathophysiology and clinical manifestations. The main findings are summarized as follows: 1. Basal cerebrospinal fluid (CSF) CRH levels are elevated, as indicated both by using a single lumbar puncture and serial CSF sampling (Baker et al., 1999; Bremmer et al., 1997). 2. Urinary cortisol levels were reported to be low in the majority of studies; however, fewer data demonstrated variable results: no differences, or more rarely, increased urinary cortisol excretion compared to control subjects (Yehuda et al., 1995; Yehuda, 2001). 3. Daily consecutive blood sampling in PTSD patients showed reduced cortisol concentrations several times during the circadian cycle, mainly in the late evening and early morning hours (Yehuda et al., 1994). A cortisol rhythm study indicated that cortisol levels in PTSD subjects were lower at the nadir, compared to control individuals (Yehuda, 2001). A study in PTSD survivors, examined years after the trauma, showed an altered circadian rhythm in salivary cortisol (Yehuda et al., 2005). 4. An increased number of lymphocyte glucocorticoid receptors (GRs) has been reported in patients with PTSD compared to controls (Yehuda et al., 1991). 5. Enhanced cortisol suppression, as reflected by lower cortisol levels after the dexamethasone (Dex) suppression test, has been noted in

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PTSD patients compared to the non-PTSD controls (Yehuda et al., 1993). 6. Salivary cortisol concentrations, as measured by single cortisol values, cortisol awakening response (CAR) and area under the curve (AUC), and as responses to stress tests, have been found low in most studies of individuals with PTSD (Wahbeh and Oken, 2013). 7. Measurement of hair cortisol concentrations is a relatively new method that increases the quality of long-term cortisol assessment in stress-related research. Recent evidence has shown that PTSD patients, as well as traumatized individuals without current PTSD symptomatology, both had decreased hair cortisol concentrations compared to controls. These findings support that trauma exposure per se might be a crucial correlate of long-term basal cortisol concentrations. Furthermore, the experience of multiple events, with a longer time since traumatization, was related to hypocortisolism. These findings in hair cortisol underscore the importance of this new method in future biological research into PTSD (Steudte et al., 2013). 8. Lower Methylation of Glucocorticoid Receptor (GR) Gene Promoter 1F has been found in Peripheral Blood of Veterans with Posttraumatic Stress Disorder and was inversely correlated with clinical markers and symptoms associated with PTSD. It is well known that enhanced GR sensitivity is present in individuals with post-traumatic stress disorder and this epigenetic mechanism may account for how trauma exposure, an external factor, leads to sustained PTSD symptoms (Yehuda et al., 2014). A second study produced similar results: cortisol concentrations, GR expression and promoter methylation levels in peripheral T lymphocytes of healthy controls were compared versus individuals with lifetime PTSD. Individuals with lifetime PTSD have lower morning cortisol release, higher mRNA expression of GR total, 1B, and 1C and lower overall methylation levels in GR 1B and 1C promoters. Cortisol concentrations were inversely correlated with hGR 1B mRNA expression. Moreover, overall and CpG site-specific methylation levels were inversely correlated with GR total and 1B mRNA expression. This study supports that traumatic events induce DNA methylation alterations in distinct promoters of GR with transcriptional modifications that associate with hypoactive hypothalamus–pituitary–adrenal axis in individuals with PTSD (Labonte, 2014).

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9. Catecholamine concentrations, as a biomarker of the SNS, have been investigated in patients with PTSD. The most consistent finding in PTSD neuroendocrine studies is increased noradrenergic activity, both centrally (Geracioti et al., 2001) and peripherally, in 24h urine (Yehuda, 2001; Southwick et al., 1999b) and plasma in adults. Mean plasma NE and 3-methoxy-4-hydroxyphenylglycol, a metabolite of NE, concentrations were higher in war veterans with PTSD than in veterans with PTSD and co-morbid depression, patients with major depressive disorder (MDD) and healthy volunteers (Yehuda et al., 1998). Similarly, children with PTSD and post-traumatic symptomatology have been reported to have increased peripheral sympathetic nervous system (SNS) activity (Delahanty et al., 2005; Pervanidou et al., 2007a). Furthermore, decreased platelet a2 receptor binding suggests NE hyperactivity in PTSD (Vermetten and Bremner, 2002; Strawn and Geracioti, 2008). As previously described, the majority of studies reveal a unique neuroendocrine profile in individuals with PTSD, with high CRH concentrations, centrally, and low cortisol in the periphery, together with high catecholamines. Several pathophysiological mechanisms have been proposed to explain the biologic findings of PTSD: The neuroendocrine profile in PTSD suggests an increased cortisol signalling capacity, so that lower cortisol concentrations may suppress more efficiently the HPA axis exerting increased negative feedback actions. This may lead to decreased exposure of the LC/NE system to the negative actions of cortisol, contributing to increased sympathetic activation.

