Psychosocial aspects of the tsunamis

Published: 3 November 2005

Thanks for your invitation, I am very honoured. You are all professionals in the field of traumatic stress, so I would like to tell you the story of the tsunami in four parts: describe and characterize the event, the unique response, some specific psychosocial aspects based on our experiences but also some concerns regarding the state of this field, and finally some conclusions.

But let me begin by showing you a short video which will also serve as a kind of table of contents of this presentation.

I. The event

We have difficulties finding words for the tsunami; we tend to repeat expressions such as "unique" and "unprecedented". What was so special was the combination of factors:

1. An extremely strong earthquake - 9 on the Richter scale, shifting tectonic plates on the bottom of the sea that rose, creating a wave of enormous force, travelling in concentric circles from the epicentre east of Aceh in Northern Sumatra in Indonesia, its deadly energy contained in a few waves that rose as they reached shallow waters near the shores, after only a few minutes in Aceh and islands along its coast, then in Malaysia and Thailand, moving with less strength north towards Myanmar and Bangladesh, but with much conserved energy westwards across the Indian Ocean, striking Sri Lanka, India with the Nicobar and Andaman islands, the Maldives, and further west the Seychelles, Somalia, Kenya and Tanzania. All in all 12 countries.

2. No warnings were issued - only in Bangladesh with a well established early warning system and Kenya where the police actually evacuated people from the beaches. Interestingly, the only other people who were saved were those on islands where the stories of tsunamis experienced by their forefathers had been passed down orally through generations. That was where people understood the sign when the sea suddenly receded. But there was no system for early warning in the Indian Ocean.

3. It was 26 December, known as Boxing Day in many countries. This is why there were many Western holidaymakers on the West coast of Thailand, and also in Sri Lanka, people with cell phones and digital cameras. In their countries of origin people were also on holiday and could follow all the news on radio and TV as they started to build a picture of a horrific event. The tsunami was captured as an event of cinematographic qualities.

4. Impact was extraordinary - the tsunami waves surged 8, 10 up to 12 kilometres in Aceh, went across whole islands in the Maldives, the grotesque images of the train Queen of the Sea that runs along the coast of East and South East Sri Lanka, thrown off the tracks by the tsunami with more than 800 trapped inside and drowning, showing the collision between ordinary, every-day life in the form of a train ride and the sudden and ruthless forces of nature.

5. The figures summarising the tsunami are numbing: 228,000 dead or missing and more than 2 million displaced. The highest numbers are in Aceh, followed by Sri Lanka, India and Thailand. In the Maldives, only 108 are dead or missing and 21 000 displaced, but the small island state with 300,000 inhabitants, completely relying on tourism, now faces a very severe economic crisis.

The enormous force of the tsunami from which only the strongest could survive, striking at a time of day when communities were separated along gender lines; fishermen on the sea while women and children were at their homes on the coast, or the elderly out on fields on higher land as in parts of Aceh, led to an impact with a clear demographic dimension. More men than women survived, more children than adults died.

6. This was a disaster affecting the whole world, including the West. In Sweden, the country most affected with some 20,000 tourists spending their Christmas holiday in Thailand, 543 are dead or missing, remarkably 523 of these have been identified. Together with the Estonia ferry disaster in 1994, when 501 Swedes out of 852 died, these are without comparison the worst tragedies in Sweden in modern times.

Along with the slow process of victim identification, with regular sending home ceremonies in Phuket, with a streak of nationalism almost as if the victims were soldiers killed in action, week after week of obituaries on the family pages of Swedish papers, whole families, children, parents, grandparents, newly wed couples on their honeymoon - a cross section of middle class Sweden on holiday. Sweden has been in mourning along with the directly affected countries.

7. A regional disaster, completely unexpected, on a major holiday, captured and repeated on TV screens across the world, leaving behind overwhelming death and destruction affecting many countries beyond the region, this was indeed a unique disaster. And a unique disaster created a unique response.

