Trauma Doctor

15 SOCIETAL TRAUMA 101 -- 18 LESSONS

2005-12-17T10:48:00.000-08:00

Disaster 101 and the Quantity of mercy

David Ratnavale MD

Into the Ark they went, two by two. Archetypal father of disaster management had no pen, no grant application to fill, but the story of Noah illustrates one of the cornerstone principles for understanding emergencies and disasters (of any type) - the assumption that in disasters virtually everyone is vulnerable and must therefore be protected.

Preparedness, yes: but in a world already bursting with man made tragedies of various wars and near daily terror incidents, major natural disasters have been piling catastrophe on catastrophe. A centuries worth of experience and lessons have come to us in less than a year, but the procession of tsunami, hurricanes and earthquakes seems to be sapping our ability to sustain a response beyond the initial squirt of adrenaline.

Disaster management capacity is reaching disaster levels, as desperate needs overwhelm all available resources, and compassion fatigue exhausts crisis response. Indeed, the quantity of mercy is heavily strained; It drops no longer as the gentle rain from heaven upon the place beneath. It seems twice cursed, hardly blessing him that gives or him that takes. The Merchant of Venice: with apologies to Wm Shakespeare.

But learn we must: I have spent a good part of the last decade involved in “managing” disasters of both natural and man made origins my own experience with disaster planning, emergency response and long term recovery in a number of countries and cultures leaves me with a short list of universal truths about disaster readiness, response, relief and repercussions, four R’s.

18 basic Issues herewith. A first draft of “Disaster 101” Bear in mind, each “lesson” comes in two parts: an observation and a reminder of the emotional impact. Eighteen lesson points, commonsense conclusions advanced to elicit comment and new insights. Best lesson formulations are invited.

1. Disaster: the human and political crisis which erupts when desperate needs suddenly overwhelm available resources.

True to every disaster, wherever it might strike, man made or natural, human disaster is by any definition an emergency. From 9/11 to Tsunami, from Bali to Bosnia, Hutu to Hiroshima, Kashmir to Katrina, or to wherever next, no real difference; with any disaster, mass trauma or loss, in the east or west - reactions of helplessness, individual and societal.

2. Masses of the miserable.
So many terms are used to define the victims of disasters, all with special meanings and political overtones. Refugees from Vietnam, “asylees” from Cuba, “evacuees” from the Gulf, the internally displaced and the boat people: But, by any other name, they are people cut adrift, unwanted, shamed and at the receiving end of trauma and abuse. Communities welcome them warmly at first, but hospitality soon wears thin. The quantity of mercy is governed by the laws of supply and demand. Competing for resources and influence becomes a locus of anger and envy. Frustration soon leads to secondary migration, homesickness, mourning and depression.

Disasters invariably create refugees and displacement. The experience of displacement and uprooting compounds the trauma brought about by the disaster create massive displacements with victims needing refuge, but ripped away. Separation anxiety prevails. Helpless, at the mercy of outside pity, refugee life from camp to camp saps every ounce of hope and threatens identity. Huddled masses revert to worst case scenarios. Thrust from seeming plenty and enough basic needs, suddenly rendered helpless and forced to beg for basic bread. Yet, no one seems to be in charge. Wars of one kind or another create refugees that fill an increasing Fourth World. Rejection is painful humiliation and abandonment: The shame of exclusion

3. Fear factor and fear psychosis.

Disasters breach the levees that shield us from the dreaded flood of terror, the fear of separation and abandonment which resides in everyone. The shock of the blow unleashes a primal communal dread. The fear is reinforced by helpless awe at the scale of damage, be it measured in numbers of dead and wounded, people missing, cries from those trapped beneath broken concrete, bloated bodies, walking dead, body parts, or old men weeping. Exquisitely personal, the fear response and its cousin anxiety, un-nerves and blunts reason, spreading to take hold of communities as a whole, even nations. Like a creeping psychosis, fear alters mindsets and infects the body politic, every contact, familiar or foreign, placing everyone at risk, yet delays building levees strong enough.

Collapse of the coalition of compassion: As the experiences which touch the heart and bring tears to the face begin to fade, life seems to move on. Outside attention withers as the news cameras scan for a new crisis scene. All this happens so fast—the cycle of violent blow, response, abandonment - that there seems no time for the victims to understand, let alone explain what they are experiencing as individuals and as a people. There is no coolly balanced perspective, only a rising level of anger and disillusion. Fear is disabling.

4. Media both informs and inflames.

The media rush in, many are outsiders with limited understanding of local cultures and history. They aim a river of “information” to the news-hungry outside world in a race to bring breaking news. It may be sensational, distorted, inflammatory, but you are the first to "know." News is drama, is rated for gripping tales of search and rescue, for morality stories of incompetence and obstruction. The ingredients of fear lie embedded in these messages. Even crisis-seasoned journalists will transmit distress signals of normal fear, their tone and body language betrays a conduit for the horror. Mixed messages will stir unconscious dread.

The hostility of viewers and listeners towards the media that churns out the confusing messages has no real outlet. Rapid fire camera shots (microphone to the face) captures the sobs, but sometimes, becomes a perfect platform for visiting politicians or angered victim, enough to ignite massive societal rage and (revolutionary) burning. Welcome as exciting news, responses can inflict further pain on the victims. Media moguls confuse information with inflammation, create false rumor. Shortage of breaking news could mean media in disaster mode. Mixed messages create mixed emotions.

5. Humanity at risk, humanity responding.

For the outside world, the on lookers from afar, the tragedy stirs primal fears of collective dissolution. As TV-borne images of death, pain, loss, and despair sweep across the globe, the images alter our complacency. Emergency teams fly in, supplies are airdropped, donations flow, rescuers arrive. Invariably, overload of unchecked NGO’s, desperately press those who fund them, keep their jobs. Funding bases swell Frequent squabbles over which one gets to aid whom, with what, or, all too often, scramble for the most heartrending and telegenic victims for attention. Welcome as they are, helpers can sometimes become part of the problem.

6. Group think begins to skew awry with leadership failure.

The power base feels threatened. Cats slip out of the bag one by one, facts come to light, and once quiet members loosen their tongues. The silence, (falsely) assumed to mean consent to past decisions, is broken. As disaster scenarios unfold, group cohesion loosens, past illusions of righteousness and invulnerability fall away. Scapegoats are hunted and the blame game begins. Ignored signals of underlying adversity emerge: how many killed in the long-running civil war, the grievances of the impoverished. Critics can no longer be ignored just to preserve shaky (but cherished) assumptions. As loyalties lapse and secrets leak, leaders are angered. Feeling betrayed and abandoned, hurt feelings prompt manipulation and revenge. The delusion of the groups’ inherent morality is shaken, hidden voices speak up and well schooled “mind guards” cannot shield the leader from the “truth”. Threats of commissions, prosecutions, threat of other political reprisals multiply. Denial doesn’t hold forever, Political complacency is shattered, many jump ship.

7. Hate and anger.

All hell breaks loose and throws us off balance. "Oh my God," the common reflex expression. Autonomy gives way, we seek to regain control. Gods are praised and reviled, but in disasters aftermath it’s still the devils playground. We answer to commands, to anyone in a uniform, to anything solid, to anyone who signifies order. Submission enslaves either to the whip of authority or the cry for food. Pushed to the edge, uncertainty precipitates extremism; hate a suitable mechanism for helping the fragile ego to stay in focus. Someone or something to hate, helps to distract from the pain. Body and soul veer between degeneration and regeneration. Identity confusion, who am I? Body and soul caught in a struggle.

8. Anything to bring order, clutch at a straw.

With no time to think, reason goes fast. Legends are recalled. Doubting confuses wrong with right, right with wrong. Intolerant of ambiguity, desperation gives in to blind faith. Superstition returns to haunt. Generated by sub-surface panic, heroism, devotion and benevolence can also be blinded. Clutching at ultra nationalism strengthens identity, but precipitates extremism.

But denial mechanisms are not effective: How could this happen to us? Such things usually the fate of unfortunates huddled in some far off place, but not to us. Bad things don’t happen to us, good people. The blame game: someone is accountable: the government, the leadership, the party in power, maybe even the victims themselves, the devil or an angry God. Never in our backyard, we thought, but suddenly it is happening on our doorstep. Standard response: Someone else is to blame.