Biological trajectories in PTSD development and maintenance Few studies have examined the longitudinal course of development and maintenance of PTSD, beginning from the exposure to the traumatic event. We have investigated the natural history of neuroendocrine changes in relation to the development and maintenance of PTSD diagnosis in children and adolescents after experiencing a motor vehicle accident (Pervanidou et al., 2007a; 2007b). These children had no previous trauma exposure, nor current or past psychopathology. We compared biological measures of stress among children that developed PTSD 1 month after the accident (30% of the population), with a group that experienced the traumatic event but did not develop PTSD and a control group without

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exposure to accident. We further compared the sub-group (15%) that developed PTSD at month 1 and maintained PTSD diagnosis at month 6, with those that did not develop PTSD at month 1 nor at month 6. Evening salivary cortisol and morning serum interleukin-6 in the aftermath of the trauma were highly inter-related and higher in children that later developed PTSD and they were both predictive of PTSD development at month 6. Plasma NE concentrations did not differ among groups after the accident and they were not predictive of later PTSD development (Pervanidou et al., 2007b). The PTSD group exhibited higher NE concentrations compared to the other two groups at both assessments. More importantly, NE became gradually greater within the PTSD group. The non-PTSD group exhibited a similar pattern of longitudinal gradual elevation of NE, but, at a lower setting, showing that development and maintenance of sub-threshold PTSD symptoms are also related to NE elevations. As evening cortisol concentrations and circadian rhythm normalized in the PTSD subjects at month 6, NE elevations became greater (Pervanidou et al., 2007a). This could be the effect of lifting a cortisol-mediated noradrenergic system restraint. This longitudinal study supports an initial elevation of cortisol in individuals exposed to trauma, followed by a gradual normalization of cortisol levels, as time passes from the traumatic event, that might lead to decreased cortisol levels in the periphery, months or years after the traumatic exposure. At the same time, a progressive elevation of NE is noted in those individuals that continue to exhibit PTSD symptoms. It seems that a longitudinal interaction of peripheral measures of the sympathetic systems and the HPA axis characterizes those that develop and maintain the disorder. Thus, low cortisol, together with high NE concentrations, may be the end stage of the disorder in adults with chronic PTSD. Low cortisol in the aftermath of the trauma has also been found to predict PTSD development in some adult studies. Low cortisol concentrations immediately after the experience of an acute stressor may reflect previous traumatization, and thus constitutes a biological vulnerability factor for further PTSD development.

Biological Effects of Early Stress and Trauma There is evidence that traumatic stress during vulnerable periods of development has substantial and permanent effects on brain development compared to the effects of stress on mature brain structures and functions

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during adulthood. Animal studies have shown that chronically elevated stress mediators may lead to alterations in brain development through mechanisms of accelerated loss of neurons, delays in myelination or abnormalities in developmentally appropriate neural synaptic pruning. Elevated concentrations of glucocorticoids during chronic stress may also result in frontal lobe deficiencies, amygdala hyperfunctioning, hippocampal damage, and consequent learning and concentration difficulties. Some brain regions are particularly vulnerable to the effects of traumatic stress during development. These regions are the hippocampus – important for learning, memory and control of the stress system because it continues to develop after birth and has a high density of glucocorticoid receptors – and the amygdala, that regulates fear, anger and emotional memory. Fluctuations of stress hormones during periods of high brain plasticity may permanently program the brain to over-react to stress and to manifest more anxiety in new stressors (Pervanidou and Chrousos, 2007; Pervanidou and Chrousos 2012).

Opioid, glutamatergic and serotonergic systems The Opiate system has been shown to be related to the avoidance/numbing and hyperarousal clusters of PTSD. There is some evidence that PTSD patients have reduced concentrations of resting plasma beta-endorphines and lower pain threshold. Normally, during stress, the secretion of CRH causes stimulation not only of Adrenocorticotropic Hormone (ACTH), but also of beta-endorphines. The mechanism of decreased concentrations of beta-endorphines in PTSD may be associated to mechanisms of decreased HPA axis activity together with high noradrenergic activity in PTSD (Hageman et al., 2001). Serotonin (5-hydroxytryptamine, 5-HT) is a monoamine neurotransmitter whose biological roles include regulation of sleep, appetite, sexual behaviour, aggression, impulsivity and neuroendocrine control. Serotonin interacts with the HPA axis and the Sympathetic nervous System and it is implicated in the pathophysiology of mood and anxiety disorders, and may contribute to the pathophysiology of PTSD. There is a little evidence of altered 5-HT neurotransmission in PTSD, including decreased serum concentrations of 5-HT and decreased density of platelet 5-HT uptake (Vermetten and Bremner, 2002); however, no differences were found in PTSD individuals, using positron emission tomography imaging (Bonne et al., 2005). It is believed that altered 5-HT may partly contribute to PTSD symptoms, and this is supported by the efficacy of selective serotonin re-