II. The response

1. This was seen by many people as an Act of God against the innocent. It was easy to understand and identify with those struck by this blind force of nature. For the West, it was easy to identify with the victims as westerners were among them. And there were many stories of selfless Thais who assisted tourists who were stranded, showing a generosity that seemed to further make us understand a fundamental predicament in many of the affected countries - that of insecurity as a key aspect of poverty.

Those of us who had been working for years to promote disaster reduction, an often abstract concept, were struck by the insights of politicians and media who had seen what it meant to be prepared as the islanders in Semelou or the Andamans, the importance of protection offered by mangrove and other coastal vegetation, and of course, the logic of early warning.

2. Immediately, large fundraising campaigns began all over the world. Rather than looking for donors, individual citizens were looking for organisations they could fund to help the victims.

Governments gave, corporations gave, everybody gave. Countries like the Solomon Islands, Mozambique and Lithuania appeared on the list of donors. Organisations, the Red Cross and Red Crescent Societies in particular, received volumes of funding that we could only have dreamed of.

Some organisations, MSF in particular, started to decline further funds declaring that they had received all they could use.

Others, such as the Red Cross Red Crescent, kept collecting funds on the basis that they would be engaged in the recovery effort for the long haul. For us, the list of contributing member Societies now includes more than 90 and the total amount collected over 2 billion USD, approximately 25% of the total amount pledged globally for the tsunami. This is indeed unprecedented in the history of this organisation.

The fact that so much money came from the individual public has had implications for the way recovery programmes are implemented, as we will see.

3. As is always the case, the first response was local. Family members, neighbours, volunteers, local government and organisations provide the first life-saving assistance. But soon NGOs, international organisations and the UN started arriving in numbers almost never experienced before.

The result was a lack of coordination, a fragmented picture of needs, and an early response that can only be described as chaotic. Some poor practices could be observed - arrival of relief items that had not been asked for, competition for survivors to help, and a disregard for the role of national authorities and organisations.

Still, we can regard the relief phase as a great success - the survivors survived, there have been no outbreaks of communicable disease and no starvation. The UN Relief Coordinator Jan Egeland has called it nature at its worst and humanity at its best. We managed to help.

4. For us, early response meant deploying all our tools and resources. So called Emergency Response Units, held on stand-by by our members, for water and sanitation, health services, logistics, telecommunications and relief distribution were quickly put to use. We estimate that some 30,000 of our national and international staff and volunteers were mobilised.

5. The generous volume of funding meant that the International Federation could very early start its work on a regional strategy and operational framework to guide the long-term response for tsunami recovery and reconstruction. Psychosocial support was included as a prominent area and one where the Federation and several of our members had significantly developed their capacity during the past 10 years.

III. Psychosocial support as part of the Red Cross Red Crescent response

1. Our policy states that psychosocial support should be an integral part of all interventions.

We view it as a long-term intervention; it addresses needs of the affected population as well as of volunteers and national and expatriate staff. It addresses communities rather than individuals, taking their particular cultural characteristics into account. It builds on the contributions provided by volunteers, trained and guided by professionals.

We emphasize the need to work in collaboration with other actors, not least government services for referral of individual cases with needs beyond the scope of our interventions. When we work in Sri Lanka it may look something like this (see video clip from Sri Lanka).

2. Just as there was a lack of coordination of the immediate emergency response, with good practice not always followed, the same can be said for interventions in the psychosocial field, although I have seen no effort towards a broader mapping of what has been provided.

However, there seems to be a wide range of external actors, many with no previous experience from the affected countries, some with pre-conceived ideas of what was needed. This is problematic, not least in an area where there is no consensus on what is best or at least good practice. There is anecdotal evidence of competition and conflicting approaches from different actors.

Outsiders, with a more therapeutic approach are contrasted with those who had already been working for a long time among conflict-affected communities in Sri Lanka, who emphasised meeting social and material needs, informed by previous experiences.

