In Sri Lanka, a holistic approach to recovery

SUN HERALDJuly 27, 2008 

It was morning when the water unexpectedly rose and rushed ashore, destroying nearly everything in its path. The human toll was inexplicable and fears of a mass mental health crisis were profound.

Those are just some of the many similarities between the Indian Ocean tsunami of 2004 and Hurricane Katrina in 2005. While the number of victims was much larger in Asia - more than 250,000 people were killed in the tsunami - the aftermath presented comparable challenges.

In one such similarity in Sri Lanka, which had the second-highest death toll from the tsunami, the world responded to the crisis not just with a deluge of bottled water, food and clothes, but also with psychiatrists, trainers and counselors. This is a pattern emerging for disasters worldwide.

Within a month of the disaster, according to reports, there were an estimated 300 aid organizations like the Red Cross and Oxfam in Sri Lanka, a fourfold increase. They all offered some way - sometimes unique, sometimes competing - through the grieving.

Besides occasionally contradictory agendas usually not coordinated with each other, only half of those aid organizations in Sri Lanka even registered with the government, said John Mahoney, the director of the World Health Organization's mental health initiative in Sri Lanka since the tsunami.

"Sri Lanka just opened its doors... there was no checking," Mahoney said. "We found one organization just handing out antidepressants to people."

Many locals began questioning whether the vast resources being poured into how to heal people were effective.

Within six months, committees were formed by pre-existing aid organizations to figure out exactly what was needed and who was offering services, Mahoney said. Before long, an overall picture of the mental health situation emerged.

"I was very frustrated after the tsunami because I lost everything," said Randombage Soma, 56, through a translator. Soma is a secondary school religion teacher from the village of Wattegama in southern Sri Lanka. Besides losing her home, she said her ailing mother had been unable to outrun the waves and died. For a brief while, Soma's frustration brewed.

Immediately after the disaster, WHO officials estimated more than 100,000 people could have lasting psychological effects. Recently, however, they have downplayed that estimate.

"We knew from previous disasters that 90 to 95 percent of people will (completely) recover, are incredibly resilient," Mahoney said.

Soma was one of them. Today, she said she can face the ocean again without fear, and no one in her large circle of family or friends, all of whom lost something or someone, suffers mentally from what happened. Life goes on, she said, and people should not fear disasters.

From pre-tsunami to today, there were and are only about 50 licensed, practicing Sri Lankan psychiatrists and psychologists in the country to help catch that 5 percent of survivors who might be ailing greatly.

One of those, Dr. Mahesan Ganesan, was the only psychiatrist for more than 1.4 million people in eastern Sri Lanka when the tsunami hit. The northeastern province he practiced in received some of the worst damage.

Because of his expertise, he and other local professionals formed an unofficial committee and began coordinating local disaster response.

"We didn't take a mental health approach," said Ganesan. "We took a psychosocial approach, more kind of a preventive (approach.) There is no way we can hold back the effects of the tsunami, but what we can do is to make sure that that burden" is lessened.

Ganesan said that in any traumatic event, there are two things that cause mental suffering.

"One is the grieving," Ganesan said. "The other is worries: worries about housing, worries about income generation. So it was that that we needed to prevent."

Throughout the rest of the country, and in some cases the world, people took notice of Ganesan's approach.

Today, Dr. Hiranthi de Silva, director of mental health services in the Ministry of Health, said focusing on making everything well and not just the mind has become the official approach. Throughout the country, de Silva said, they are establishing psychosocial centers, not mental health centers, to be prepared for future disasters and to help in everyday life.

This approach to post-disaster mental health, say many people like Ganesan, is a better allocation of funds than the Western approach of saturating disaster zones with psychiatrists and counselors.

In explaining the reasoning for this approach to a reporter immediately after the tsunami, Ganesan gained some international renown while echoing Sri Lanka's Buddhist roots when he said, "To suffer is to survive. To bear it with grace and dignity is to live."

The series
Post-disaster mental health, like mental health in general, is a dark art. While there is a lot of research and many years of practice in both, there is no guaranteed, positive way to handle post-disaster mental heath issues like there is, say, a broken bone or a cut.

The general agreement among American professionals is that disasters necessitate some sort of mass public mental health intervention. However, figuring out exactly who will be affected and how they are affected exactly is still anyone's guess.

This three-part series examines what has happened in Sri Lanka since the tsunami in terms of mental health issues through the lens of the post-Katrina experience.

Sunday: The Sun Herald looks at the response itself. There was a troupe of organizations that rushed in to lend a hand, to rebuild homes and rebuild allegedly fragile psyches. What did they do? What did they offer?

Monday: The Sun Herald looks at how individual Sri Lankans are recovering today. About 30,000 people died in the tsunami in Sri Lanka, so nearly everyone either lost someone they knew, or knew someone who lost someone they knew. At the same time, the population is dealing with an ongoing 25-year civil war and has dealt with large-scale trauma repeatedly. Prior to the tsunami, Sri Lanka had one of the highest suicide rates in the world. What kind of effect did that have on their mental health recovery from the tsunami, if at all?

Tuesday: The Sun Herald looks at what Sri Lankans have to say to their Gulf Coast counterparts as they glimpse into the future of disaster mental health. Mentally, why and how did the Sri Lankans get to where they are today?

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