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uptake inhibitors in patients with PTSD. Gamma-aminobutyric acid (GABA) is a neurotransmitter with an inhibitory role in the CNS. It acts on GABAA receptors which are components of the GABAA/benzodiazepine (BZ) receptor complex, and may be involved in the pathophysiology of PTSD, as evidenced by decreased platelet BZ- binding sites in patients with PTSD as well as decreased BZ receptor binding in the hippocampus, cortex and thalamus of PTSD patients (Gavish et al., 1996; Geuze et al., 2008; Pervanidou and Chrousos, 2010).

Conclusions A large body of evidence supports the crucial role of the stress system and its mediators in the pathophysiology of PTSD. These chronic neurobiological alterations, such as chronic hypocortisolism and high catecholamines, are associated with metabolic, behavioural and cardiovascular changes that can lead to increased morbidity and mortality in individuals with PTSD. Psychosocial and behavioural interventions, together with pharmacological therapies, are essential for the promotion of mental and physical health of patients suffering from conditions and disorders related to chronic stress.

References American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing, 2013 Baker DG, West SA, Nicholson WE, Ekhator NN. Kasckow JW, Hill KK et al. Serial CSF corticotropin-releasing hormone levels and adrenocortical activity in combat veterans with posttraumatic stress disorder. The American Journal of Psychiatry, 156(4), 585–388, 1999. Bonne O, Bain E, Neumeister A, Nugent AC, Vythilingam M, Carson RE, Luckenbaugh DA, Eckelman W, Herscovitch P, Drevets WC, Charney DS. No change in serotonin type 1A receptor binding in patients with posttraumatic stress disorder. Am J Psychiatry. Feb;162(2):383-5, 2005 Bremner JD, Licinio J, Dammel A, Krystal JH, Owens MJ, Southwick SM, et al. (1997). Elevated CSF cortico- tropin-releasing factor concentrations in posttraumatic stress disorder. The American Journal of Psychiatry, 154, 624–629.

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Chrousos GP. Stress and disorders of the stress system. Nature Review Endocrinology, 5(7), 374–381, 2009 Chrousos GP and Gold PW. The concepts of stress and stress system disorders. Journal of the American Medical Association, 267, 1244– 1252, 1992 Delahanty DL, Nugent NR, Christopher NC, and Walsh M. Initial urinary epinephrine and cortisol levels predict acute PTSD symptoms in child trauma victims. Psychoneuroendocrinology, 30(2), 121–128, 2005 Hageman I, Andersen HS, Jørgensen MB. Post-traumatic stress disorder: a review of psychobiology and pharmacotherapy. Acta Psychiatr Scand. 104(6):411-22, 2001 Gavish M, Laor N, Bidder M, Fisher D, Fonia O, Muller U, Reiss A, Wolmer L, Karp L, Weizman R. Altered platelet peripheral-type benzodiazepine receptor in posttraumatic stress disorder. Neuropsychopharmacology. Mar;14(3):181-6, 1996 Geracioti TD, Jr, Baker DG, Ekhator NN, West SA, Hill KK, Bruce AB, et al. CSF norepinephrine concentrations in posttraumatic stress disorder. The American Journal of Psychiatry, 158(8), 1227–1230, 2001 Geuze E, Westenberg HG, Heinecke A, de Kloet CS, Goebel R, Vermetten E. Thinner prefrontal cortex in veterans with posttraumatic stress disorder. Neuroimage. 1;41(3):675-81, 2008 Labonté B, Azoulay N, Yerko V, Turecki G, Brunet A. Epigenetic modulation of glucocorticoid receptors in posttraumatic stress disorder. Transl Psychiatry 4:e368. doi: 10.1038/tp.2014.3, 2014 Pervanidou P. Biology of Posttraumatic Stress Disorder in childhood and adolescence. Journal of Neuroendocrinology, 20(5), 632–638, 2008. Pervanidou P, Chrousos GP. Post-traumatic Stress Disorder in children and adolescents: From Sigmund Freud’s “trauma” to psychopathology and the (Dys)metabolic syndrome. Hormone and Metabolic Research, 39(6), 413–419 2007. Pervanidou P, Chrousos GP. Neuroendocrinology of post-traumatic stress disorder. Prog Brain Res.;182:149-60, 2010 Pervanidou P, Chrousos GP. Posttraumatic stress disorder in children and adolescents: neuroendocrine perspectives. Sci Signal. 9;5(245):pt6, 2012 Pervanidou P, Kolaitis G, Charitaki S, Lazaropoulou Ch, Hindmarsh P, Bakoula, Ch, et al. The natural history of neuroendocrine changes in pediatric posttraumatic stress disorder after motor vehicle accidents: Progressive divergence of noradrenaline and cortisol concentrations over time. Biological Psychiatry, 62(10), 1095–1110, 2007.