9. Healing and repairing gestures increase.

Leaders shift the blame but hasten to ground zero. Fearing political fallout, they voice the need for unifying the disparate in their common fate, stifle riots and prevent panic. From ivory towers, health pundits will preach on the long term effects of trauma and the ubiquity of special syndromes. Economists will calculate cost. Pundits pump out platitudes to pacify, pronounce protection, mostly warnings, what not to do in a disaster, almost nothing on what must be done, alone, if lost or together. No easy cure for traumatized societies. Accountability and transparency

Spiritual dimension: Because of the centrality of religious beliefs in most cultures, seeking help, finding social support and understanding adversity often take place in the context of the religious community. This was particularly pronounced during the early post-tsunami emergency phases in Sri Lanka and other tsunami affected areas. In more than one respect the community as a whole came together as one, soon after the tsunami. In the immediate aftermath of the tsunami disaster the leaders of the various religious came together creating a harmonizing and unifying influence upon their followers who also came together. Buddhist, Hindus. Muslims and Christians willingly opened their centers of worship to all citizens regardless of their individual religious beliefs. Religion can be used to divide people as it could to unite them. The humanizing effect of prayer

10. Disasters expose fault lines – everywhere.

Earthquakes and tsunamis expose much more than fault lines in the ocean floor. The sudden shock to individuals and communities reveal flaws in our resilience, in the political system, our leadership and in our fellow citizens. These catastrophes tear down everything that braces a society’s scaffolding. With sudden overwhelming stress, cracks run to expose vulnerabilities in our social arrangements, our emergency services, our politics, even our foreign policy. Suddenly everything we thought we could rely on is, not enough. Basic trust is shattered, links are cut, 911 not answered and mobile phones go dead. We do not feel safe, the world is unreliable. We lose our bearings.

Disasters spawn mini-disasters, often exposing problems that have lain hidden for long periods. Eddy currents like a social whirlpool bring up deposits hidden under society’s floor. Welcome as dignitaries and are at disaster sites they inevitably continue to prompt a “how about us?” reaction from those in dire need but not in the tsunami catchment, but also from strategic thinkers who weigh the tsunami beside humanity’s long list of other devastations A number of op-ed writers have spoken of the “man-made, perennial tsunami of poverty here in Sri Lanka. Other commentators note the huge annual death tolls from malaria or any of the other pestilences that afflict millions in many other countries.

11. Disasters bring out the best and worst of human emotions and behavior.

Disaster compounds. They tell of blood and tears, of the divine or bestial levels to which humanity can rise to or sink; concede or not, kith and kin drop to the depths of despair and degradation, everyone’s hidden third world. Human rights abuses will be visited upon women and children, the crippled old and the poor. Be prepared for any contingency, anything comes anything goes. Disaster's violence inevitably lingers beyond the aftermath, and occurs sporadically down the road.

The darker side of instinct raises its ugly head. Along with great heroism and the heights of human spirit come acts of looting, violence, rape and vandalism. Unimaginable crimes seize the headlines. A vendetta somewhere or suddenly an opening for revenge long withheld. Happens on the frontlines, with collateral damage and friendly fire, happens after any disaster, 9/11, forest fire arson, Asian tsunami, Katrina, Rita, others waiting landfall, and now in earthquake in Pakistan or Central America. Imagine, some people were actually shooting at doctors tending patients at deaths door: all this as if post-disaster phenomena are unusual and inhuman. Not so. Denial mechanisms cannot easily hold up to reality.

Sex and violence find outlets. Unexpected to the outside visitor is the neighbor-on-neighbor depravity, the rape of the helpless, even the dead, human trafficking and pedophiles on the prowl. Con artists feed upon the luckless like vultures on dying meat, and curfews are called: Hostility is released like it can when one is filled with grief: same kind of fury that flares into panic or is projected onto a passing object, person or thing, thus to ease the collective distress, soften the blow, find distraction, a counter-irritation to muffle the moans of mourning. The mindset is attuned by dire straits, heat of anger, a range of impassioned post-traumatic acts, explained away as unusual quirks. Not so. Sex and violence - powerfully linked.

Political and business opportunism. For the governing (or revolutionary) class, sympathy quickly gives way to political maneuvering and calculation. Campaign jargon takes hold, voters need to be steered away from the disaster all the way to foreign policy, to the way we meet the threat of terrorism, and the price of bread. Under the gun of urgency, national safety and territorial imperative, we strain to decipher who’s best suited to defend the land, grant security for all. It is a testing time for nations at risk and for anyone in charge. And yet, there is always money to be made wherever there are bursts of emergency funding. No-bid contracts are splurged upon the favored, disasters raise land values brings business. Disaster can be good business – political business and “business” business

12. Grief is the inevitable outcome of loss. Everything is usually connected to everything. Connection is broken. Societal trauma.

Numbers: September 11, 2001, 2752, December 26^th 2005 - Asian Tsunami, 169,752, August 23^rd-31^st Hurricane Katrina, 1536, October 4^th Hurricane Stan, 1513, October 8^thEarthquake in Pakistan, 73,000: “Numbers dead” is how disasters are generally reported, for loss is the heaviest price of disaster. The loss of one life can have far reaching repercussions on the lives and futures of several families. The Asian tsunami affected eleven sovereign nations, Hurricane Stan affected four in Central America, and the Pakistan earthquake crossed the borders of the divided region of Kashmir. Numbers missing are unknown. Novel rituals must be invented to deal with new problems, as in funerals for victims whose bodies cannot be identified or are missing. Count the ratio of military to civilian dead. Disasters are about dying, people and things. Death tolls provide no reliable index of the level of societal trauma or the disaster-related consequences in those regions; not counting the casualties occurring in less publicized locations of the world.

Faced with a sudden catastrophe people may not only feel a loss of control over their lives, but also a loss of the safety, control and containment that society normally provides them. In a climate of collapsing psychological infrastructure, regaining a sense of safety and security is not simply a matter of bouncing back. Then, as the boundaries rupture or blur, hope ignites as news tells of dramatic search and rescue, despite delays and obstructions. Disasters are about losing contact. Believing that no matter what kind of trouble you get into, all you have to do (in America) is dial 911. In Katrina thousands of calls never reached the magical number. Lack of connection is nearest thing to death

13. Disasters and Stress.

No need to look far back in history. In the aftermath of every disaster is profound stress. Whether of natural or man-made origin, a tsunami of emotion erupts as one's capacity to control is lost. Brought home from Vietnam were the hard truths of the traumatic stress syndromes, symptoms mirroring ruptured basic trust, violence aimed at self and at others. Post Traumatic stress disorders are of many kinds. Too many victims, too few the healers

14. Culture and counseling.

The signs and symptoms of psychological distress vary widely across cultures and even within cultures, but counselors don’t always know that people of different civilizations have different views on the relation between man and God, on what happens after death and how to grieve, of the individual and the group, the citizen and the state, man and woman, parent and children, husband and wife, of liberty, independence, authority and hierarchy, of shame and guilt, of modesty and sexuality, of saving face and humiliation, as well as differing views of the relative importance of rights and responsibilities. Pundits pump out lists of what not to do in a disaster, but nix about what to do, alone or as a team. Cultural competence essential in disaster relief operations is often lacking

15. The one great leveler.

Disasters show no preferences. They cross borders, and in the immediate aftermath, unify people through in their common fate. Survivors and relief responders feel a common bond; a coalition of compassion collects helping people to re-connect. Hair raising and heroic rescue efforts bring a sense of exciting joy. Always a little child unearthed, claimed from the jaws of death. The infant whimpers, but a loud cry brings cheers all around. Aha! Life again and we sigh in delightful awe. Re-birth. Bitterest foes join hands in facing the crisis they share. Much wishful thinking, talk of healing old wounds, once and for all times. Disasters don’t discriminate. Friends in need are friends indeed.

16 Interoperability failure -- coordination is the new catchword: everyone demands coordination, no one wants to be coordinated.

State, non-state and worldwide aid agencies move in. Harmonious at the start, they turn to compete in the environment of confusion, duplicity, dwindling funds, propaganda and personal glory. Together in time of need, military and police tend to move apart.

Interoperability is key. The intervenors -- their products, systems and agents -- must work towards a common task, in this instance saving lives and preventing further destruction. Can be defined in a purely technical way as in telecommunication communications-electronic systems, but could be applied broadly taking into account social political or organizational factors, as in disaster management. Breakdown of contact between first responders or with a command center leads to haphazard action, often dangerous. Sustained connections via a specific radio signal band essential but rarely available.

