AFTER THE TSUNAMI – HARNESSING AUSTRALIAN EXPERTISE FOR RECOVERY
Canberra, 31 March 2005
The human face of disaster
Dr Jim Robertson, Australian Federal Police and
Professor Beverley Raphael, Department of Health, NSW
Jim Robertson
Powerpoint presentation (443KB)
There are benefits and disadvantages about being the last, or second last, speaker here. Time is obviously flowing on, but it does give me the opportunity of picking up on some of the comments that earlier speakers have made.
First of all, it is a great pleasure and I do welcome the opportunity to contribute to this forum and give you a brief insight into the DVI, disaster victim identification, process. I was very pleased to see the acknowledgement by earlier speakers – Bruce Billson and David Templeman – of the DVI process in this. There has certainly been a greater public awareness in Australia (regrettably, flowing out of Bali and now with this) but I think interestingly perhaps the Australian public have put even less pressure on us in this incident and there is now much greater tolerance for the complexity and difficulty and the time it takes, and to get results and more acceptance. And I think that is because this is a natural disaster and not a man-made event.
The AFP was a member of the task force that you heard about earlier, that was established in the very early days, and DVI assistance – as I will show you in a slide in the moment – was specifically requested by the Thais and has been, and is, a significant part of Australia’s assistance to the region. It is an ongoing exercise; we are going to be there for at least the rest of this calendar year.
Of the 270,000-plus people – and who will ever know what the exact figure is? – who have died across the region, I think it is interesting to note that international DVI standards have only been broadly applied in Thailand to about five and a half thousand of those people. Quite frankly, it is outside the scope of my talk and the time available to me to go more deeply into the reasons for that, but I guess they are practically realistic and they are cultural as well.
David Templeman talked earlier on about being asked to assist, and we were asked to assist. The reason why is that we have been in the region – the AFP and Australia more generally – building relationships in normal times. I think that is a really, really important part of this. We can’t expect to go in and assist, or be asked to assist, in these regions if we are not actually investing and actually doing things for our neighbours during the normal times. Often the role that agencies can play is that we cut across some of the political stuff and just get on with it, against a backdrop of political realities.
Very quickly: as I said, how did we get involved? Well, the request was specifically made to assist with the disaster victim identification process. One of my managers, Julian Slater, chairs the Australasian DVI Committee and we have a plan which was activated, and an Australian group – this is not an AFP exercise, it is an Australian exercise – deployed on 29 December. Interestingly, David also commented earlier on about us turning up with resources. Through our rapid response plan – I will be blunt with you, developed for counterterrorism, not for natural disasters – we had been developing rapid response capability. We are the only country that actually turned up in Thailand with supplies to get things moving. That was to the great surprise of many of the other international countries, who just turned up there and expected that in some strange way it would be all there for them.
Our role in response to international incidents is to coordinate Australian assistance, and as I say, we deployed consumables in support of the operation.
Another one of my managers, Karl Kent, who you would have seen on the television many times over the last few months, was asked early on in the process by the Thais to take on a role as so-called Joint Chief of Staff, answering to a Police General, although there were a number of government departments in Thailand involved in this. As Chief of Staff he has been responsible, with a Thai equivalent, for coordinating all of the international assistance. During the first three weeks that built up to over 30 countries, with over 400 people assisting in the DVI process. It is a massive operation, culturally very difficult, bringing all of those people together.
I was asked in a radio interview a number of weeks ago where you start with something like this, and I wasn’t being flippant when I said, ‘At the beginning,’ because when the people arrived on the ground there were five and a half thousand bodies lying in a decaying condition on the ground.
There are five phases to the DVI process. The starting point was to just start preparing the deceased for post-mortem examinations. There were no refrigerated cabinets available; those had to be arranged. By the end of the first week, they were starting to be put into refrigerated containers, but by that stage there was major decomposition.
Our people have to deal with that. They have to be able to handle that, and they have to be able to do it in an objective way in order to obtain the end result, which for us is to be able to identify deceased persons.
For the people on the ground, there is an equal number or more people back in other places such as Canberra here, in incident rooms, dealing with the relatives of deceased, back in Australia. We started off here in a situation where it was expected there might be many hundreds of Australians amongst the thousands deceased.
Working with DFAT, that could be reduced over the weeks and we are now in the position, I guess, that we can say fortunately that it looks as if we may get out of this with 27 Australians deceased – 21 have now been identified and grave concerns are held for six.
The Thai government estimate the total number of deceased to be of the order of five and a half thousand, but there are likely to be many bodies that are never recovered, have been washed out to sea, and the DVI process will continue for many more months.
To date, over 100 Australians have contributed to that effort. That has included representatives from all states and territories, from police and non-police organisations, covering a wide range of different types of people, from forensic people to specialist DVI police, pathologists, missing persons staff, odontologists, scientists, family liaison officers, psychologists, counsellors and chaplains. I think that Beverley, who is following me, is going to pick up on the role of some of those people – the important role they play in helping staff such as the people involved in the DVI work to cope with what they have to deal with.
