Worst of Times, Best of Times

Worst of Times, Best of Times Reflections of a Tsunami Medical Relief Worker in Aceh Province, Indonesia “People’s recovery in the aftermath of disaster constitutes the Janus face of a major catastrophe, the social countenance laid over the physical reality. It can be a time of not only just material but social devastation, fragmentation and despair. For many, it can also be quite remarkably, a time of social cohesion, purpose and almost glory.” -Susanna Hoffman The Angry Earth What is a Disaster • Disasters are all encompassing • Every aspect of human life is affected: – Environmental – Biological – Sociocultural • Interplay of environment, society and technology • A disaster becomes unavoidable in the setting of a historically produced pattern of vulnerability • That vulnerability determines the unfolding of the disaster more profoundly the physical force of the destructive agent Anthony Oliver-Smith and Susanna Hoffman Catastrophe and Culture Who are the Victims? • • • • Direct victims Indirect victims Peripheral victims Entry victims Stages of The Disaster • The First Phase: The Crisis and first phase of recovery – Life promoted over death – Survival overwhelming the pull of possessions – Aid evolving into commonality • The Second Phase: Survivors in the Aftermath • The Third Phase: Passage to closure Musée des Beaux Arts About suffering they were never wrong, The old Masters: how well they understood It’s human position; how it takes place While someone else is eating or opening a window or just walking dully along; How, when the aged are reverently, passionately waiting For the miraculous birth, there always must be Children who did not specially want it to happen, skating On a pond at the edge of the wood: They never forgot That even the dreadful martyrdom must run its course Anyhow in a corner, some untidy spot Where the dogs go on with their doggy life and the torturer's horse Scratches its innocent behind on a tree. In Brueghel's Icarus, for instance: how everything turns away Quite leisurely from the disaster; the ploughman may Have heard the splash, the forsaken cry, But for him it was not an important failure; the sun shone As it had to on the white legs disappearing into the green Water; and the expensive delicate ship that must have seen Something amazing, a boy falling out of the sky, Had somewhere to get to and sailed calmly on. W. H. Auden 1938 Aceh Province • 3.5 million inhabitants: distinct ethnic group with separate language – 80% of population involved in agriculture • Rice • Coffee • Cocoa • Fishing industry is vital • 15-20% of Indonesia’s oil and gas reserves Aceh Province • 96% Muslim: the “frontporch of Mekka” • Long history of aversion to outsiders – Dutch needed 30 years to bring province into submission – Region given special autonomy status in 1959 – 30 year civil war pitting GAM ( Aceh Freedom Movement) against Indonesian army – 10,000 deaths – Thousands of human rights violations – Significant restrictions to travel for foreigners – Province under Shariyah law Worst of Times-Tsunami Survivors A view of life in the camps for internally displaced persons Best of Times: The experiences of Tsunami relief workers “We can do no great things; only small things with great love” -Mother Teresa The Medical Aspects of Disaster Relief in Aceh • What we treated: – – – – – – – – – – – – Malaria Dengue Bronchitis/asthma Otitis Influenza Scabies, scabies, scabies Dysentery Post traumatic stress disorder Insomnia Panic disorder Varicella Every other chronic disease of adults and children Disaster relief medicine • • You treat what is in the bag The differential diagnosis is based on 1. What will kill someone if you miss it 2. What will kill someone if you miss it and have something to treat it with 3. If it isnt life threatening what does it most ressemble that you can treat The Barriers to good Medical Care in a Disaster • Chronic diseases don’t take a holiday – YOU CANT TREAT HYPERTENSION WITH A DIURETIC AND SALT RESTRICTION IN A TROPICAL CLIMATE WHERE WATER IS SCARCE AND EVERYTHING IS SALTED • STOP SENDING ALBENDAZOLE!!!!!! • Disaster relief medications are woefully inadequate after the first month • Practicing in chaos Worst of Times, Best of Times: rebuilding healthcare infrastructure • Scope of the task – 75,000 dead in Banda Aceh ( population250,000 pre Tsunami) – 400,000 displaced persons – 150 puskesmas ( health centers) in Aceh: 78 destroyed. Most still standing have limited staff – RS Zainul Abidin Hospital: 100/400 beds open Healthcare needs in Aceh • • • • Primary care Rebuild