3. For a layman like myself, looking at a kind of intervention where you would expect extreme sensitivity towards people who are in their weakest and most exposed moments, extremely vulnerable, it is difficult to understand that this field is characterized by "a lack of consensus on goals, strategy and best practice" , or as expressed by someone who was involved in support to victims of the conflict in Sri Lanka before the tsunami: "The polemical nature of the debates in the field, has made the accommodation of diverse perspectives and methodologies within a single framework difficult".

It seems that the differences relate particularly to a more individual, counselling or therapeutic approach contrasted with a more community-based approach, where a range of activities and interventions are seen to contribute to reorientation and psychosocial wellbeing, and the possibility for referral of serious individual cases.

4. To us, the conceptual framework developed by the Psychosocial Working Group makes much sense. It looks at individuals as part of families or households who are located within an affected community. Their psychosocial wellbeing is defined through the core domains of human capacity, social ecology and culture and values. These in turn correspond to the human, social and cultural capital available to people to respond to external challenges.

Interventions can be provided in all three domains, or using the corresponding capital which of course are interlinked. The framework also acknowledges that the intervening external community also comes with its human capacity, social ecology and culture and values. Ultimately, a successful intervention will build on open communication and negotiation between the two.

5. Let me mention three examples with psychosocial implications that I have come across which emphasize the need for good contextual understanding. First, one agency, Help Age International, has observed very worrying signs of deteriorating mental health among elderly survivors in Sri Lanka, a clearly neglected group, including clinical cases of depression.

The loss of sense of individual value and dignity as assets meant to be inherited by younger relatives have been lost; the loss of meagre means of making a living, leading to dependency on relatives and agencies; the inability to grieve and come to closure in cramped IDP camps - all contributed to deteriorating mental health, particularly when put in relation to the capacity of overwhelmed mental health services.

But Help Age International also pointed to the success of organising a pilgrimage to a holy site in Sri Lanka. Those attending spoke of the tremendous importance and impact of completing rituals and religious duties to the dead, how the clouds of depression had lifted.

6. Second, in the Maldives more than 20,000 homeless were brought together under camp-like conditions likely to last for at least a year as new housing projects were planned and implemented.

A country, little known by outsiders except as a tourist resort, revealed other situations of concern. High and increasing levels of drug - particularly heroin - addiction among youth, frequent incidences of domestic violence and child abuse became apparent, where the cramped living conditions for the displaced seemed to exacerbate the situation. Social capital and the strength of cultural values seem insufficient in a changing society under great strain.

7. And third, and somewhat unexpectedly, it seems that the large volumes of funding from the public have led agencies to neglect their obligation to be accountable to their beneficiaries, particularly in Aceh.

Keeping media and the donors informed about their actions, best of all the rapid construction of houses, seem to have been the main focus of the organisations. But the people still in tents or living with host families remain uninformed. A UNDP study in Aceh showed that much of the population, women in particular, were unaware of what was going to happen to them, of the plans of agencies and the government and why they were still waiting for a home. This obviously made the psychological stress already experienced worse.

IV. Conclusions

So let me try to conclude. The tsunami graduated as a global disaster through the overwhelming response, showing what humanity is capable of. In spite of a partly chaotic relief phase, people received the help they needed.

The tremendous generosity of the global public has enabled us to engage in a long term programme for recovery and reconstruction. This includes psychosocial recovery - we can only remotely sense the pain of all those who lost everything. But questions remain.

Why do external agencies intervene without knowledge of a community's history and values, claiming they know how to address its grief?

Why is there no agreement on good practice of psychosocial interventions?

Where is the evidence on which we can agree and use to plan our programmes?

The steadily increasing number of disaster victims should have a right to expect these questions to be answered. You who are active in the area of trauma and stress have a very important task before you.

The IFRC and its worldwide network of Red Cross and Red Crescent member societies are committed to this goal.