We take a very positive view of what we do. Some people again say, ‘Well, how can you do this sort of work?’ The reality is because, in our culture, bringing closure to people is important, being able to return their deceased loved one to them brings closure to them. We have heard a number of people through this morning talk about cultural sensitivity. Interestingly, it is a two-way street. It is important as well that the countries you are working in recognise the culture that you live in.
So in this instance you might ask, ‘Well, why is it that in Thailand, in particular, they have put a heavy emphasis on this DVI process?’ If you wanted to be slightly cynical you might say it is about tourism, because they recognise that at the end of the day they are not going to get the Western tourists to go back there unless there is a sense of confidence that they do the right thing by people if they find themselves in a situation like this. I would like to take a less cynical view and say that it is because they recognise culturally the importance to Western society that we actually are able to identify people and return them to their loved ones.
We are about the business of trying to create a sustainable future to deal with these sorts of incidents, and interestingly one of the reasons why we were able to respond so quickly, to be able to take supplies with us, was this rapid response project. But we also were planning to deliver five DVI courses around the region this year, and as part of that we were actually going to be delivering consumables and to deal with up to 200 victims of disasters to those countries.
We are about capacity-building, we are about trying to recognise the cultural sensitivities, but to deliver practical solutions to countries around the region so that they can start to deal with these in their own way.
Thank you very much for the opportunity to talk to you this morning about that. As I say, I hope I have set the scene for Beverley to pick up and now talk about some of the psychiatric/psychological impacts. Thank you.
Beverley Raphael
Powerpoint presentation (13,687KB)
Na suo masuala.
I am going to fill in some of the issues that affect the human response in disaster and the human outcomes. There are a number of key messages I would like to give you, and some of them build on what has been said earlier today.
My last talk in this meeting place for the Academy of Science was in the 1970s, when we held a Natural Hazards symposium, and many of the lessons there get repeated as though they are new, in some of the things that we have done today. One of the hardest things after many years working in this field is to pick up on what is known, to communicate well about the science – as was said earlier on – and to take forward from there instead of reinventing the issues.
So, pre-disaster prevention, planning, readiness and mitigation are critical, and recognising what the human factor impacts may be. There are the death and destruction, the encounter with death and the shock and horror that leaves, the loss of loved ones and resources, the grief that follows. I was very pleased to follow Jim because much of the research in mental health is focused on trauma. PTSD is the catch phrase. Are they traumatised? Bring in the trauma counsellors – without recognising that grief is a profound component of this and has separate phenomenology.
Dislocation and separation of families: we have failed in the past, quite often, in many fields, to recognise the strength and resilience of local communities, even in a cultural context, and we have quite frequently placed a control over or a failure to recognise their strengths in recovery.
The meaning of a disaster is important. Natural is often seen as fate, or God, sometimes the spirits are blamed for it. Man-made: the issues of human malevolence and neglect come in. I won’t go into those today because they do not fit so well with this.
I am filling you in very quickly on some of the science that is evolving in our understanding of the responses to trauma and subsequently to grief. Shock, dissociation, fear, and repeated fears and traumatic anxieties followed, particularly in countries where the aftershocks came. The medical teams who went there were quite affected by it.
And then we have the multiple exposure to dead bodies – something which may traumatise all of those so exposed. We have to recognise that it is quite a normal reaction to be hyper-aroused, to be focused on images, to be fearful of something returning, and to try to avoid and be numb and shut out some of the issues.
Studies have suggested that in the first month the acute severe reaction which disables people might be called acute stress disorders, although that is under critical appraisal, and post-traumatic stress disorder, PTSD as it is known, is frequently diagnosed. But many other conditions can happen in behavioural changes.
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I just put this up, not to run through the details of the brain scan, but to show you that subjects with PTSD have certain patterns of reaction in their brains in the aftermath – not to do with medication but to do with some of the impacts of psychological trauma.
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This shows two different patterns, a husband and wife who were in a car accident. One was numb and had a certain pattern of brain reaction, and the other was more aroused and intensely focused on it, and had a different pattern.
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We show too here – this is after September 11, not a natural impact – that even after such a horrendous experience, people living quite close by settled in a period of time in terms of their psychological trauma, although some things come on later.
What we do to mitigate and prevent: I will use the words ‘mental health’ if I dare say that prevention and treatment is a possibility, and much of the science developed in this country about the sorts of models that might be assistance and prevent it at this time. We know now that critical incident stress debriefing, which has had great favour, is not indicated for disaster-affected populations and may in fact do harm, creating more morbidity in the longer term. Multiple studies in different countries, and recently randomised controlled trials, have established this.
Capacity building: as many workers and speakers before me have said, this is one of the focal areas – how we help people use these things for learnings in the interim, and taking them into the personal disasters, and building resilience. Social mitigation is one of the factors.
Loss, grief and bereavement bring a different set of reactive processes and phenomenology: angry protest, searching and yearning for the lost one, scanning, looking for the lost person, sadness, mourning. This is not depression, this is grief.