hospital/specialty care Medical school faculty and students Disease specific needs – Lung disease – Mental health – Women and children Mental Health Post Tsunami • 50% of affected population develop significant psychosocial distress • 5-10% ( 100,000 people) may require treatment of stress related psychiatric disorders • Lack of resources – – – – five psychiatrists 90 psychiatric nurses 3 psychologists 5 social workers Barriers to Intervention • Aceh is a deeply religious society • Acehnese are resilient and self-reliant • Western constructs of intervention (trauma counseling/psychiatric approach) may be unacceptable or ineffective • Coordination between NGOs, government organizations and local efforts A Reasonable Plan of Intervention • Restart clinical activities in psychiatric hospitals • Activate local coordination of efforts • Rapid assessment of magnitude and distribution of psychiatric needs • Widely disseminate uncomplicated, reassuring, empathic information on normal stress reactions to the community • Deploy 4-6 community health teams • Integrate trauma response to these teams • Develop community based guidelines for management of psychiatric conditions What about Lung Health? • Challenges – Huge burden of obstructive lung disease – Increase in acute airway problems in victims who were submerged in tsunami – Long term exposure issues • Burning of refuse • Biomass burning • Automobile engine combustion Lung Health Post Tsunami • • • – A research/intervention agenda Longitudinal assessment of air quality in Banda Aceh Longitudinal assessment of asthma prevalence in Banda Aceh Explore feasibility of time series analysis Links variation in air quality to respiratory events • • • Deaths from asthma Admissions/ed visits Prevalence • – – Intervention Community based provider education Reasonable guideline driven care of asthma Some Personal Reflections • Why do this? • Why are most American relief organizations faith based? • Mission statement of Northwest Medical Teams: The mission of northwest medical teams is to “demonstrate the love of Christ to people in crisis” In various developing countries, we carry out this mission in partnership with Christian organizations that work in cooperation with local Christian churches… I am applying for volunteer service with NWMTI whose primary purpose is to extend the love of Christ through disaster response, relief and development, specializing in medical care and health education for the needy people of the world. – “Faith without works is dead” – James 2:14-26 – Works without faith is ? A Contrasting View: Médicins san Frontières (Doctors without Borders) MSF unites direct medical care with a commitment to bearing witness and speaking out against the underlyinng causes of suffering. Its volunteers protest violations of humanitarian law on behalf of populations who have no voice. MSF is an organization based on volunteerism. In helping to relieve the suffering of others, the MSF volunteer not only gives freely of his or her humanity, but creates a link of solidarity from his or her own community to a population in need. Why do this? • We are graced by our work as health care workers with an unbelievable and unequaled capacity to do good • Service to others is at the core of what we do as healthcare professionals • The Duke environment powerfully enables us to do good and render service • We should carry this spirit and capability beyond our walls • That effort should be as important as the other missions of our hospital and department Thank you Musée des Beaux Arts About suffering they were never wrong, The old Masters: how well they understood It’s human position; how it takes place While someone else is eating or opening a window or just walking dully along; How, when the aged are reverently, passionately waiting For the miraculous birth, there always must be Children who did not specially want it to happen, skating On a pond at the edge of the wood: They never forgot That even the dreadful martyrdom must run its course Anyhow in a corner, some untidy spot Where the dogs go on with their doggy life and the torturer's horse Scratches its innocent behind on a tree. In Brueghel's Icarus, for instance: how everything turns away Quite leisurely from the disaster; the ploughman may Have heard the splash, the forsaken cry, But for him it was not an important failure; the sun shone As it had to on the white legs disappearing into the green Water; and the expensive delicate ship that must have seen Something amazing, a boy falling out of the sky, Had somewhere to get to and sailed calmly on. W. H. Auden 1938