Challenges of post-tsunami reconstruction in Sri Lanka: health care aid and the Health Alliance

The health needs generated by the tsunami have included both the acute provision of emergency relief and the longer-term process of reconstruction and development. The problems to be addressed are deep and varied.1 Many health care personnel in the region were killed or injured, and hospitals and clinics were damaged or destroyed. The sheer number of casualties placed a great burden on remaining local health services and on those brought in from outside.2 There is evidence that the impact of the disaster was particularly great on women and the very poor.3,4 The risk of communicable diseases such as gastroenteritis greatly increased, and environmental disturbances led to vector proliferation and an increase in mosquito-borne diseases, including malaria.5,6 Contamination of water storage reservoirs with salt or poisonous waste; cramped living conditions; inadequate nutrition; and damage to crops, farmland and fishing fleets compounded the risks. In many cases, the problems were magnified by the fact that pre-existing public utilities were limited.

In spite of the scale of the problems and logistic difficulties, it is widely agreed that the immediate relief effort after the tsunami was largely successful.4 Emergency food, water and shelter were provided, and the steps taken to avoid the outbreak of epidemics were mostly effective. Satisfaction of the longer-term health care needs, however, is both more complex and less tractable. It requires careful assessment of the needs of local populations, which may vary greatly in their degree of exposure to the disaster, and of geographical, social, cultural and conflict-related factors. The infrastructure to provide ongoing medical and nursing care, public health programs, clean water supply and sewage disposal needs to be reconstructed, or in some cases, constructed de novo. Programs need to be established to provide psychological support; nutritional education and supplementation; vaccination; and obstetric, maternal and infant welfare care. Attention needs to be given to minimising the effects of future disasters and planning responses to them. All this has to be achieved in the setting of short-term foreign aid commitments and limited social investment in health. Some of these problems may be illustrated by experiences recounted along the eastern coast of Sri Lanka, which was particularly hard hit by the tsunami.

Shortages of specialist medical staff are common throughout southern and South-East Asia. These include almost every area of specialty, but the deficiencies are particularly severe in the area of psychiatry and psychological medicine. This is in spite of the fact that psychological and psychiatric needs present one of the largest problems in the post-disaster reconstruction and development.7,8 In the eastern region of Sri Lanka, for example, it is literally the case that one psychiatrist is responsible for the care of 1.2 million people. Dr Ganesan works long hours and travels extensively to cover a vast area ravaged by years of war and, now, the tsunami.

The case of psychological medicine illustrates well the complexity of relief and development aid in the field of health care.9 Despite long-held beliefs, there is little evidence to support the effectiveness of immediate post-disaster critical incident stress debriefing — rather, recent data suggest that it may in fact have deleterious effects.8 Ironically, therefore, a significant task of a disaster health care response has become the prevention of adverse iatrogenic interventions initiated by either local or international agencies. This is not to say that acute psychiatric and psychological needs do not arise after a disaster. On the contrary, grief and acute stress reactions, brief psychotic disorders, and relapse of pre-existing psychiatric disorders (including major depression and schizophrenia) are common, and delirium in medical and surgical patients may be confused with other psychiatric disorders. Adults, children and adolescents may all be affected.9,10 Although treatment is warranted for serious chronic disorders and symptom relief is beneficial in some other cases, the vast majority of affected people will improve with skilled facilitation of culturally and religiously appropriate grieving and health practices.11,12

A “second wave” of psychiatric morbidity may follow acute reactions to a disaster, often occurring after the withdrawal of medical teams and international aid.13,14 Psychiatric conditions may include complicated grief reactions, major depression, substance use disorders, post-traumatic stress disorder, behavioural disturbances, and phobic and anxiety disorders. Although all of these may require medical or psychological intervention, they commonly go unrecognised by both communities and health workers and are mislabelled as “normal responses”, misattributed to sociocultural factors or concealed by fear of stigma. This emphasises the need for a case identification process in conjunction with broad management strat-egies.15