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Southwick SM, Paige S, Morgan CA 3rd, Bremmer JD, Krystal JH, and Charney DS. Neurotransmitter alterations in PTSD: Catecholamines and serotonin. Seminars in Clinical Neuropsychiatry, 4(4), 242–248, 1999 Steudte S, Kirschbaum C, Gao W, Alexander N, Schönfeld S, Hoyer J, Stalder T. Hair cortisol as a biomarker of traumatization in healthy individuals and posttraumatic stress disorder patients. Biol Psychiatry 74(9), 639-646, 2013 Strawn JR, and Geracioti TD. Noradrenergic dysfunction and the psychopharmacology of posttraumatic stress disorder. Depression and Anxiety, 16, 14–38, 2008. Vermetten E, and Bremner JD. Circuits and systems in stress. II. Applications to neurobiology and treatment in posttraumatic stress disorder. Depression and Anxiety, 16, 14–38, 2002. Wahbeh H, Oken BS. Salivary cortisol lower in posttraumatic stress disorder. J Trauma Stress 26(2), 241-248, 2013. Yehuda R, Golier JA, and Kaufman S. Circadian rhythm of salivary cortisol in Holocaust survivors with and without PTSD. The American Journal of Psychiatry, 162(5), 998–1000, 2005. Yehuda R. Biology of posttraumatic stress disorder. The Journal of Clinical Psychiatry, 62(Suppl. 17), 41–46, 2001. Yehuda R, Kahana B, Binder-Brynes K, Southwick SM, Mason JW, and Giller EL. Low urinary cortisol excretion in Holocaust survivors with posttraumatic stress disorder. American Journal of Psychiatry, 152, 982–986, 1995. Yehuda R, Lowy MT, Southwick SM, Shaffer D, and Giller EL, Jr. Lymphocyte glucocorticoid receptor number in posttraumatic stress disorder. The American Journal of Psychiatry, 148, 499–504, 1991 Yehuda R, Southwick SM, Krystal JH, Bremmer D, Charney DS, and Mason JW. Enhanced suppression of cortisol following dexamethasone administration in posttraumatic stress disorder. The American Journal of Psychiatry, 150, 83–86, 1993 Yehuda R, Siever LJ, Teicher MH, Levengood RA, Gerber DK, Schmeidler J et al. Plasma norepi- nephrine and 3-methoxy-4hydroxyphenylglycol concentrations and severity of depression in combat posttraumatic stress disorder and major depressive disorder. Biological Psychiatry, 44(1), 56–63, 1998. Yehuda R, Teicher MH, Levengood RA, Trestman RL, and Siever LJ. Circadian regulation of basal cortisol levels in posttraumatic stress disorder. Annals of the New York Academy of Sciences, 746, 378– 380, 1994.

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Yehuda R, Daskalakis NP, Lehrner A, Desarnaud F, Bader HN, Makotkine I, Flory JD, Bierer LM, Meaney MJ. Influences of Maternal and Paternal PTSD on Epigenetic Regulation of the Glucocorticoid Receptor Gene in Holocaust Survivor Offspring. Am J Psychiatry doi: 10.1176/appi.ajp.2014.13121571, 2014 Yehuda R, Flory JD, Bierer LM, Henn-Haase C, Lehrner A, Desarnaud F, Makotkine I, Daskalakis NP, Marmar CR, Meaney MJ. Lower Methylation of Glucocorticoid Receptor Gene Promoter 1(F) in Peripheral Blood of Veterans with Posttraumatic Stress Disorder. Biol Psychiatry pii: S0006-3223(14)00100-0. doi: 10.1016/j.biopsych.2014.02.006, 2014