Disciplines may clash. Experts eye each other with suspicion. They hold tight to closely guarded protocols, questionnaires-- and especially to their sources of funding -- but each group is certain their brand of compassion is beyond compare. Workshops, assessments and lessons learned are aired in the emptied resort hotels. Definitions will be argued and tested. Almost invariably medico-psychological therapy versus psychosocial interventions, curing with drugs or relying on the natural healing powers of society? Who needs doctors when the soul is on fire? Working as a team demands much practice. Status consciousness, professional jealousies and inadequate training as a team creates rifts hindering appropriate action.

17. All disaster hazards bring common consequences.

The human factor is the least predictable. Consider hurricane warnings, albeit still a fledgling science. No longer can we artificially separate disaster types or phases. Pre-war is pre-disaster, post-disaster circumstances could be the pre-disaster climate for war. At any given moment we may are in the midst of many disaster situations as one runs into the other, as one is superimposed upon another, with the ultimate consequences across cultures the same. That is why a multi-hazard approach to disaster management strategy is most useful, as it incorporates planning for and consideration of all potential natural and technological threats including terrorism.

The multi-hazard approach is an integrated disaster management strategy that incorporates planning for and consideration of all potential natural and technological hazard threats, including terrorism. Critical issues and lessons identified from both human caused and natural disasters may have psychosocial differences but in management, ultimately the same across cultures and a measurable activity. A disaster is a war of sorts, sooner or later, and war is a disaster.

18. Disasters begin and end as local events.

Despite the enormous value during the initial emergency response phase, international external assistance is ultimately if less significance than the “natural” spirit of self-help that arises within affected communities themselves. Economists seem to hold the same view. Echoing Tip O’Neal’s statement that “all politics is local,” some economists declare that “all development is local.”

"Go Local" is a basic tenet. Capacity building grows best on an existing foundation with local bricks and masons. Development and humanitarian intervention often misses the fact that it is the communities own local resources (and resilience) that are going to be crucial. Unanticipated and highly innovative sources of relief assistance appear de novo or when the initial crisis has lessened. Ultimately it is local resilience that prevails.

Prescription:

Understand the fundamentals of managing disasters!

Keep in mind that when disasters strike, the number and type of responding groups, agencies and jurisdictions increase monumentally.

Know that relationships among organizations will keep changing continuously.

Recognize that adjustments in traditional divisions of labor and resources increase the need for multi-organizational and multidisciplinary coordination.

Aim for coordination of resources (including information) lest they not be shared, or distributed according to need.

Communicate clearly and often to prevent duplication of effort, omission of essential tasks, and activities that could make matters worse.

Manage disasters (small or big) before they manage you.

14 THE RIGHT TO CRY

2005-05-09T23:11:00.000-07:00

Sooriyamoothy takes leave. Looking back through my notes from my tours of the several tsunami-affected regions, this encounter stands out:

Walking along the seashore at the point in one district where the tsunami had the greatest impact, my escort and I see all the signs of heavy casualties among the army personnel and civilians who had lived there. Crossing the loose, hot sand we hasten toward some shade at the last remaining hamlet, only half blown away, spared slightly by its position on a slight elevation.

We find a middle-aged gentleman in white shirt and gray cotton trousers. Beside him stands a younger man, maybe 28; a shiny motorbike waits a few feet away. The two men are together, but each seems to be alone. Nearby a bare-chested fisherman strings a few tattered clothes across a fence to dry. All gaze out to sea, eyes on the horizon.

We bow to each other in the customary gesture, mostly a twist of the head to say, Yes we are all here for the same reason. In a soft, low tone, the older man speaks, in English: “I am Sooriyamoorthy. I came here to this place, where my daughter…the place...the Tsunami swept her away...exactly three months ago.” His eyes are sad, intense, bleary, tearless.

What will words do for us, I wonder. He offers, “My wife is a Singhalese. At this moment she in her village in the south, she has gone to perform customary funeral rituals, the special rites on the day.” It is our custom, three months after, to perform an almsgiving to the Buddhists monks

He struggles against suddenly threatening tears. “My son is with my wife today.” Turning to the younger man beside him, “he was to become my son-in-law; he has come here to be with me. Three months ago my son and I found my daughter entangled in the reeds here, dead. They took her body to the hospital with the others. She was a lecturer at the University. She came for a holiday with some friends, and she came here that day with her brother, to this beautiful place to see the sea and to stroll.“

“They were together when the tsunami struck. My son escaped the storm and found his way home.” My eyes inquire. What happens to us at times of such helpless anger, at things beyond our control? He tells me of his son’s rage.

Inconsolable after returning to help find his sister’s body, the son went home, shattered the religious (Hindu) images, and tore the pictures of deities off the wall of their shrine room, cursing God. “I do not know if it was the will of the gods but I can understand how my son felt, his only sister. I know it was no punishment, but I know that God took her away when she was just a young girl beginning to start her own life and family.”

He and I hold a quiet, timeless conversation about sadness, about loss and difficulty, about accepting. We speak of hurt and anger. He wonders about God’s acts, punishments he did not deserve.

He muses aloud, Was it providence that brought us to today’s meeting? Our presence, he reflected, was what allowed him to release his tears today. Before he could not. (My escort, who has heard so many stories since “26/12,” watches unmoved.)

We talk about religion, Do we need it? We talk about customs and rites. How does the spirit leave the body after death? We talk about suicide. I offer him some examples of those who wanted to end their lives by suicide, to rejoin the lost loved one or as an act of revenge against what one did not know. “The idea crossed my mind,” he said, “but it would be very wrong.”

I ask what brought him to this particular place today. He talks of the human spirit, of how it lingers and finally goes away. This is where life had left her body, a sacred place though they could touch her no more. He teaches in soft, unhurried tones the wisdom of the ages. At times I am not sure who is speaking, who is teaching.

He inquires further about my name, saying he has heard it before, a family of doctors, teachers perhaps? Yes. “You know,” he says, “your presence here has made it all right for me to cry.” “I knew nothing about you, really, you were just people walking along the beach.”

One or two more teardrops he allows himself; allows us some moisture behind the sunglasses as well.

Why all right to cry, I wonder? Does anyone need permission to cry, to open the gates of sorrow? Maybe yes, for those who think and feel in private, who keep themselves unexposed, safe alone. Or maybe yes for those pray aloud, drowned by the chants that echo in the halls of their temples.

“You know,” he said in anger, “someone came and offered me money. What do I need money for?” We spoke about how people grieve and express their condolences in different ways.

I try to exchange a few words with his once-to-be son-in-law, about his work, but the young man is blanked out, staring far off into the sea.

It is time to move, time to go our different ways. As we turn to leave I pull Sooriyamoothy towards me. We exchange addresses and phone numbers not knowing why, but the bond was made. No forgetting; maybe we’ll meet again. He writes his name, such a neat script. We clasp our hands as if in prayer and we move away.

All is calm except the quiet waves. I walk further inland to see how the displaced are starting to live again. Workers are busy digging new wells and setting up small brick houses with coconut thatch roofs.

We watch as sturdy men with stringy muscles, cement mixed, trowels in hand, build anew. Cottages rise up near the shore. Carts bump along a broken road that hugs the sea. Families hang out their clothes, flanked by many roofless walls and pieces of boats. Broken tiles are scattered among massive rocks unearthed from the seabed and rolled in by the water’s force. A fisherman says, “this is home.”

I look back towards the hamlet, but no one is in sight in that airy temple by the sea. Remember the dead, preserve the memories – but it is time to move on

13 - REFLECTIONS: THE SPRITUAL DIMENSION

2005-03-20T23:45:00.000-08:00

Mental Health - Everyone is affected: One of the cornerstone principles of understanding the effects of emergencies and disasters (of any type) is the assumption that virtually everyone is affected by it. The nature, magnitude, population vulnerability and duration are of course quite variable, but some type of psychological effect is to be expected.

“Normal” response: Most reactions represent ordinary (expectable) responses to the extraordinary situation that is created. Calling these reactions “normal” does not mean they are trivial and it is easy to be fooled by a calmness that hides the signs of hidden symptoms. Relief workers must not let their wishful thinking interfere with objective assessment.

