Feature: Aftermath - In the wake of the tsunami

18 July 2007. By Penny Bailey.

Learning how to deal with the impact of disasters.

Three years after the Boxing Day 2004 tsunami receded from Sri Lanka's shores, the tragedy continues to haunt survivors in subtle and perplexing ways. A steady stream of Sri Lankan adults and children are visiting doctors complaining of a range of physical symptoms - from headaches, chest and abdominal pains, and respiratory problems to fatigue and sleep and memory disturbances. Similar physical complaints have been reported in survivors of catastrophic events elsewhere in the world, including a 'World Trade Center syndrome' among people affected by the 9/11 attacks.

Such medically unexplained symptoms present a problem for doctors, who can find no direct cause for them. "Doctors try to reassure patients that there is nothing wrong, or just treat the symptoms," explains Dr Athula Sumathipala at the Institute of Psychiatry, King's College London. The result is that people continue to suffer without knowing why, and go from doctor to doctor in search of answers and relief. The solution, he says, is to take into account psychological, social and physiological factors rather than a purely biological approach.

Two trials in Sri Lanka in 1997 and 1999, funded by the Wellcome Trust, found that distress, costs and the number of visits to healthcare providers could be reduced by 'simple structured care'. In this approach, a doctor aims to understand what is causing the distress, and then provides treatment in weekly half-hour sessions. A more specialised psychological intervention, cognitive behavioural therapy (CBT; see box), was even more effective, but more expensive because healthcare workers require intensive training. It therefore makes sense for doctors to start with structured care, and add CBT if further help is needed.

Both approaches can be delivered by primary healthcare workers, exploiting one of Sri Lanka's strengths. Although the country has only a small number of mental health institutions, operating on similar lines to asylums in Victorian Britain, and 30 psychiatrists for a population of over 20 million, it has an impressive level of maternal and child care, and preventative services with strong immunisation programmes. Indeed, Sri Lankan neonatal mortality and life expectancy rates are comparable to those in the West. The system's effectiveness was demonstrated by the notable absence of communicable diseases following the tsunami.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) focuses on the causal links between what a person thinks about themselves or a situation and the way they feel and behave. The individual and therapist work together to understand and change the ways of thinking that are causing distress or making it hard to live a normal life.

Unlike counselling, which offers people support and an opportunity to talk about their feeling, CBT is very structured, and undergoes extensive testing before it is used in routine clinical practice. The therapy is used to treat a wide range of illnesses, including post-traumatic stress disorder, depression, panic disorder and eating disorders.

After the tsunami

Immediately after the tsunami, the Sri Lankan President set up the Centre of National Operations (CNO) to coordinate relief work, and asked Dr Sumathipala and colleagues to staff its psychosocial arm.

Working in consultation with the UK-Sri Lankan Trauma Group - established in 1996 at the Institute of Psychiatry to help develop capacity in dealing with war-related trauma - Dr Sumathipala's team and others set about bringing the problem of post-tsunami medically unexplained symptoms to the attention of health workers.

Their first step was to hang posters explaining medically unexplained symptoms, for patients and doctors, on the walls of hospital walk-in clinics. This campaign was then backed up by workshops funded by the World Health Organization (WHO) across the country, which trained over 300 doctors in structured care and CBT for distressed individuals.

The psychological welfare of children - hundreds of whom had lost their families and homes - became a priority. "Schools became camps for adults and children who had lost their homes. We started a national campaign, using the slogans 'Children Back to School with Dignity' and 'Children First, Even in Disaster' to reopen the schools as soon as possible," says Dr Sumathipala. Within three to four weeks all the schools were open and children were going back to school, equipped with 200 000 school kits, including uniforms and new books and learning materials, donated by UNICEF.