Corresponding Author: Panagiota Pervanidou, MD, PhD Lecturer of Developmental & Behavioral Pediatrics University of Athens School of Medicine Aghia Sophia Children’s Hospital Athens, Greece e-mail: [email protected]

WAR AND THE MENTAL HEALTH OF CIVILIANS: WHAT DID WE LEARN SO FAR FROM LEBANON? ELIE KARAM, JOHN FAYYAD INSTITUTE FOR DEVELOPMENT, RESEARCH, ADVOCACY AND APPLIED CARE (IDRAAC) AND DEPARTMENT OF PSYCHIATRY AND CLINICAL PSYCHOLOGY, SAINT GEORGE HOSPITAL UNIVERSITY MEDICAL CENTER, BALAMAND UNIVERSITY, FACULTY OF MEDICINE, BEIRUT, LEBANON

CLAUDIA FARHAT INSTITUTE FOR DEVELOPMENT, RESEARCH, ADVOCACY AND APPLIED CARE (IDRAAC), BEIRUT, LEBANON

LYNN ITANI INSTITUTE FOR DEVELOPMENT, RESEARCH, ADVOCACY AND APPLIED CARE (IDRAAC), BEIRUT, LEBANON

ZEINA MNEIMNEH INSTITUTE FOR DEVELOPMENT, RESEARCH, ADVOCACY AND APPLIED CARE (IDRAAC), BEIRUT, LEBANON AND INSTITUTE FOR SOCIAL RESEARCH, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA

AIMEE KARAM, GEORGES KARAM INSTITUTE FOR DEVELOPMENT, RESEARCH, ADVOCACY AND APPLIED CARE (IDRAAC) AND DEPARTMENT OF PSYCHIATRY AND CLINICAL PSYCHOLOGY, SAINT GEORGE HOSPITAL UNIVERSITY MEDICAL CENTER, BALAMAND UNIVERSITY, FACULTY OF MEDICINE, BEIRUT, LEBANON

Abstract War has accompanied closely the history of homo sapiens and continues to be a source of worry in the modern world. Interest in the mental health dimensions of wars has increased in the past four decades and has paralleled advances in field research. Lebanon, a hitherto peaceful republic, was ravaged by what has come to be known as the Lebanon Wars

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which started in 1975 and our group (IDRAAC) embarked on studying a little researched population: civilians in war. We have conducted both cross sectional and prospective studies since 1980 on children, adolescents and adults. More recently we have included a new set of civilians from a neighbouring country: Syria. We established through our successive studies that war, in civilians, was clearly a major predictor not only with reference to the first onset but also with reference to the severity of mental disorders. Furthermore, the mental health of civilians got worse with repeated exposure to war: they do not get used to or get “hardened” with more exposure. Suicidal behaviour was also related to exposure to war, mediated through mental disorders, independent of the time period (during or after war), and exacerbated in the presence of pre-war impulse control disorder. We found too that, in the acute aftermath of wars, while mental disorders in children and adolescents peak immediately, they gradually decrease in their prevalence but with a clear exception: impulse control disorders. Quite importantly, post-war mental disorders were linked to intra-familial stressors such as exposure to family violence, and not only to direct witnessing of war events, highlighting our repeated finding, in all our studies, that the evaluation of the effect of war on mental health should always include the assessment not only of pre-war disorders but also of childhood adversities and other traumata in the life of the individuals. Moreover, we found that the relation of war to mental health disorders does not dwindle with time: war echoes continue into older age. Our large scale intervention studies are teaching us to explore new dimensions in mental health, namely personal competence and other constructs of resilience. Reflecting on our findings, it is hoped that, in addition to physical disabilities, policy makers and world leaders keep in mind the real, costly scars of wars, namely the long term mental health consequences of wars, and include them on their various balance sheets.

I. Introduction Exposure to war is one of the most stressful experiences that homo-sapiens have been subjected to, actively or passively. Besides the fatalities, the physical injuries, the economic and the political losses that result from war, an important question, largely forgotten by historians of wars, has forced itself increasingly into our understanding of these tragedies: what about the mental health consequences of war? Alas, these are showing to be of colossal importance: the mind does not recover that easily.