The spiritual dimension: The physical, emotional cognitive and behavioral signs of stress easily gain attention, but the spiritual dimension of stress is less often addressed. Because of the centrality of religious beliefs in most cultures, understanding how and why the religious beliefs of people are challenged, weakened or strengthened is of crucial importance in managing interventions aiming to reduce societal distress.

In natural disasters particularly, the offending agent of destruction is not as easily defined as in human-caused disasters. Responsibility is assigned to one single God, to one or more of a pantheon of deities, to one’s karma, or to one’s own misdeeds, as in “what did I (we) do to deserve this?”

Seeking help, finding social support and understanding adversity often take place in the context of religious belief and in the religious community. Sometimes referred to as the first line of defense, people find comfort in their spiritual leaders and in the prayerful protective environment of their temples, mosques, churches or school. Priests, like community elders and politicians, rise to the event, easing the victims’ pain by sharing their grief.

Mental health experts who fail to involve the faith community in designing and delivering relief interventions are not making use of one of society’s most significant natural healing systems.

In all cultures religion plays a role in daily life, but in times of distress religion is called upon to become involved in rituals that tradition demands. How much more will they be needed in mass traumas and in situations where bodies are missing, whole communities left bereft and without a base.

Speaking at a lecture on “The Humanizing affect of contemporary religion on society” Lynn Ockersz, Associate Editor Daily News, remarked:

The ideal of service to mankind is a central element in the teachings of all major religions; we wouldn’t be witnessing the current effort on the part of the clergy and committed laymen of most of the religions of the land to bring relief to the victims of the tidal wave disaster of last December, if love and compassion for one’s fellow beings was not considered a cardinal virtue by these religions.

A fact worth noting is that the humble Buddhist temple is playing a key role at present in bringing to the suffering in this tragedy irrespective of race, religion or social status. The same is true of many Hindu Kovils and Muslim mosques. Indeed, people fleeing the onrushing waves went first to these places of worship for safety and comforting.

How to support the spiritual dimension? As noted above, the spiritual dimension of social life represented by what we loosely call the religious community needs no invitation to become involved. What may need to be done is to provide support and assistance in integrating their strengths towards the overall relief needs.

12 - REFLECTIONS AFTER TRAVEL

2005-03-20T23:29:00.000-08:00

As a result of my tour of the southwestern and eastern coastline area I came to realize that the numbers of traumatized people is so great that the visiting short term counseling teams do not reach the people who are literally lost in mind and space.

The note on "Should a man cry?"[Blog 11] reveals that we have to find a way to actively search for the traumatized. Otherwise they will suffer longer and in silence. Eventually their problems will surface in ways that could be harmful to them and to society.

If the survivors of the tsunami are in a puzzled frame of mind regarding their religion how do we prevent them from losing heart? I certainly do not know the answer but this is the challenge.

Some of these people are on a "suicide watch," which means that the family (what is left of them) and others have to be policing them while feeling helpless themselves and at a loss on what to do.

We may never know the full count of numbers affected.

In their misery cannot expect these suffering people to limp into the hospitals; even the mobile clinics are unlikely to reach them. Although there will be some comfort gained by being in a camp, there'll be others who will walk away and hide.

What the nation is facing is not a pathological problem but a social problem, one so great that society has to find a way to heal itself using all the resources it possesses.

11 - TRAVEL INTERVIEWS, PART III KADAVUULAY

2005-03-20T23:03:00.000-08:00

I am tasked with touring the hardest hit eastern shore of the island. My aim is to gain a sense of the devastation, its impact on the remaining communities, and the progress in relief operations. I want also to study the “eddy currents” emanating from the huge wave.

SHOULD ANY MAN CRY? KADAVULAAY! Oh God! Why? Thambiluvil, Eastern coastline, early March. Driving along the coastline highway, itself torn apart in many sections, one sees miles of physical despair -- roofless houses cracked into pieces, temples turned over, schools flattened. The minarets of once stately mosques lie helpless on the ground. Upside down, tombstones are flung across the road, rows and rows of cemeteries dishonored.

Not a soul in sight, just coconut trees at an angle with their tops lopped off and twisted electric pylons in a ghost town hundreds of miles long. We drive along in silence, for what is there to say? Everyone has left these unstable dwellings or been swallowed by the tsunami. There is no one to see, no one to ask “what happened here?” It is not as if we did not know, but there is a hunger to make sense of no sense. And calmly sits the placid ocean, not even a wave, more like a lake, surface like a mirror, deceptive, unpredictable.

After long stretches of wasted land, with not a living thing, not even sea gulls, we see at a distance a faint figure moving, maybe a shadow of a man. I motion the driver to stop the car. We too, feel alone in that world, like the few leafless trees. As we near, yes, it is a real person. Thank heaven, something living, a man standing angled by a shattered home, leaning. Doors, all shorn off, no roof. I climb out of the car to get closer.

“Ho” I say to announce my approach, he acknowledges with a wave, and then, out of the blue we hear this deathly moan. “Kadavulaaay” he utters aloud, meaning “Oh God” as he looks to the skies. He is crying loudly. I think, Oh my God, should we be here? He approaches, limping, and in his native Tamil language pleads, “please, please! how can this happen?” I advance and he stares with glassy eyes into mine. “All gone” he gestures with a twist of his hands and sobbing louder. My driver can’t stand the scene and sound, he moves away to hide his watering eyes under the shade of a nearby tree. Empathy can be hurtful.

The man gesticulates with his left hand as the right one wounded hangs limply down. He motions me to one room, brightly lit from the noonday sun coming straight thorough, and what do we see? Clothes splayed across the floor, small piles, soggy from last night’s rain. Wife and two daughters are gone, he says. He picks up a brownish pink dress – his teenager’s, only fourteen. He holds it up for me to see and suddenly throws it over his left shoulder as he must have done with a living child inside, and yells, “this was her”, then flings it down to pick up this time a frilly one, blue and white, of daughter number two, he says. “She was hardly eight.” Some books and school files scattered on the floor, papers and smudged notes. “This was hers, and she is not here anymore, I do not know where they’ve gone – with the rest of everything else, who knows?” Sand everywhere, no chairs, no nothing floated away, just the wet clothes on the cement floor, a harsh reminder of a family’s foundation, once full of life and cheer.

I want to leave but he holds me, probably hasn’t spoken to anyone on this barren earth, maybe cursed at the God who forsook him. I don’t know what to say and only gaze into his eyes: intense, wild, angry and yet wonderfully gentle. We walk to where the veranda used to be, just an empty space, three walls flung apart, no kitchen, not a pot or a pan.

He moans and hides his face – is it in shame? Maybe he’s never cried out in years – a man, once upon a time the head of his growing family, formerly soothed by the ocean’s tide, by the mighty sea. He looks up again to the skies, as if he had made contact with the force that took his family away, “Kadavulkaay, kadavulaay,” oh God! God! why! he cries, eyes blurring up once more.

In this cloudless, bird-less, washed out and truly abandoned washed place, he leans on me with his pale blue shirt and tousled head. I stroke his back. Time hangs and there is little to say, silent counsel. He points to a heap of broken bricks, the house next door. “My brother’s,” he whispers. I feel embarrassed to offer him money. No mammon can match the loss and it is not from pity, but I press a note to his hand. We exchange our thoughts in silence and he waves us away. He turns towards the house that was, a memory never to fade.

We are silent, only the purr of the engine as we pull into the road. Not much to say, is there? I wonder if I could forget the scene. I do not want to be awake at nights re-living the scene, hearing the moan. We think aloud the same sentiment, “too many more like him” with only the sea to hush their cries.

A DOG JUST SITS It was this eastern shore that bore the brunt of the Tsunami coming straight across from Sumatra’s cleft with no warning. Only the birds and beasts knew, nature’s instinct messaged by vibration said move to higher ground. They say not one animal succumbed.

A dog sits on a pile of debris, torn clothing scattered against a broken wall. He watches us pass through this desolate place. Some live humans inside, maybe he wonders.

Is he waiting for his master or the kids with whom he played, or is this just my way of making sense of nothing, just a dog on the roadside?

10- MUSINGS WHILE I TRAVEL

2005-03-20T22:20:00.000-08:00

Everything changes however hard we try to keep things the same.

Scratch the surface and you’ll see a fault line, probe too quick and face a tsunami of rage or tears.

