Implementation of Mental Health Programs for Survivors of Natural Disasters in Latin America

 

Handbook of International Disaster, Vol 2, chapter 4

Edit. Gilbert Reyes & Gerard A. Jacobs

Praeger, Conn.USA, 2006

 

Author’s Note: The first part of this chapter presents the evidence of the recurring impacts of disasters occurring in Latin America.  The remainder of the chapter, published below, focuses on adapting the knowledge accumulated through the worldwide experiences of workers who assist survivors.  The public health model offers a structure to apply these lessons toward a preventive guidance model.  It also supports the establishment of a "culture of preparedness" for countries who regularly suffer the consequences of these catastrophes.

 

 

Why Public. Mental Health Models for Latin America?

 

The region of Latin America already has many of the components necessary to organize a grassroots community mental health model of prevention and mitigation within its traditional and cultural structures. Starting with local benevolent organizations found in many villages, towns, and small communities scattered throughout the Andes, river beds, and tropical valleys, many of them isolated from transportation networks for centuries until the present time, their self-sufficiency modality has been transmitted from generation to generation. Their government systems have generally relied on native leaders to assist the officially elected mayors or religious representatives that have developed human links in their day-to-day needs.

 

This grassroots tradition can be used to build the foundation, first-level system of an integrated health-mental health emergency program. The organization of their health delivery system, ranging from simple “posts” linked to primary health teams, to clinics and to hospitals, lends the basis for integrating emergency mental health following a disaster (Lima, 1987). It can be accessed to build a system of preparedness for disaster response according to the natural dangers endemic in their region.

 

Organization Components of the Model

 

Additional components that could improve effectiveness immediately after a disaster and beyond include mental health principle education, guidelines for evaluating victims, communication technology linking providers ­and service units, and basic resources allocation. After the immediate postdisaster days, the regional governments would link their teams to the local groups (including teachers and clergy) in a “seamless system” of planned and organized approaches (Myers, 1994). A public health model would serve as a set of coordinated and integrated guiding directions to the expectations and objectives chosen by the region.

 

Few regions are currently capable of fully developing and organizing this integrated model, but they can start becoming aware of what resources are available. They can then identify the programs that are fragmented and have not been linked and integrated with the different organizations needed to develop the integrated program. Other communities may not have the component at the present, but they may build them during a period of time available according to their resources. It would be helpful for regions that have histories of disasters to have some preventive models to use as they obtain resources and experiences. For instance, in El Salvador there are accounts of seven earthquakes occurring between 1575 and 1854.

 

Use of Telecommunication to Enhance Disaster Programs

 

Today, with the capacity of the Internet and computer technology, the ability of sharing knowledge across vast, distant regions is a reality. Using the methodology published and available on the Web worldwide, it is practical to consult, train, and problem-solve from the initial impact of a disaster to the final days of mental health programs months or years later, when all the experts, consultants, and agencies have left. A network of expert consultants could be identified and organized in advance to assist government officials when needed. They could provide technical advice for disaster policies, plans, and programs, which could assist in developing effective mental health interventions that adequately integrate language, tradition, culture, and other local resources.

 

Objectives of the Public Mental Health Model

 

The aim of a public health model is to promote the prevention and mitigation of negative effects on the health of populations. In disaster experiences, where little cross-cultural research has been published, much is known from experience. Knowledge can be increased from research publi­cations done in countries outside Latin America (Lima, Chavez, Samaniego, & Pal, 1992). This knowledge supports the belief that it is possible to strengthen the coping skills of individuals to deal with a disaster and to pre­pare them specifically to lessen its effect. A disaster-preventive public health model could be conceptualized to address “primary prevention” in all the activities structured to prepare and educate the population in countries of known risk in Latin America for the most often occurring disasters in their territory. Secondary prevention activities would describe the activities that would be instituted postdisaster to assist all citizens who have been trauma­tized and who could be helped using teams of local, native helpers and para­professionals supervised by mental health professionals available in that region. “Normal reactions to abnormal situations” would be differentiated from emerging signs and symptoms that could indicate pathological syn­dromes in need of further care from professionals (Lima et al., 1992). Ter­tiary prevention would consist of assistance to individuals with clear manifestation of chronic pathological signs and who would need specialized mental health intervention for a longer period of time (Logue, Hansen, & Struening, 1981).

 

Training, Planning, Organizing, and Delivering Postdisaster Mental Health Programs for Latin America

 

Governmental and nongovernmental emergency agencies should help to organize and coordinate disaster mental health programs at community and regional levels according to each country’s Emergency Planning Legislation (Myers, 1994). Although most countries have national guidelines to deliver emergency services, few have elaborated their mental health component. Training and identifying individuals who assist survivors to respond effec­tively to the aftermath of disasters are a constant necessity in countries buf­feted by disasters. The workers may come from a variety of professional backgrounds and levels of education. Latin American countries must some­times wait hours or days before outside help is available, and so the first responders are typically community citizens who can respond immediately. Therefore, their knowledge of how to offer crisis assistance is paramount.