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When we at the Institute for Development, Research, Advocacy, and Applied Care (IDRAAC) started researching the mental health consequences of war in the early 1980s, the world literature had several research gaps. First, it focused mostly on military subjects (Archibald et al., 1965; Brill et al., 1955; Egendorf, 1981; Grinker et al., 1963; Helzer et al., 1979; Lifton et al., 1973; Yager et al., 1984), studying war only in general terms and with only a few studies investigating specific events that occur during war (Egendorf, 1981; Lifton et al., 1973; Yager et al., 1984). In addition, war studies on civilians were either restricted to clinical studies (conducted on patients) or to small samples (Kinzie, 1986; Nasr et al., 1993; Saigh, 1984), and did not attempt to quantify war exposure on large or nationally representative levels. Also, most studies on civilians assessed war as a single variable and did not assess the wide gamut of mental health disorders. In this context, the Lebanon wars offered us the opportunity to have a better understanding of the mental health effects of war. Lebanon has witnessed a series of wars since 1975. The longest of them, the “Lebanon wars” involving a variety of internal and external protagonists, began in 1975 and ended fifteen years later in 1990. The Lebanon wars ravaged the whole country and about 15% of the population was physically injured (one third of these being fatalities). Two subsequent much shorter major wars (weeks) occurred exclusively with external protagonists: the “Grapes of Wrath” in 1996, and 10 years later the “July War” in 2006. In the next few pages, we present a review of the studies that have been conducted by IDRAAC on war and mental health; these studies were carried out on children, adolescents and adults.

II. War and Mental Health: Adults We contemplated the assessment of the relation of war exposure to mental health in the early 1980s, soon after the establishment of research activities in the Department of Psychiatry and Clinical Psychology at St Georges University Hospital in Beirut and the creation of IDRAAC (Institute for Development, Research, Advocacy and Applied Care). We wanted to “exploit” the fact that we were “lucky” in that we would be able to explore a subject (war and mental health) which had not been studied widely among civilians in a rigorous and scientific way in “modern” times. We thought then that war would not really have any impact on major disorders, including depression. The military conflicts were unabating, so

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we got prepared, waiting for a lull, and went ahead and adapted epidemiologic instruments into Lebanese Arabic, including the Arabic Diagnostic Interview Schedule (DIS) (Karam et al., 1991). Our hypothesis was then tested somewhat accidentally in a first run in 1987 when data were collected on 150 consecutive women who had just delivered at Saint Georges University Hospital in Beirut (using the DIS). Data was collected on the second post-partum day: we thought they would constitute a very healthy segment of society, obviously not admitted for mental health problems and at the same time available for interview in the safe enclave of the hospital. The lifetime prevalence of DSMIII-R major depression in this very healthy group was, we thought then, alarmingly high (31.3%) especially as then we had never had data on the prevalence of depression in any Arab country (El Khoury et al., 1999).

The War Events Questionnaire The study described above made us feel that maybe something was really going on in this country known for its “joie de vivre” and thus we moved on and as a next step, we thought, we needed to evaluate exposure to the Lebanon Wars. The hitherto existing instruments had several shortcomings. First, questions on the frequency and the intensity of exposure to war events were often neglected. Second, war events whose direct victims were members of a social network (friends and family) were frequently missing; in addition, questionnaires often disregarded the fact that the impact of a war event on a respondent could depend on the relation of the respondent to the direct victim. Third, questions did not inquire about how closely the event was witnessed. Fourth, scales assessing war stressors can frequently be confused as a reaction to the traumatic event. For this reason, IDRAAC developed the “War Events Questionnaire” (WEQ) an easily administered and reliable questionnaire that covered a wide variety of war events that avoids the tautological assessment of the mental health effects of war and confusion of it with its purely descriptive goal. The WEQ relies first on objective data and then adds weights both of which could be increased or decreased by individual researchers in various theatres of war depending on the specifics of that war (Karam et al., 1999).

The Four Communities Study (Phases I and II) The WEQ was then used in a prospective study which investigated the possible relation of mental health problems to differential exposure to