The tsunami has precipitated a focus on counseling even among psychiatrists known to devote more time to treating severe mental disorders who are often limited to the prescription of drugs. There are hardly 30 psychiatrists in the land of 18 million -- not a popular specialty, for reasons not quite clear even for a nation at war.

Out of the 20 year ethnic conflict emerged a realization that sharing your suffering is better than holding it in. Talking to an outsider is not shameful and mental distress is not mental illness.

9 - TRAVEL INTERVIEWS, PART II

2005-03-20T22:09:00.000-08:00

I continue my travels through the affected areas – two stops on Feb. 25^th.

RUHUNU (Media Foundation) RELIEF SERVICES – Hambantota. This NGO is organized by provincial media correspondents for area children who were students of St. Mary’s College, Zahira Collegeand the Hambantota Maha Vidyalaya. Sri Lankan benefactors and NGO organizations are bringing the basic necessities, but the local staff are concerned that badly needed counseling services are unavailable. Our discussions focus on arranging for counseling services and the need for bilingual staff. The refugees are Muslim, Singhalese and Tamil.

CCF Sri Lanka PSYCHOSOCIAL PROGRAM IN POLATHUMODERA (Translated as coconut leaf) [CCF: Christian Children's Fund] With US Embassy assistance I visit this USAID-funded program, one highlighted for its psychosocial focus and given considerable publicity. This is a badly damaged coastal town near the southernmost tip of the Island. This site became famous because former President Clinton and Bush visited a few days earlier.

Groups of school children and some parents gather in an area where most of the building structures have been destroyed and replaced with tents. School had just ended and they were expecting me. In a roadside makeshift playground where homes had stood, I found a girl swinging on a tire hanging from a tree, women chatting, some waiting to collect their kids from school, a common small town scene, children in spotless white dresses and long plaits. The children were to perform for my benefit with song and dance. Plastic chairs are arranged in a semicircle on the floor of a home that has no walls anymore. I am introduced to three of the local volunteers, dressed in white. They plan the play and art sessions for the kids. It is only later that I realize that we are gathered on the living room floor of the “home” of one of the volunteers, a slim woman of maybe 25 or so.

The beat was rhythmic enough with many kids trying to make an impression; even atwo year old thumps on a toy drum. Girls ranging from 7 to 16 sin, sway and clap to a catchy tune. After each dance sequence some children look bored, others are preoccupied or chat in smaller groups. Smiling faces (when turned on for us), bright eyed, energetic but lacking in luster. As Bill Clinton noted in a newspaper interview “there is a lot of emotional damage not easily visible. I notice sadness in their eyes.”

A few children came close to show me their crayon drawings and paintings, the teachers proudly noting how bright and beautiful the themes. For me (a former instructor of art psychotherapy), their art work is more like an arts class test. The pictures reveal no signs or symbols of distress – maybe just denial.

Discussions with the parents centered on need for building materials, houses, jobs, problems of unemployed men, school facilities and of people still hurting from the loss of loved ones. Some children clung close to their mothers, aunts or older sisters as mother substitutes.

The young woman volunteer, in whose “house” we were gathered (her fisherman husband is away looking for work) edged up to me to ask how she should cope with her own loss while trying to cheer the children. It was only then that I realized it was her property and that the bouncy two year boy was hers. She described the tsunami’s fierceness and how they fled inland just as everything started to tumble down. Then she broke down with sobs. “I lost my brother, my only brother…this is the time I really miss and need him.” I ask, do you have a picture of him and she brought one out, a tall handsome young man, possibly 20 years, smart in military uniform.

She kept talking about how much she missed him, and just loud enough for others nearby to speak of their losses. Here’s a photo of my son! “All our chairs and tables have gone and we can’t find anything anywhere” “when will the government give back our homes. More discussion followed about the precious things, the jewelry, the photos, the mementos no longer to hold. More discussion on feelings – hurt, anger, guilt and sadness as people wondered if these losses could be healed. It is easy to be angry, why weren’t we warned in time and yet, how can all these things be replaced for the thousands (it is nearly one point seven million) displaced?

More anger: We know we can replace the chairs but not our loved ones. They are washed away and so are the little things that connect us with them. Others join in to say we should be grateful for what is being done for us, even express our thankfulness, we are not really alone.

Referring to our host, Dishanthi’s living room floor, I ask of those around if we should be thankful for her hospitality. Yes, they joined, we should have said so long before. She calls me aside, tears streaming, and I ask, would you like to have your place to yourself, your home? It is still your space? I’m curious as I look around. Tell me, what was here, and what was there. She shows by hand, a big cupboard was here, dinner table there, pictures on this wall – pointing. The kitchen as there!

Should these people leave, find another place to gather, I ask? Yearningly she says yes, but how can I tell them? I’ll try, I offer and started to talk with a few beside me. Surely, they agreed, we should find a larger space, there’s a little green field a bit away from the main highway, we could ask for that space.

I think to myself, what if it were me, my home or what was left of it. Yes, we had some famous guests here yesterday, a lot of excitement and noise, but mercifully, they are gone. I’d want to sweep and keep it clean, a few plants maybe here along the edges, it is mine and ours to protect, our precious boundary, until the bricks and mortar are ready. Dishanthi, speaking in halting English, writes her name on a paper and scribbles the phone number of a neighbor. Please come to see us again.

Organizers of CCF Sri Lanka explained that they were only just getting started with the program, they call psychosocial. No foreign relief workers anywhere in sight.

8 - TRAVEL INTERVIEWS, PART I

2005-03-20T21:33:00.000-08:00

RAJJIPURA, A CAMP FOR A COMMUNITY DISPLACED BY THE TSUNAMI. 26 February. This report is from the road. I’ve been invited to travel to several of the affected areas. About sixty people, mostly woman and babies, wait in a school building near their tents for the distribution of food items and clothing. Seated on the cool cement floor, some of the women fan themselves while others watch their little ones. They are feeling settled and safe in this camp maybe 10 kilometers from their coastline home town, torn apart by the massive wave.

This camp, like most others has been visited by scores of well wishers from the city bringing gifts of food and household needs, kettles, pans. Trucks from a local aluminum processing company brought in cots while we were there – donations sponsored by an international NGO named “shore to shore” It was gladdening to see the joy in the faces of those who handed over these gifts.

Discussion centered on fear the ocean and dread a recurrence. The women especially are against the idea of going back. They’d rather be settled where they are now, and are willing to wait until they could move from their tents to newly built homes the government was promising.

The women said they felt safe as the camp was patrolled by navy police. Life was getting comfortable, some said. Seeking to understand the strength of their conviction we wondered why you say “we don’t even want to see the sea” but some of the older women merely shrugged their shoulders. When a husky teenager was asked if he, too, feared the sea, he turned sheepishly to his mother, as if she would answer for him. The navy police guard turned and asked “would be interested in joining the navy?” He blushed. When I asked to see the oldest person in the group, a gentle gray-haired woman came forward smiling. She had been swept into a ditch many meters from her shattered home. Do you fear to go back I inquired, she with a smile said “not at all.” A disapproving hum followed from people crouched in the back of the hall. One young woman leaned over to me and said, “Do not pay attention to her sir! She’s a bit mad”.

The local chief is prompted to ask “would you be willing to go by the sea if we take your there in a bus, “just to see?” Embarrassed smiles, some nods. Clearly these folks were deeply attached to the shoreline, the men mostly all fishermen, whose source of their livelihood was dependent on the fishes of the sea. When I whispered to the Chief Secretary asking if caste considerations might be a factor in re-settlement, he said “possibly, yes”.

We discussed rehabilitation. One carpenter said he had lost all his tools and would like to have a new set. Another wanted the materials to make bricks and some women asked for cloth to sew their needs. The provincial chief secretary announced that his office would release the funds for the projects requested. The overall mood was pleasant, the local chief seemed contented.

In the Buena Vista Camp there were just three families left. One mother pointed to her 10 year old daughter noting that the girl had been swept away but was saved when she got entangled in the branches of a high tree. The kid smiled proudly, as if she had performed a great feat. Another mother said she lost six family members. The body of only one of the sons was recovered. They spoke of a kindly “sudhu nona” (white skinned woman) who hearing their woes offered to build them a house

7 - POST-TSUNAMI EDDY CURRENTS

2005-02-27T18:14:00.000-08:00

Deeper forces. The giant tsunami waves have done their destruction and receded, leaving bare a broken land and broken hearts: 31,000 lost, 1 million displaced in this country alone. All is calm at sea, fishermen are venturing out, bodies not longer drift ashore, and tourists are invited to return.

