[PPT] - CROSS CULTURAL MENTAL HEALTH CROSS CULTURAL MENTAL HEALTH AND AND PowerPoint Presentation

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CROSS CULTURAL MENTAL HEALTH CROSS CULTURAL MENTAL HEALTH AND AND THE INDIAN THE INDIAN OCEAN TSUNAMI OCEAN TSUNAMI

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WHAT WHAT’ ’S AHEAD S AHEAD

The tsunami The tsunami Operation Unified Assistance Operation Unified Assistance Focus on behavioral health Focus on behavioral health

– – Infrastructure Infrastructure – – Observations Observations – – Considerations for action Considerations for action

Home stretch Home stretch

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The most powerful earthquake in 40 years erupted under the The most powerful earthquake in 40 years erupted under the Indian Ocean near Sumatra on Dec. 26, 2004. It caused giant, Indian Ocean near Sumatra on Dec. 26, 2004. It caused giant, deadly waves to crash ashore in nearly a dozen countries, killin deadly waves to crash ashore in nearly a dozen countries, killing g tens of thousands. tens of thousands.

THE TSUNAMI THE TSUNAMI

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ABOUT THE EARTHQUAKE ABOUT THE EARTHQUAKE

The 9.0 earthquake occurred along 1,200 km of The 9.0 earthquake occurred along 1,200 km of seabed at a depth of 10 km seabed at a depth of 10 km it was so powerful, it made the earth wobble on it was so powerful, it made the earth wobble on its axis and permanently altered the region its axis and permanently altered the region it generated energy equivalent to the it generated energy equivalent to the simultaneous explosion of 23,000 Hiroshima simultaneous explosion of 23,000 Hiroshima atomic bombs atomic bombs it moved small islands off Sumatra's coast by it moved small islands off Sumatra's coast by as much as 20 and the north as much as 20 and the north-

western tip of

western tip of Sumatra by 36 Sumatra by 36 metres metres

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ABOUT THE TSUNAMI ABOUT THE TSUNAMI

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

100 ft tall]

100 ft tall]

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0759 0930 1.0 0830

Tsunami Strike Times Sunday, December 26, 2004

0830 0900 2.0 0930 3.5 1000 6.0

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KOH LANTA, THAILAND

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PHUKET BEACH, THAILAND PHUKET BEACH, THAILAND

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WORLDWIDE SUMMARY WORLDWIDE SUMMARY

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BANDA ACEH, INDONESIA

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BANDA ACEH SUMMARY BANDA ACEH SUMMARY

127,000 dead. 30,000 missing 127,000 dead. 30,000 missing 40% municipal employees perished 40% municipal employees perished 90% all public buildings destroyed 90% all public buildings destroyed 12 of 21 health centers, 5 of 7 hospitals 12 of 21 health centers, 5 of 7 hospitals destroyed destroyed 100 schools rendered unusable 100 schools rendered unusable Coastal fisheries, rice fields destroyed Coastal fisheries, rice fields destroyed

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BANDA ACEH SUMMARY BANDA ACEH SUMMARY

2/3 of all land records lost 2/3 of all land records lost Majority of bank records gone Majority of bank records gone Cement industry ruined Cement industry ruined Main commercial strips leveled Main commercial strips leveled Warehouses flattened Warehouses flattened 8 8-

12 inches of dense, salt

12 inches of dense, salt-

saturated mud

saturated mud covers the city up to 3 km from the shore covers the city up to 3 km from the shore

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OPERATION UNIFIED ASSISTANCE

275 Medical Personnel: Physicians, Nurses, Corpsman, Specialists

USNS MERCY

►Floating Tertiary care hospital

► 1000 bed capacity, 250 for OUA ► 12 Operating Rooms, CT, Pharm, O2 ► Full crew – 1,200+ personnel ► Built a Supertanker in ’74, convt’d ’86 ► 894 ft long, disp 70,000 t. ► Last key mission: Persian Gulf War 1990 ► Instances of previous use of flight deck

for patient operations: 0

90 Medical Personnel: Physicians, Nurses, Social Workers 18 Pub Health Personnel: Physicians, Nurses, Environmental Health, Medical engineer Psychologists Social workers

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* *Primary mission: Project support ashore.