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wars. The study was carried out in four communities which were chosen to represent increasing levels of exposure to war. It is to be remembered here that simple geographical delimitation cannot account for real life exposure to war because of frequent movement of people from one area to another: visiting friends or families or for business. This is why, in war, in addition to area of residence (which carries by itself a loading with regard to global exposure to war), the individual subject by subject exposure has to be evaluated. It was not unusual for subjects residing in the safer areas to be caught in shelling or in a car bomb while visiting in another community. In Phase I (1989) of the four communities study, a total of 658 adults (age 18–65 years) were randomly selected from four communities and were administered, in their own homes, the WEQ and the Lebanese Arabic DIS by trained psychologists (Masters). The lifetime rate of DSM-IIIR Depression in the sample was 27.8%, and ranged from 16.3% to 41.9% across the four communities. The Total War Score was calculated for each subject as the sum of the WEQ war event scores, weighted by the respective witnessing factors and the number of times each event occurred. The war score was not normally distributed and thus logarithmic transformation was used. In a model including log total war score, depression before the war, marital status, age, gender, community of residence and participation in military activity, the following parameters were highly significant: depression before wars (OR=7.55, CI: 3.17–17.97) as well as log total war score (OR=2.42, CI: 1.45–4.04). When replacing the log total war score with specific war events, the following events predicted the occurrence of depression during war (in addition to depression before the war): house damage (OR=1.96, CI: 1.22–3.13), physical injury (OR=1.74, CI: 1.30– 2.34), kidnapping (OR=1.31, CI: 0.94–1.82) and business loss (OR=1.65, CI: 1.22–2.23). We had established beyond doubt that war, in civilians, was clearly a major factor in the genesis of depression (Karam et al., 1998). With the support of the National Institute of Mental Health (USA), Phase II was conducted in 1991 thus allowing us to carry out a prospective arm of the Four Communities Study. A total of 234 subjects were reinterviewed again by trained psychologists, 14–17 months later, using the same instruments (DIS and WEQ). The Phase II questions focused on the time period after the conclusion of Phase I. The results of the Phase II study showed that the one-year rates of major depression and PTSD were 33.3% and 10.3% respectively. War exposure was associated with both of

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these disorders (as well as their comorbidity). Moreover, the relation between depression in Phase I and depression, PTSD, or their comorbidity in Phase II was significant: the Phase II rates of major depression and PTSD almost doubled in the presence of Phase I depression (vs its absence). We then wondered: what if the relation of prior depression (in Phase I) to comorbid PTSD and Depression in Phase II was due simply to war exposure in Phase I, (which itself could predict more exposure in Phase II)? We thus ran a logistic regression model that included: exposure in Phase I, depression in Phase I, exposure in Phase II, a special set of serious war traumata: fatal events in Phase II, and the interaction term (depression in Phase I x fatal event in Phase II). An interesting finding emerged: the risk of developing co-morbid PTSD and depression in Phase II increased around 6-fold if a subject had previous Phase I depression and had also experienced a fatal war event (Karam, 1997). Findings from the field were clearly mirroring clinical findings: the mental health of civilians got worse with repeated exposure to war: they do not get used to or get “hardened” with more exposure.

The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation (L.E.B.A.N.O.N.) Study We had been waiting to carry out the “big” study: a national study. We were fortunate to join the World Mental Health (WMH) Surveys led by WHO (Geneva) and Harvard University (USA), and we were able to conduct a nationally representative study on Lebanese adults, the L.E.B.A.N.O.N study, with the support of the Ministry of Health and many other donors. A major purpose of this study was to map comprehensively the landscape of mental disorders all over the country, the first ever to be carried out internationally with exemplary coordination and supervision. We decided it was also our once in a lifetime chance to investigate the effect of exposure to war on a wide array of mental health outcomes and on national level. As part of this project, data on a nationally representative sample of 2,857 subjects was collected between September 2002 and September 2003. Mental disorders were assessed based on the World Health Organisation Composite International Diagnostic Interview that we translated (CIDI 3.0) which generates DSM-IV diagnoses. The disorders assessed included anxiety, mood, impulse-control and substance disorders.

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Prevalence of war traumatic events in the total population of a country Lebanese adults, all over Lebanon, were asked, as part of the L.E.B.A.N.O.N survey, whether they have been exposed to any of the following war-related traumatic events: being a civilian in a war region, being a civilian in a terror region, being a refugee, or a rescue worker, witnessing death or injury, witnessing atrocities (an extremely cruel act), experiencing death of a close one, experiencing a trauma to a close one, being kidnapped, robbed and/or threatened by a weapon, and sustaining a life threatening war-related injury. These traumata, already present in the CIDI which is used by 26 countries, were modified so that respondents were asked to specify if they had occurred in peacetime or in the context of war (sexual molestation, threatened with a weapon…). In addition, useful details about these war traumata were asked when appropriate, for example: the perpetrator, the duration (e.g. in kidnapping), the frequency, the relation to the victim (sudden death...). Around two-thirds of Lebanese adults (68.8%) were exposed to one or more of the identified war-related events; half (47.0%) were exposed to one or two, while 21.8% were exposed to three or more events (Karam et al., 2008). The most frequently reported war-related event was being a civilian in a war region (55.2%) followed by being a refugee (37.7%). About a quarter (29.0%) witnessed death, injury or atrocities and a tenth of the population (10.2%) had experienced the death of a close person. The Lebanese who were 11–35 years at the onset of the Lebanon Wars were the most exposed to the majority of war events. In fact these were, in many specific ways, the more mobile sector of the population. Males were more likely than females to witness death or injuries, witness atrocities, be kidnapped, be robbed or threatened by a weapon, be a civilian in a region of terror or be a rescue worker. Females were more likely to be civilians in a war zone or to be refugees. Events which were uncontrollable, such as death of a loved one or trauma to a loved one, did not differ between genders (Table 1).