But as dignitaries bring sympathy and monetary aid jumps to the billions, eddy currents, like a social whirlpool, bring up deposits hidden under society’s floor.

One example: the “how about us?” syndrome.

High profile visitors like UN Secretary General Annan and the two former American presidents, Bush & Clinton, keep refreshing the hope of those in the tsunami destruction area that their lives and livelihoods will be rebuilt. There continues, too, to be a keen awareness of the societal trauma dimensions of the tragedy. President Clinton noted “a lot of emotional damage not visible.” Welcome as these visitors are, they continue to prompt a “how about us?” reaction from those in dire need but not in the tsunami ‘catchment’ and also from strategic thinkers who weigh the tsunami beside humanity’s long list of of other devastations A number of op-ed writers have spoken of the “man-made, perennial tsunami of poverty here in Sri Lanka. Other commentators note the huge annual death tolls from malaria or any of the other pestilences that afflict millions in many other countries.

Another example of these undercurrents can be seen in the preference of some for political battle over empathy and reconciliation. Here in Sri Lanka group of monks, unsympathetic to the ceasefire between the government and the Tamil rebels, are preparing a march to protest peace negotiations. Denouncing the UN Secretary General’s expression of sympathy for the recent slaying of a top Tamil leader, they accuse Mr. Annan of trying to extend political recognition to the guerillas. The protest is taking on an air of “How come you sympathize with them but never when one of ours is killed?” another example of “how about us?”

Babies, mothering and rebirth: Baby 81 now has a name and a mother. After DNA tests confirmed the real mother, baby Abilash has gone home. This closes this immensely symbolic saga. There were different versions of the infant’s magical survival and rescue: he was “caked with mud and lying on the beach,” or he was “found under a heap of twigs and debris” – narratives hinting at mystery and special powers, at strong karmic forces.

The story shouts symbolism. Baby 81 seemed to mirror everyone’s wish for resilience, to start life again. Just as the baby survived the impossible, the nation yearns for rebirth after two decades of internal strife. Note, too, the universal, mythic themes: the basket floats along the Nile; Moses is secretly received by the Pharaoh’s daughter; water is the purifier, the origin of the species.

6 - HELPERS

2005-02-15T22:33:00.000-08:00

The second tsunami: Relief aid, like the tsunami, came in a massive wave, an unprecedented outpouring of compassion and generosity from a caring world. But the distribution and impact of this peculiar bonanza has inevitably been less than perfect.

Even among the grieving families there is a mixed response to the well-meaning caregivers. The simple stories of loss and grief get muddied by press reports of complications. Newly-arrived helpers and material are not distributed equitably; helpers are occasionally – rarely – reported to have abused vulnerable victims, even some outright theft. The NGO’s are accused – sometimes by “competing” organizations – of manipulating the crisis for their own publicity and gain. And swirling through these contradictory media reports are articles worrying that ceasefire violations and political favoritism might upset the delicate ceasefire agreement from a war now stretching back two decades. It is easy for the mourning and the healing that goes with it to get sidetracked.

Can there be too much help? Some observers suggest that the affected children, most of them from poor fishing communities, cannot fully absorb the toys, the food parcels, the crayons and the attentions of the kind-hearted foreigners who sit with them to draw pictures, show instant photos and offer counsel in various forms. Journalists hold microphones to their faces and listen to harrowing tales. Heart-wrenching episodes are transmitted verbatim for the media world, incidents possibly embellished as each new interviewer re-winds the memories of the event.

Then just as suddenly as they came, the helpers leave. Their “deliverables” – the play therapy, art therapy, drama therapy and all the many other forms of intervention – are passed like a relay team to another set of newcomers. The visitors are mostly short term folks who must return to their universities, their regular jobs, and their own life styles.

Local caregivers, themselves already experts in all these modalities – surely, after 20 years of internal conflict they are overloaded with their own therapeutic programs – follow through. There is one benefit: they receive a booster shot to their skills and energy. The visiting experts reinforce and validate the dedication of the resident caregivers.

Obstacles to long-term action: Welcome as they are, the high profile visits of heads of state and UN leaders tends to keep focus on the immediate crisis. Asking to see first the devastation, their visits tend to confirm an ongoing, urgent need for relief for the people’s pain. The result: emergency medical/surgical teams keep arriving, only to find little work to do. One side effect: the excess of first-line medical capabilities shows by contrast the core deficiencies in basic health care available in poor communities.

Surveys: There are lots of surveys – “assessments” in the jargon of humanitarian aid – and many checklists of first response actions to be taken. Teams of counselors (local and international) carrying lists of do’s and don’ts have combed the stricken areas, but they could not remain on scene long enough to move beyond “mental first-aid” to witness and address the inevitable, post-honeymoon heroic phase, the time when reality hits and disillusionment begins. This is the phase when special medical procedures like DNA tests are needed, when those assumed to be “missing” are accepted as gone, when deaths are certified, insurance claims are filed, and families and communities start to rebuild.

As this second stage unfolds within a harsher climate, the initial “coalition of compassion” begins to crack apart at fault-lines still unhealed. The heavier tasks lie here, in this troublesome second stage, as leaders learn to tolerate tensions, make good the promises to the needy, steadily face the aftershocks, attend funerals, invent new rituals and make maximum use of international support.

A personal caution for helpers: All wounds do not heal at the same speed and there is no right or wrong way to feel. We project onto the helpless those feelings and thoughts we think would emerge within us if placed in their circumstances. Hence smiling children annoy those who want see them cry, while others wonder “why be sad?” when so much compassion pours in. We must seriously guard against maneuvering those needing help around our hidden wish to fulfill our own fantasies.

Keep perspective. There are tsunamis that affect most of us but not all in equal share. I saw a polio-crippled beggar this morning, angling his way across a busy intersection. He reads no paper, might even have overheard this new word “tsunami” but limps on.

Life can be hard, loss is common. Unless one is directly impacted, the tasks of daily life can take up all one’s energy and attention.

5 - CHILDREN AND MOTHERING

2005-02-11T04:50:00.000-08:00

The mother instinct. The 81^st admission to the Kalmunai hospital, known as “baby 81” is a bit closer to going home. "Mother" Janita says little Abilass was ripped from her arms as waves tore through her beach front hamlet. Caked in mud, he was found on the beach nine hours after the tsunami slammed Sri Lanka’s eastern shore on December 26^th

Nine other women have also claimed this 9-month child, say hospital officials. As he heals from minor bruises he is at the center of much maternal fussing by the nurses and attention from others who come from curiosity to see this lucky child. Although a court ordered that he be given to Janita, the doctors have resisted saying he needed medical attention and that they feared other problems.

The “mother” has filed a case in court and is asking to be allowed near the child but not to remove him. She has even appealed to Sri Lanka’s woman President for help. DNA testing is ordered, results in a week or so. No need to summon Solomon, but stay tuned. It’s not over until it’s over.

This story is getting international TV news attention. The magic of this special child reflects this nation’s yearning for life in the midst of such sorrow. It also shows the power of the mother instinct – as we see from the world-wide attention, something that works at the societal level, too.

More parenting – down to the sea again. A young Danish social worker had made her home in the coastal village close to the site where the tsunami wiped a train off its tracks, drowning her and a thousand others. Her friends, a team with local volunteers, have joined to help the children in nearby shelters to feel safe, and are inventing ways to still their fears. They build sand castles some distance from the waters edge, draw pictures and trace names in the sand. Wavelets push undulating patterns of sea weed and bubbly foam up on the sand. It is a kind of littoral art therapy designed to ease the haunted young mind. Slowly they edge closer to the water, wade in the shallows, watch tiny fish dart around in small coral pools, splash, and then, with time, swim. Commonsense - the healing art.

4 - LOSS AND CONNECTION

2005-01-30T19:08:00.000-08:00

I continue my observations of societal stress from Colombo.