Primary mission: Project support ashore. Project Primary Care medical capability ashore: Project Primary Care medical capability ashore: Primary Medical Care Primary Medical Care -

Internal Medicine,

Internal Medicine, Infectious Disease, OB/GYN, Pediatrics, Infectious Disease, OB/GYN, Pediatrics, Optometry, Dental, and Optometry, Dental, and Mental Health Mental Health. . Project other support functions ashore: Project other support functions ashore:

Disease Surveillance, Field Testing, Laboratory Services, Disease Surveillance, Field Testing, Laboratory Services, Immunizations, Insect Control, Preventive Medicine, Veterinary Immunizations, Insect Control, Preventive Medicine, Veterinary Assistance, Engineer, Supply Distribution and field Assistance, Engineer, Supply Distribution and field-

based

based services determined by HN and NGO partners. services determined by HN and NGO partners.

* *Secondary mission: Shipboard Health Services

Secondary mission: Shipboard Health Services

MISSION MISSION

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1

MERCY OPERATIONS SEQUENCE MERCY OPERATIONS SEQUENCE

RTHP San Diego

05 May 6 Jan 29 Jan

Singapore VIC Banda Aceh, ID Majuro, MH

22 Apr

Transit Transit HADR Assistance Ops Medical / Dental TSC Events

LOCATION

Kepualuan Alor, ID Dili, TP Singapore U/W from San Diego Pearl Harbor

3 Feb 19 Mar

Madang, PG

As of 17 Mar 05

Unclassified Unclassified USPHS 1ST Rotation

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INDIA INDONESIA Colombo U-tapao SRI LANKA Medan

Med Team

Aceh

2 x C-130 LPA – CJTF 629 Helos x 2

Khao Lak

1 x DVI Team Male Med Team Ships x 4 Helos x 3 Fixed wing x 3 Medical Team x 4 Ships x 5 AN-32 x 7 MI-8/17 x 6 Helos x 3 Fixed Wing x 2 Medical Team x 2 C-130 x 6 B-707 x 1 UH-1 x4 LST x 2 C-130 x 5 CH-47 x 4 Super Puma x 4

Darwin

Hospital Ship Helos x 2 French Ships X 2 Helos x 8 Med Team Swiss Helos x 3 ETA: TBD FFG ARS 2 x helos Ship x 1 Enroute C-130 x 1 Ships x 2 LPD/AOR CH-47 x 3 HH-60 x 2 Med Team

Participating Nation Military Operations Participating Nation Military Operations

C-130 x 1 Ships x 2 C-130 x 2 Ships x 2 Eng Team

UNCLASSIFIED UNCLASSIFIED

C-130 x 1 Water System Field Hospital C-130 x 2 Ships x 2 Helos x 3 Med Team Eng Team Field Hospital Eng Team Fixed wing x 1 MP Team C-130 x 1 Hospital Ship Ship x 1 C-130 x 2 Helos x 2 Med Team Eng Team RNZAF B-757 in region

Meulaboh

Ship x 1 Helo x 1 DART Team ROWPU x 4 Med Team Eng Team Forensic Team C-130 x 1 LST to ID LST to SL Helos x 4

K.L.

Helos x 1 C-160 x 2 Field Hosp Eng Team x 2 ALT x 2 HH-60 x 2 Field Hospital Ships x 30 Helos x 30 Fixed Wing x 22 Med Team Eng Team C-130 x 2

AUS AUT BGD IND JPN KOR SGP NZL MYS GBR FRA DEU PAK CHE CAN BRN NOR LKA IDA THA

Ships x 7 Ships x 12 Helos x 13 Fixed Wing x 5 Ships x 28 Helos x 2 Fixed Wing x 15

USA

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Click to edit Master text styles Click to edit Master text styles Second level Second level Third level Third level Fourth level Fourth level Fifth level Fifth level

CLERK

INDIA CHINA PHILIPPINES Diego Garcia Medan Jakarta B-Aceh Male Phuket U-Tapao Colombo MALDIVES SRI LANKA AUSTRALIA SINGAPORE INDONESIA MALAYSIA Darwin THAILAND Butterworth Sumatra Meulaboh

THAILAND 35 NGOs Operating

Thai Red Cross: food

distribution

World Vision Int’l: building

materials, water/sanitation facilities THAILAND 35 NGOs Operating

Thai Red Cross: food

distribution

World Vision Int’l: building

materials, water/sanitation facilities ANDAMAN / NICOBAR

ICRC
Catholic Relief Services:

home rebuilding ANDAMAN / NICOBAR

ICRC
Catholic Relief Services:

home rebuilding MALAYSIA (Near KL)