War and the Mental Health of Civilians

Kidnapped Robbed/threatened weapon

Trauma to close one

Death of close one

Refugee

Civilian in terror region

Civilian in war zone

Witness atrocities

Witness death or injury

Rescue worker

Individual war events:

by

% (se) 3.0 (0.9) 18.0 (1.3) 10.6 (1.4) 55.2 (2.9) 8.6 (1.5) 37.7 (3.6) 10.2 (1.2) 7.6 (0.8) 3.0 (0.7) 2.2 (0.5)

Total

5.9 (1.3) 0.04 (0.0) 0.6 (0.2)

9.2 (1.3)

44.4 (4.0)

6.5 (1.3)

61.2 (3.5)

5.5 (1.4)

10.2 (1.6)

1.2 (0.5)

% (se)

Female

9.4 (1.7) 6.1 (1.5)** 3.9 (1.1)**

11.2 (1.8)

10.6 (2.4)* 30.9 (3.5)**

49.0 (4.0)*

4.8 (1.8)* 26.0 (2.2)** 15.8 (2.1)**

% (se)

Male % (se) 2.9 (1.1) 13.5 (2.0) 7.2 (1.7) 46.8 (3.8) 7.9 (2.0) 32.2 (5.0) 4.6 (1.1) 5.7 (1.0) 1.8 (0.6) 1.0 (0.4)

0 to 10 % (se) 5.8 (2.5) 27.1 (4.2) 15.7 (4.3) 61.2 (6.8) 8.7 (2.3) 55.2 (7.0) 16.0 (6.0) 10.1 (3.8) 4.3 (2.3) 4.6 (2.0)

11 to 18 % (se) 2.8 (1.6) 24.0 (3.0) 16.0 (2.6) 68.4 (4.6) 9.7 (2.8) 45.3 (4.8) 21.4 (3.7) 11.8 (2.3) 5.0 (2.2) 4.4 (1.8)

19 to 35

1.4 (1.0)*

3.9 (2.2)

6.5 (2.6)

9.1 (2.4) 30.9 (5.1)** 9.2 (2.3)**

10.8 (3.5)* 62.5 (4.7)**

1.0 (0.6) 18.2 (4.2)**

% (se)

>35

Table 1: Rates of exposure to war events and differences in exposure to individual and cumulative war events by sex and age at start of war.

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23.6 (2.5)

23.4 (2.2)

10.7 (1.3)

One

Two

Three

11.6 (2.3)

29.4 (3.5)

25.4 (3.6)

27.9 (3.5)

9.8 (1.6)

17.4 (2.4)

21.8 (3.1)

34.6 (4.1)**

5.7 (1.4)

22.5 (3.9)

21.7 (3.3)

41.4 (4.6)

17.2 (4.3)

29.0 (5.2)

22.8 (5.3)

15.4 (4.4)

18.9 (4.1)

23.6 (4.2)

25.7 (4.6)

16.0 (3.4)

11.4 (3.6)

21.7 (4.6)

29.3 (6.2)

28.6 (4.3)**

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Model 1:

War periods Post-war Pre-war During war Mental Disorder Major depressive disorder before war Impulse-control disorder before war Social phobia before war Substance use disorder before war

1.9–8.5 0.1–4.1

0.9–9.6 5.1–57.9 1.0–143.0

4.1 0.6 1 3.0 17.1 12.0 -

Ideation OR 95% CI

6.3 † 60.9 -

6.0 0.7 1

Plan OR

5.3–696.0

1.8–21.9

1.7–20.8 0.2–3.0

95% CI

Table 2: War period and mental disorders as risk factors for first onset of suicidality

6.7 25.5 † 270.6

2.6 0.8 1

60.8–999

1.7–25.8 5.3–123.9

1.2–5.8 0.2–3.7

Attempt OR 95% CI

Four + 11.1 (1.2) 5.8 (1.0) 16.5 (1.9) 8.6 (1.2) 15.5 (3.8) 15.8 (3.4) 9.0 (2.5) se: Standard error Significance level was measured using Chi-square for number of war events (as one categorical variable ) versus gender and age each as one categorical variable: *P-value