Sharing the grief “May they attain nibbana” (nirvana) is usually the final line appearing in obituary announcements for Buddhists. These days there are many. One example: under photographs of two middle aged women and a smiling girl, possibly 16 or 17, a brother writes, “We express our heartfelt appreciation and gratitude to all members of Sri Lanka, Buddhist priests, doctors, and staff of the hospital, relatives, lawyers, doctors members of the armed forces, friends in Sri Lanka and overseas who called at our residence, attended the funeral, sent messages of condolence and floral tributes, and assisted in numerous ways while standing by us at our time of need and grief at the demise of ... and ..., our sister, sister-in-law, cousin, daughter in the tsunami on 26^th December 2004. We also thank everybody who attended the almsgiving”.

A friend and medical schoolmate phoned. “David! don’t forget to come to my mother’s death anniversary almsgiving.” His mother died over 10 years ago, but I have often been present at the yearly custom where close family and special friends gather for the ceremony of almsgiving when food, and sometimes gifts, are bestowed on the invited monks. In addition to chanting “pirith” the monks may make short sermons noting the impermanence of life and blessing the departed. Once the monks complete their meal, (they must eat before noon) the gathering is an occasion for family members to be together, remember the departed, and partake a vegetarian lunch.

The event bears some similarity to the traditional American thanksgiving where family links are strengthened and a inventory taken of who’s gone, who’s born, who’s prospering, and who’s not. Sometimes the Buddhist ceremony involves the tying of thread blessed by the priests around the wrists of those present. In a future blog I will say more on the meaning of this practice, the “nool” of connectedness -- in the Sinhala language the “thread”.

What about us? During Sri Lanka’s 20 year war, the disabled, especially the military casualties, received considerable sympathy and modern medical/psychological support. This aroused the resentment of ordinary people with disabilities. The ordinary disabled were not only neglected, they were often stigmatized and made objects of discrimination. Now it is the turn of the poor in the areas not affected by the tsunami. The outpouring of relief aid has been focused on the people hit directly by the tsunami. Left homeless, hopeless and in deep grief, these largely poor populations have received great sympathy, offers of assistance to rebuild their damaged homes, and other benefits including a previously rare level of medical attention. Naturally, the “How about us?” syndrome has spread among the undamaged populations.

I have seen this before. While assessing mental health needs in Southeast Asia following the Cambodian crisis and the harrowing times of the Vietnamese boat people, I noticed this phenomenon in Bataan in the Philippines. The delivery of basic necessities to Vietnamese refugee camp dwellers stirred the envy of the neighboring – and far less endowed – villagers. This is a challenge for national leaders, disaster managers, aid donors and economists who must weigh crisis needs against development strategies.

Another phenomenon: survivor guilt. I am hearing tales of unrelenting survivor guilt among those who escaped the tsunami’s rage, and of many who speak of envying the dead.

Responder stress. An important kind of “compassion fatigue” has started to show among people aiding the survivors of the tsunami, especially among those ordinary civilian neighbors involved in rescue work or the gruesome tasks of unearthing bodies, often those of family members and friends. We must anticipate and be prepared to deal with these kinds of mental repercussions, which are possibly much more complicated than for traditional emergency workers. But even experienced military personnel and Red Cross workers tasked with body identification and recovery suffer psychological fallout.

3 - PATTERNS

2005-01-24T21:07:00.000-08:00

The predictable roller coaster. We are capable of anticipating many of the contours of societal response to massive trauma like the tsunami. Looking back through a chapter titled “Crisis Management” that I wrote in 1999 for inclusion in the Presidential Action Plan produced by the Sri Lanka Task Force on Human Disaster Management, I discover an interesting example:

Addressing the divide between “cleared” (Government controlled), and “un-cleared” (Tiger held) areas, I wrote: “Thus disaster management in an “un-cleared” area may require the cooperation of parties not ordinarily in partnership and/or through the intervention of mutually acceptable neutral liaison intermediaries. Such a situation would arise – to use a “natural disaster” example – if a tornado’s sweep would encompass both cleared and un-cleared regions. As the forces which generate a disaster are not constrained by geographic or political boundaries, anyone or anything in its path is vulnerable.”

And indeed, that is what has happened. We have seen the efforts of the government and LTTE forces spontaneously combined, boosted by the participation of international rapid response relief teams. A common enemy can bring conflicting parties together. Knowing that, a “peacebuilding” component might be a standard part of the response to a disaster which sweeps through a society already caught up in a conflict. I.e., disaster response should not put peace and reconciliation efforts on hold. Rather, the humanitarian response ought to attempt to use the sudden willingness of the warring parties to work together as part of a long-term recovery and peacebuilding strategy. In that regard, note the following development here in Sri Lanka:

Death wish. A newspaper headline: “Tiger leader is re-incarnated.” Since December 26^th, there has been nationwide speculation that the LTTE leader was swept out to sea with everybody else. His ‘failure’ to emerge, to pronounce leader-like words of comfort and to support relief efforts sparked joy among those who considered their prayers fulfilled. Some papers even carried an obituary and described elaborate funeral rituals. But those fears (or hopes) were premature. From seemingly nowhere the LTTE chief emerged to confer with the visiting Norwegian foreign minister on Norway’s refreshed commitment to facilitating a final peace. A definite plus for the peace process.

More progress. Today, one day short of a month when Tsunami ignored the boundaries between “government” and LTTE areas, we all note with approval that government agents are meeting at Tiger headquarters to discuss tsunami relief operations.

“The media in all its varied and marvelous forms is a precious and powerful social and educational instrument” That quote is from another section of the 1999 Action Plan. Addressing the Role of the Media in human disaster management, we said, “The media, often regarded the ‘eyes and ears’ of the community, exerts a profound influence on how people think and how they might act. This is of crucial importance during times of peril, remembering that due to some vulnerability, immaturity or other physical/mental state, individuals may not be able to access or interpret information accurately.”

We have seen the media play exactly that kind of helpful role in this crisis. Drawn from some of this week’s newspaper headlines, here is a sample of media support to public sentiment: “Time to heal mental wounds,” “Israeli trauma counseling team arrives,” “They too need love: not only humans but their much loved pets and livestock were caught up in the tsunami – the Tsunami People Animal Disaster Relief Coalition is helping,” “It is all about humanity – a man’s karma is never lost,” “There is no escape of one’s past whether good or evil,” “Helping to rebuild minds,” “The Coalition for Assisting Tsunami Affected Women called for heightened sensitivity to women’s vulnerability,” “A disaster chapter needed in school curricula,” and “Mix of tsunami aid and preaching stirs concern.”

Instinct over “intelligence” No dead animals were to be found in the low lying forests in which they usually roam. Heeding vibrations or whatever, they and the birds got to safer ground. But big fish and sharks were marooned and could not get back to swim. The price we pay for evolution

Privation, loss and fear of abandonment. I listen to people speak of the tsunami’s devastation, of innocent lives washed away, of miraculous escapes and rescues, of abiding compassion, and of the smiling resilience of little children. And then I learn of behaviors that are shockingly cruel, insensitive or violent (especially towards women). Is there an explanation for this dark side of post-disaster behavior?

We are not, as a rule, fully aware of our dependence on our personal relationships and our reliance on our (safe) environment until something goes wrong. Similarly, we realize our hunger for connection when we cannot reach the people we love, should they reject us, go missing, or die. Rarely are we forced to confront the level of trust we place in our society or vest in the organization to which we belong. A disaster – an earthquake, a power failure or a strike, an event in which we discover that the trusted cannot be counted on – challenges all of our personal assumptions.

Possibly more than anything else, a disaster makes transparent our dependency and underlying helplessness. For it is then that we realize – often with reluctance, sadness, rage and despair – the terrifying extent to which we rely on a benign nature and on the good will of other people. At our deepest level – at the thinking-feeling-acting sense of being – this discovered dependence feels dangerous, and threatening. a tsunami shock of loss or abandonment.

This is more easily understood than one might think. Likely everyone has had something like this experience:

Your 10 year old son often sneaks to the sweet shop across the busy highway. You warn and warn. One day you are in the garden tending the orchids by the gate. You hear the screech of brakes, a bus comes to a sudden halt. Your son bursts in the gate, trips and falls near where you stand. What would be your first impulse? Note: My sons listened most of the time.

Thus this emotional tsunami, this angry realization of how much we depend on others and the environment. And thus, too, the reason why we tend to move so quickly to amnesia for the event.

If “there’s a tide in the affairs of men (and nations) which taken at the flood, reaches on to fortune” maybe it applies to nations. Island people are usually sensitive to tides, fishermen particularly. With their boats split apart, perched far from the water’s edge, fewer fishermen can venture out. Despite shortages, fish prices are down, depressed by fears the fish might have fed on the dead.