Malaysian Red Crescent

MALAYSIA (Near KL)

Malaysian Red Crescent

MALDIVES 17 NGOs Operating

Save the Children

MALDIVES 17 NGOs Operating

Save the Children

SINGAPORE

ICRC Regional Hub

SINGAPORE

ICRC Regional Hub

SRI LANKA 84 NGOs Operating

ICRC: household items,

shelter, water, medical care

IFRC: household items,

shelter, food, water, medical care

Oxfam: water, sanitation
IOM: water
Care Int’l: general relief

items

Mercy Corps: cash-for-

work, household items, food, water SRI LANKA 84 NGOs Operating

ICRC: household items,

shelter, water, medical care

IFRC: household items,

shelter, food, water, medical care

Oxfam: water, sanitation
IOM: water
Care Int’l: general relief

items

Mercy Corps: cash-for-

work, household items, food, water

Civilian Relief Operations Civilian Relief Operations

Banda Aceh

Indonesian Red Cross: cooking/

hygiene items; water/sanitation

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

food, relief supplies

IOM: shuttling IDPs
Care Int’l: food

Banda Aceh

Indonesian Red Cross: cooking/

hygiene items; water/sanitation

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

food, relief supplies

IOM: shuttling IDPs
Care Int’l: food

Meulaboh

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

work, food

Meulaboh

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

work, food

Medan

Medecins Sans Frontieres
IOM: shuttling IDPs

Medan

Medecins Sans Frontieres
IOM: shuttling IDPs

INDONESIA

68 NGOs Operating

INDONESIA

68 NGOs Operating

Kuala Lumpur

Unclassified Unclassified

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

Part humanitarian relief Part international diplomacy Part global public relations Part experiment in military-civilian joint

perations

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Constraints of timing

– on-site arrival (6 weeks post-incident) defines nature of med/surg and mental health activities

Constraints of access

– to potential aid recipients, planning partners and ready communication

Constraints of time (in theater)

– limiting access to target populations and

rganizations

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

CONSTRAINTS TO MENTAL CONSTRAINTS TO MENTAL HEALTH MISSION HEALTH MISSION

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OPERATIONS PLAN OPERATIONS PLAN

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FOCUS ON BEHAVIORAL FOCUS ON BEHAVIORAL HEALTH HEALTH

BANDA ACEH, INDONESIA BANDA ACEH, INDONESIA

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Mental Health Infrastructure Mental Health Infrastructure Aceh Province, Indonesia Aceh Province, Indonesia

Before the disaster

– Psychiatry rare ~1/2 dozen in province – One psychiatric hospital. No institutionalized system of community care for the seriously mentally ill. – No psychology – No social work – Unable to determine the nature and extent

f role of Islamic leaders in psychosocial

care

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Before the disaster

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

After the Tsunami

– One flooded, marginally cleaned, still US 1950’s vintage psychiatric hospital – 60+ patients remain, the others died in the wards or escaped as the waters rose

Mental Health Infrastructure Mental Health Infrastructure Aceh Province, Indonesia Aceh Province, Indonesia

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BANDA ACEH, INDONESIA

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Factors promoting emergence of Factors promoting emergence of psychosocial symptoms psychosocial symptoms The acute response phase of the disaster has passed In addition to the enormous loss of life, there is widespread social disruption and economic and institutional destruction Rebuilding is on a slow track because of endemic mismanagement and tepid political support for the province

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Acute response phase has passed Great loss of life + widespread social, economic and institutional disruption Rebuilding slowed - mismanagement and tepid political support for the province Unavoidable, omnipresent traumatic reminders (everything has been touched by earthquake / tsunami)

Factors promoting emergence of Factors promoting emergence of psychosocial symptoms psychosocial symptoms

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The large number of missing delays the important process of grieving for many Population has access the emotions of pain and loss and the Culture has language to express it Emergence of religious justification of events Unavoidable, omnipresent traumatic reminders (everything has been touched by the earthquake and tsunami)

Factors promoting emergence of Factors promoting emergence of psychosocial symptoms psychosocial symptoms

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12 August 2005

“…the tsunami triggered an...unprecedented attention to the mental health of the survivors, many of whom saw their children

r other family members carried away by the waves.”