Case identification may use a multi-tiered approach encompassing community awareness programs, education of key community workers (eg, teachers, religious leaders, traditional health practitioners), and training of primary health workers in basic diagnostic and management skills. Treatment can then be initiated and monitored through primary care medical health staff overseeing primary health workers. Reliance on specialist psychiatric services needs to be avoided. Specialists would be more usefully employed in teaching, training and research activities, acting only as a final port of call in providing treatment. Limiting the extent of “second wave” morbidity involves broader management approaches that include addressing other public health needs, nutrition, education, employment and social reconstruction, as well as directed primary prevention of both physical and mental disorders such as diarrhoeal and respiratory illnesses, alcohol misuse and domestic violence. The psychological implications of disaster require specific attention when designing aid programs, including, in particular, the use and facilitation of local, community-based capacity.

If aid programs are to contribute to the long-term improvement of health care, they need both to address locally specific needs and to enhance community health care capacity. This requires effective mechanisms for community consultation and an ability to draw on a diverse range of resources and competencies. The Australian Health Alliance to Assist with Post-tsunami Reconstruction has been established to facilitate such an approach (Box).

The Health Alliance was formed in early 2005 by a group of medical and non-medical health professionals in Australia who wanted to assist with the health care response to the tsunami and to ensure that a focus on developing community capacity and satisfying local needs was maintained. It is an open coalition led by the Royal Australasian College of Physicians and includes participants from the Royal Australasian College of Surgeons, the Royal Australian and New Zealand College of Psychiatrists, the Royal Australian College of General Practitioners, the National Nursing Organisation and other professional associations, universities and research institutes. The group encompasses a wide range of competencies in medicine, nursing, public health and health service delivery and reflects the scope of the knowledge, educational resources and skills within the Australian health care community. Many of the participants have first-hand experience in the developing world, and all are keen to offer their skills to communities that could benefit from them. The Health Alliance has received assistance from the participant organisations and the Australian Government to consult with national and international groups with a view to fostering contacts, refining its goals and modes of operation, and developing a formal program and operational plan. As part of this process it sent a mission to Sri Lanka and India in May 2005.

The broad aim of the Health Alliance is to provide a framework for an efficient, coordinated response from the Australian health care community to the health needs of the region in the wake of the tsunami. It acts as an umbrella group to identify and coordinate the delivery of services from the Australian health care community to developing countries. It is seeking to achieve its aim by:

• providing a forum in which Australian health professionals can share experiences, knowledge and ideas about the health needs created by the tsunami and cooperate in developing collaborative projects;

• developing an inventory of services and resources that can be made available to governments, non-government organisations and other groups seeking assistance from the Australian health care community;

• providing a point of contact for potential donors seeking access to particular forms of expertise, knowledge and other resources; and

• where appropriate, developing action plans in partnership with local organisations by conducting needs assessments and engaging in community dialogues.

The Health Alliance envisages that the Australian health care community will contribute to the development of long-term, sustainable health care capacity by helping to train community-based health workers; develop programs in public health, nutrition and disease prevention; and provide materials and skill-based resources in special areas such as women’s and children’s health. It will draw on the extensive local experience of community-based educational campaigns in relation to HIV/AIDS, mental health and substance-related disorders and the vast resources available in the fields of health management and administration, quality assessment and control and health information systems.

There are some key areas in which particular contributions may be possible. Developing primary care facilities and a community infrastructure to assist in delivery of psychological health are two areas that should be emphasised. Several programs in these areas are already under way. For example, the Australian Medical Aid Foundation has supported the establishment of a primary care facility in Trincomalee, and a number of groups are helping to establish an integrated mental health program in the north-east, east and south of Sri Lanka. Elsewhere in the region, including Indonesia and the South Pacific, surgeons, physicians, nurses, optometrists and others (some of whom are contributors to the Health Alliance) have actively participated in training and health care delivery programs.16 Some of these contributions are simple and cheap — for example, provision of educational materials on diabetes that could be adapted to local conditions. Others are likely to require extensive consultation and substantial resources. The Health Alliance’s ability to identify local contributors and maintain liaisons with government and non-government bodies in Australia and overseas should facilitate projects at all such levels.