And yet, I feel the milk of human kindness flowing here. Gentle waves of sympathy, compassion and generosity – local and international – are helping as the wounded nation gears up for the 5 R’s. Relief, Rehabilitation, Reconstruction, Regeneration, and above all Reconciliation.

2 - BLAME

2005-01-22T10:03:00.000-08:00

Phase II – the apportioning of blame. Interviewed on a “Good Morning” type radio program, I was introduced as the former Chairman of the Human Disaster Management Council. The main question was “Doctor! Do you think that if the plan you helped to develop had been fully implemented the tsunami damage could have been prevented?” My Trauma Doctor response: Even with warning I don’t think any country in the world has the capacity to handle a sudden disaster of such magnitude. 9/11 would be another example, where a modern country with sophisticated alerting systems was unprepared, despite some earlier warnings of such a possibility.

This is a major theme now: Could it have been prevented? Why weren’t we warned? Maybe my child would be alive today if not for...[fill in the blank]. Who did this to us? Was it God, the devil, or my enemy? Perhaps it is a punishment for my sins, but what did I do that was so bad as to deserve this?

Alongside these questions comes much talk of trauma counseling, and wondering if we have enough trained people to deal with the distress.

Disasters bring out the best and worst. The tsunami is bringing out the best and also the worst in us individuals. I read the various incidents less as judgments than symptoms, as reflections of deeper, unfinished business. This must also be true for the ways in which societies as a whole react to disasters, but the behavioral symptoms of societal distress are harder to detect. Some ask with puzzlement why people exploit the weakness and helplessness of even their own people - as if this were a new phenomenon.

Disasters bring us to realize our lowest common factor, staying alive. Once the waves blew in, all boundaries were violated, whisking everyone in its path – no discrimination. Each body washed ashore was no more dead or less dead than the other. Searching the debris for “missing” loved ones tears at the heart. Moving from one to the other brings mixed feelings, lifting one body to release another – “thank heaven that’s not my mother! Maybe she hasn’t really died, and how can humans smell so? For all the others still breathing life, they clutched and clung to one another as if kin, naked and alive. Disasters cause a leavening and an equalizing effect.

Starvation thins the stomach wall. Sometimes death comes after the event – but is no less painful. I recall being in a Cambodian refugee camp in Thailand in June 1981. Limping mothers carrying children emaciated near to the point of death streamed into Khao-I-Dang, a camp on the Thai border with Cambodia where a huge humanitarian disaster was unfolding. As refugees arrived in camp anxiety prompted a rush-to-feed frenzy. The rice was cooking but not quite ready. In one section of the camp fearing the worst, some nursing aides couldn’t resist the instinct to hand feed the little things. The reflex to suck was strong enough, and sleep soon overtook their little hearts, but not for very long. The rice kept swelling until it ripped their paper thin stomachs - and they were gone. These “aftershocks” will continue here, too. The spectacle of utter helplessness stirs the mind like nothing else.

Politics as usual. As a colleague noted, “the first thing people need to know about disasters is that whatever else they are, they are always political events. Those who don’t understand that will be very disappointed or maybe eaten alive.” As they are all across the region, the cross-currents of multiple political agendas are already afoot; now to see if these differences can be channeled into the healthy struggle to help the country back on its feet, stronger than before – or if these are the early seeds of a future hurricane.

Follow up on the Sri Lankan woman from Texas. Both children lost while here on holiday, she is being comforted by the company of friends and family who do not probe with questions or fuss. No one insists she must eat and no one says “I know how you feel.” The family is using suicide precautions. She appears to find clam in quiet meditation as others go back to keep searching the shore, just in case… Multiply this grief by tens of thousands!

1 - RETURN TO COLOMBO

2005-01-19T01:06:00.000-08:00

I RETURN TO SRI LANKA. My Sri Lankan Airline flight from London to Colombo is usually packed with noisy Brits heading to Sri Lanka’s exotic beach resorts and a few British-based expatriate families going “home” for the holidays. Not so this time. Almost all are brown faces, many those of elderly women traveling alone, grim and pensive. Of about a dozen or so westerners, there are five young Americans wearing bright yellow T shirts bearing the sign “Volunteer Minister” of the Church of Scientology. A few middle aged western men travel alone; it is hard to tell if they are UN or NGO types, or diplomats returning to post.

On my right a middle aged Sri Lankan woman, buried in her prayer book, tells me she’s heading for a spiritual retreat in India. On my left a gentle lady plays solitaire; across from me a woman is deep into a TV re-play of a Sri Lankan romantic tragedy. Music is very subdued and the announcements by the chief steward polite but brief. Even the pilot sounds cut and dry going through usual welcome and flight plan.

I open the in-flight magazine “Serendib,” the latest edition before the Tsunami, full of shiny photos of suntanned and shapely youth frolicking on the sunny beaches along the coasts of the Maldives and Sri Lanka. One cannot imagine anything more exciting and yet more tranquil in those blue horizons. A mobile phone company advertisement shows a foreign girl beamingly gazing into her phone. She’s alerted to a prompt by her adoring companion “tell them you are on Paradise!”

As the altitude drops the quiet is broken by infants and small kids crying and passengers reaching for their bags.

Back in Colombo, newspaper headlines report the seemingly endless stream of visiting dignitaries. Today it is US Under Secretary of Defense Paul Wolfowitz, described as a master military strategist in the war in Iraq; yesterday it was the Archbishop of Washington; some days ago, the tours of UN Chief Kofi Annan, US Secretary of State Colin Powell and a Japanese delegation. All come to express sympathy to the President for the nations’ losses, all want to see the devastation and embrace a child.

The papers report offers of huge sums of money – in billions – for relief and reconstruction. The World Bank and IMF are said to pitch in as never before. On another page, aid donors are reported to worry that tsunami relief funds will be spirited away. There are appeals for equitable allocation of goods and fear of corruption. “Visiting Canadian Prime Minister makes plea for equitable disbursement of funds.”

But for a person who says he has lost everything – “all gone” – a smile, a cup of tea, feels more real than a billion dollars in international aid.

Among other news headlines I read: “President is expected to come up with a master plan for building the nation,” “Japan pledges the largest aid,” “FOSTER CARE BEFORE ADOPTION IS MORE SUITABLE!” (an article in response to fears of child trafficking and the threat of predatory pedophiles. Remember “Operation Babylift”: soon after the fall of Saigon?); “Innovative laws needed for relief to bereaved families;” “Speedy handling of foreign ships to meet the demands” “Money to tsunami affected families.”

And this headline, “POST TRAUMA CONFLICT IN THE OPPOSITION PARTY,” describes a split as certain factions agree with the government aid distribution policies and others don’t. The common tragedy blurs political identities.

The editorial pages are busy, too: “AVOIDING A POLITICAL TSUNAMI.” says one. Others: “Tsunami – is this a curse?” and ‘Tsunami-sized waves of big money may threaten security – the second disaster.”

And, of course, letters to the editor. This from a young woman… “OH MEN, PLEASE STOP EXPLOITING THE DISASTER’S MISERY FOR PERSONAL GAIN,” a response to reports of men stealing jewelry from the corpses and incidents of rape in refugee centers A UNICEF worker writes, “Women and children are the most vulnerable.” “Women are more injured or hurt through the loss and bereavement,” says a female Buddhist monk.

Still more news: 9 MOTHERS CLAIM ONE BABY reports a local paper. Compounding the deaths, devastation, and despair, up to nine mothers (so far) are claiming a baby as their son. Possibly 3or 4 months old and bruised from the tsunami’s force, the baby is known only as Baby 81. Amid the scene of distress outside the hospital some mothers threaten suicide. This has happened before – similar disputes required DNA tests. This highlights the need to carefully control adoption guidelines.

This is a huge problem. About 4000 children have lost one or both parents because of the Tsunami. The number of parents who have lost children is much higher. And the Official death toll, now 38,196, is expected to rise as the sea gives up what it has claimed.

Observation: The honeymoon phase of post-disaster response is passing.

6:00 AM. The front door bell rings. A Sri Lankan couple from Washington wants to know if I could see a young woman from Texas, a Sri Lankan who was on holiday here with two small children. They had been out on a safari when the water came. She is the only survivor, remains stunned.

I am making plans to do what I can. There must be thousands more. What can one person really do!