The WHO suggested that: 1) 50% of the 5 million affected people would experience psychological distress that would fade without intervention over the course of a year or more. 2) Roughly 5% to 10% would develop more persistent problems, such as depression, posttraumatic stress disorder (PTSD), or

ther anxiety disorders that would be unlikely to resolve

themselves without intervention. 3) And perhaps 1% to 2% would be left with incapacitating mental problems such as major depression or psychosis.

NEWS NEWS

The Tsunami The Tsunami’ ’s Psychological Aftermath s Psychological Aftermath

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Mental Health Observations Mental Health Observations Banda Aceh, Indonesia Banda Aceh, Indonesia

Respectful reluctance to speak of events use of avoidance, redirection, rather than denial Willingness and interest in speaking of events when topic arises unavoidably An ability to express and share sadness

– Father, son and former insurance agent

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Mental Health Observations Mental Health Observations Banda Aceh, Indonesia Banda Aceh, Indonesia

Expressed optimism about the future and simply stated resignation about the tragedy An understanding that events, feelings and function in the world are linked

– the father and a foundation – psychosis and miscommunication

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

Islam teaches that human beings have no control over matters of life and death. The day of death for every individual is decided upon his birth. Daily prayer ritual provides continuation

f pre-disaster routine and reminder of

God’s presence and will. Islamic charities very active in humanitarian relief post-disaster

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

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

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12 August 2005

NEWS NEWS

The Tsunami The Tsunami’ ’s Psychological Aftermath s Psychological Aftermath

“At the same time, many people who have worked with tsunami survivors are struck by their resilience. Asian culture, with its emphasis on group welfare over individual self-reliance, seems to have been a powerful, positive influence.” Sadly, a long-standing familiarity with upheaval and tragedy may also have bolstered the coping mechanisms of many tsunami survivors. People here have a tough life to begin with,…The expectations in life are very different from those in the West. Many people…view the tsunami more as the latest obstacle life has thrown at them than as a cataclysmic blow.”

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What Interventions Make Sense? What Interventions Make Sense?

Institutional Institutional

– – Support existing institutions Support existing institutions – – Rebuild destroyed ones Rebuild destroyed ones

Individual Individual

– – Provide individual or group services Provide individual or group services

Population Population

– – Adapt well Adapt well-

heeled population interventions to

heeled population interventions to current cultural context current cultural context

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

Restore homes, community, institutions and economic infrastructure Provide psychosocial education through community leaders, networks and structures (“erte”)

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

Primary care/mental health professional development

– reconstitute preexisting established professional structure – consider primary and maternal child care cross-training – Use health care professionals and paraprofessionals to disseminate pyscho- educational information

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

Make substantial outreach to faith leaders to encourage:

– a declaration of pardon to relieve followers who were not able to perform death rituals – a statement clarifying position on the personal/population blame for the disaster – advice to those whose loved ones are still missing – the provision of faith-appropriate psycho- educational information

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THE HOME STRETCH THE HOME STRETCH

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“ “They knew to run They knew to run…” …”

The Sydney Morning Herald The Sydney Morning Herald By Lindsay Murdoch, Correspondent in By Lindsay Murdoch, Correspondent in Simeulue Simeulue December 30, 2004 December 30, 2004 They knew to run on They knew to run on Simeulue Simeulue, a palm , a palm-

fringed island

fringed island closest to the closest to the epicentre epicentre of Sunday's devastating

f Sunday's devastating

earthquake. earthquake. "Our ancestors have a saying "Our ancestors have a saying -

if there is an

if there is an earthquake run for your life," earthquake run for your life," Darmili Darmili, the mayor of , the mayor of the island, said yesterday. "Thousands of our people the island, said yesterday. "Thousands of our people were killed by a tsunami in 1907 and we have many were killed by a tsunami in 1907 and we have many earthquakes here." earthquakes here." Only five of 70,000 villagers on Only five of 70,000 villagers on Simeulue Simeulue were killed were killed, , all of them in the earthquake that struck at 7.55am all of them in the earthquake that struck at 7.55am last Sunday. Nobody perished in the five last Sunday. Nobody perished in the five-

metre

metre-

high

high walls of water that followed. walls of water that followed.

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A NARROW ESCAPE

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LAMNO

LAMNO Isolated from points North, South and East

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