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These faces were shown by Charles Darwin in his book on the expression of emotion in man and animals, over 100 years ago. The face of shock and horror, and the face of grief and sadness – two different sets of faces.
Outcomes: normal grief over time, complicated grief and bereavement, and perhaps depression and other behavioural changes, can follow if normal grief does not continue, and particularly in the sorts of deaths that occur in these circumstances.
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Here are shown different patterns of brain activation in someone grieving.
Mitigation, what might we do? We have positive expectancies, we have specialised counselling for those at high risk when there is a need. And some of these even build on, as they do with trauma, on web and other sources.
And building the health system capacity to deal with other losses, as well as recognising and supporting the social recovery processes.
Psychological trauma and bereavement can occur together, and the particular circumstances in which they do relate to the horrific deaths that occur in natural or other disasters. That is where there is a major overlap with the DVI process. After Lockerbie, comments and investigations suggested that a very powerful factor in terms of how well people recovered was the degree to which they were supported and looked after through the DVI process. There are excellent processes in place through the DVI nationally in Australia and taken into models that are used.
Interventions involve those that might be about the circumstances of the death, the cause of the trauma and the loss – the review of the history of the lost relationship and the grief processes.
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Mitigations occur – I show you this picture, this is one of the medical teams that went from New South Wales, and this is the sad face of a woman who has lost everyone in her family but this child – and the engagements and support and affiliation that occurs for those who offer help in such circumstances.
We have separation of families, the focus on reunion which a number of people have presented earlier on, the place – finding a place, a shelter and, ultimately, a home which someone can take on as their own place, not necessarily a house we provide but one that is socially and culturally appropriate.
With the tsunami disaster, mass deaths impacted in the most incredible way: mass grief, and the issue of DVI, probably mostly for Westerners, burials in socially sanctioned and culturally and religiously appropriate ways, the injuries which had to be treated – some of the surgeons came back, having done an excellent job but concerned about how they had not been able to do the level of work they might have done in a developed country and in other circumstances – and uncertainty, prolonged uncertainty about the future.
Social structures are impacted in major ways. As we heard earlier, the education system had lost many of its teachers.
Immediate effects: event reminders and triggers have ongoing impact in terms of mental health and adjustment over time, and long-term impacts come, of course, from the profound devastation, the ongoing loss and the trauma.
Social systems are critical to understanding this, and the human face of disaster. Prevention and planning: we often live in the myth of the ‘lucky country’, complacency – this was touched on earlier.
In the initial phase there is a social phenomenon called the ‘honeymoon’ phase, where everyone converges on the scene with well-meaning intent, there is an affiliative set of relationships, people get close to those they help, people who have been through the same experiences get close together. A convergence may occur to a degree which overwhelms the local resources in this country, and sometimes a convergence of multiple do-gooders in other countries.
Altruism and social networks are important parts of the recovery process. There is a phase of disillusionment that follows – government departments come in and offer money, then which government department is going to pay comes into it. And recognising that it is not going to go away.
The disaster responders are often amongst the hidden victims, because the sort of work they do, even though sustained by very good systems to look after their mental health, may at times become overwhelming for personal reasons, such as identifying someone like yourself or identifying with children who are deceased, for example with a degree of gruesomeness and mutilation. This is often much worse in man-made disasters.
Making meaning of what has happened, blaming the human factor and shared meanings are often part of the ongoing process afterwards, as some of my colleagues, Derek Sullivan in particular, have commented on.
I have had the privilege of chairing the National Mental Health Task Force, which has been involved in both supporting response for Australians, and Australians with relatives overseas, and also coordinating Australia’s international outreach in terms of mental health and psychosocial support, with teams involved in support – in linkage with AusAID and Emergency Management Australia – to both Aceh through the WHO and also through Indonesia and as well through Sri Lanka, India and other support processes in Thailand.
To conclude: important social rituals are the memorialisations and testimonies that occur afterwards. We have seen that in the photos people put up afterwards, the candles after September 11 and Bali. We always have to recognise the social and cultural issues. Many people in non-Western countries have, it has been said, had the cultural imperative placed on them of believing in PTSD, post-traumatic stress disorder, rather than recognition and acceptance of their ways of healing after traumatic exposures like those of mass death.
So, recognition of the cultures of meaning, of understanding of what has happened, reaction/recovery are critical in working in a collaborative and consultative way with communities that have been impacted on. This is a very human issue, and takes the great sensitivity that has been reflected on by some of the earlier speakers. You have to remember that you get identified with what has happened. Aceh will always bring to all of our minds the idea of this tsunami.
Coordination through chaotic times is difficult. Even the best-meaning organisations have difficulties. Even in Australia, with lots of backup, we have difficulties. But one of the learnings that have to go forward is that this coordination in preparation, as well as readiness, like the emergency response that Jim [Robertson] mentioned, is important.
Finally, I would like to say, when people ask me why I have worked in this field for 30 years, that you see the best of human nature. You see the great courage and strengths people deal in their human response to disaster: altruism, hope and renewal. One study after the Newcastle earthquake showed that the strongest predictor of getting better was hope.