Among the influx of foreign relief workers and volunteers, mental health workers from all over the world came to lend their help. But, argues Dr Sumathipala, their methods were not always culturally sensitive or locally appropriate: "They meant well, but most of them didn't speak either of the two Sri Lankan languages, and one-off compulsory counselling sessions for everyone, which these workers were recommending, was against scientific evidence. And completely unnecessary: we have very strong, rich local resources for dealing with bereavement."

Problems also arose with foreign researchers who came to study the effects of the tsunami on the population. In the absence of a central research ethics committee in Sri Lanka, many of these were able to collect data from people in camps simply by asking permission from the police, or from contacts in Sri Lanka, without any rigorous ethical clearance. "Some of this research was highly unethical. For example, eight-year-olds in camps were asked whether they were manipulated sexually, and in another project they collected blood to find out neurobiological markers of stress," says Dr Sumathipala.

In an attempt to contain the situation, his group held workshops and used mass media to stress the importance of ethical clearance for research - particularly research on vulnerable individuals - through the 'Prevent Re-traumatising of the Traumatised' campaign, and worked with 50 professionals whom they had trained in research ethics, funded by the Wellcome Trust Biomedical Ethics Programme. In October 2005, Dr Sumathipala and colleague Dr Sisira Siribaddana published an article in the Lancet, appealing to journal editors to ensure that any post-tsunami research they published had ethical clearance from the country where it was done.

For Sri Lankans, the impact of the tsunami is being felt. In Colombo district, for example, which was not badly affected by the tsunami, 20-50 per cent of patients coming to primary care doctors have medically unexplained symptoms. To discover the effect of the problem, an island-wide survey has been commissioned to find out the prevalence figures for medically unexplained symptoms and all common mental disorders.

Work remains ongoing, and lessons learned from the tsunami - in particular the need for genetic services to identify bodies, and to ensure that research meets international ethical guidelines - are helping to shape the future of research and practice in Sri Lanka. The Sri Lankan Ministry of Health and the newly formed Ministry of Disaster Management and Human Rights are now supporting plans to establish a state-of-the-art genetics laboratory in Colombo (funded by the Wellcome Trust, in collaboration with the Human Genetics Programme of the WHO and King's College London), and a programme for managing dead bodies in collaboration with local and expatriate forensic experts. A central ethics committee dedicated to the tsunami is also being established.

Experience gained in Sri Lanka is also having an impact beyond its rebuilt shores. After the October 2005 earthquake struck Pakistan, Dr Sumathipala and colleagues trained 25 psychiatrists to deliver structured care and CBT to survivors suffering from medically unexplained symptoms, and in January 2007, a Wellcome Trust-funded Working Group on Disaster Research and Ethics brought together experts from Sri Lanka, Pakistan, India and Thailand to develop a draft of a national and international ethical frameworks for research following a disaster.

Showing respect

In the devastation that followed the wave, many bodies were quickly buried or cremated in mass graves. This meant that survivors who had lost loved ones and relatives were deprived the succour of knowing what had happened to them, and of burying and mourning them with dignity.

"Identifying the deceased has huge implications for living people to help them through the grieving process," says Dr Sumathipala. "The WHO and Pan American Health Organization have published a manual for handling dead bodies during disaster,1 which states that dignified burial is a basic human right. We worked with politicians to get these manuals to the Prime Minister and President, so that although bodies couldn't be kept long, they were at least wrapped in a piece of clothing to dignify their burial."

Penny Bailey is a writer at the Wellcome Trust.

Reference
1. Management of Dead Bodies in Disaster Situations. Washington, DC: PAHO/WHO; 2004.

Further reading

• Sumathipala A, Siribaddana S. Research and clinical ethics after the tsunami: Sri Lanka. Lancet 2005;366(9495):1418-20.
• Sumathipala A et al. Management of dead bodies as a component of psychosocial interventions after the tsunami: a view from Sri Lanka. Int Rev Psychiatry 2006;18(3):249-57.
• Sumathipala A et al. Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka. Psychol Med 2000;30(4):747-57.