 

The mix and match within the groups assembled after a disaster will vary according to the region of the continent in which the disaster occurs and according to the human resources available. The initial response to an emer­gency, or “first disaster,” will evolve as time goes by and the mental health assistance becomes organized, and training activities to address the specific needs of the survivors will change according to the characteristics of the “second disaster” (i.e., the challenges and frustrations that follow the disas­trous event). This period may present housing, bureaucratic, and interper­sonal difficulties, adding to the citizens’ problems (Cohen, 1990).

 

Adequate preparation for disaster response includes training the workers of mental health and human services agencies (Red Cross, nongovernmental organizations, public, religious) that will deliver postdisaster counseling assistance including outreach activities, crisis intervention, and referral services. Training has to be adapted continually as survivors move through the different phases of the adaptive process. Continuous supervision and training is needed throughout the duration of the program as content keeps changing according to the postdisaster developmental phases. Curriculum content can be found through the Internet and computerized searches. A repository of disaster documents has been accumulated and can be obtained from the Regional Disaster Information Center, Apartado Postal 3745-1000, San Jose, Costa Rica. If videotapes are to be used for training exercises, it is important to use tapes depicting the same cultural groups as the survivors and the trainees.

 

Table 4.1 identifies a public health prevention program that organizes the type of assistance to fit the needs of survivors at each phase of postdisaster development. These transitional phases are used as a way to guide the appropriate intervention. Workers use this model worldwide and modify it to match local tradition, culture, religious customs, resources, and political environments.

 

The phases are relevant to the behavior and reactions of individuals who initially are threatened by a disaster, receive the impact of the disaster, and then beging the reconstruction, rehabilitation, and adaptive efforts of individual and community activities. Although preventive plans may be written in national mental health emergency programs, many communities only begin to mobilize mental health assistance several weeks after the impact, because of the lack of resources. Many of the programs that should be instituted rapidly when the threat is imminent could be developed in countries where disaster occurs frequently.

 

Table 4.1

Disaster Assistance Public Health Model

 

Primary

Secondary

Tertiary

Threat Phase

·        Collaboration with emergency agencies

·        Mental health program development

·        Community organizing

·        Consultation

·        Public education

·        Professional education

 

 

Impact Phase

·        Organize local help and link with survival efforts

·        Assist families during burials or shelter services

·        Children and elderly first aid assistance

·        Outreach

·        Crisis intervention

·        Consultation to emergency and medical personnel

·        Counseling

·        Collaboration with housing

·        Group therapy

Short Term

·        School programs

·        Consultation

·        Education

·        Counseling

·        Collaboration with housing

·        Group therapy

·        Clinical care for all ages and conditions

Long Term

·        Support programs

·        Family guidance

·        Consult to community

·        Care of chronic patients – physical & mental

 

 

 

Threat Phase

 

Methods of raising public awareness in countries at elevated risk for disasters include consultation with emergency agencies, education of the public through the mass media, and shortwave radio programs, including planned meetings, workshops, and conferences. The primary purpose is to educate people about ways of modifying the effects of a disaster by preparing to take care of themselves and their communities. To prepare and assist children and their family, school programs offer an excellent venue to transmit knowledge (Earls, Smith, Reich & Jung, 1988). These messages should be crafted with sensitivity to the cultural beliefs and the ages of the children (Dana, 1993; Mileti, 1996).

 

Primary Prevention – Immediate Threat Phase

 

Modern technology has developed the capability to forecast many natural disasters with the use of weather satellites, radio signals, and television. Earthquakes are the disaster that still surprise populations, but new building codes in some countries are mitigating the consequences of these tremors. When populations are forewarned of a threatening disaster and are given the probabilities of risk, the possibility of assisting them within the public health model exists. As shown in Table 4.1, there are multiple approaches that will maximize prevention and minimize damages. Communication, education, and coordination with emergency agencies prepare a community to act during the threat phase. It will be helpful to identify and develop a list of all the available resources that can be used during an emergency. Many of these activities, including integrated, documented plans with agencies and organizing a disaster response program for mental health, take time. There is a relation between the time expended in achieving these objective and the effectveness of response when the threatening catastrophe is approaching.

 

Impact Phase

 

Primary Prevention

 

The immediate effect of a disaster is to dramatically and catastrophically alter the situation. Individuals in the affected areas will immediately mobilize themselves and participate with the efforts of rescue, shelter, and safety for the ns. During this phase, they will organize themselves in the most drastically ­affected areas and apply their knowledge of first emergency aid while waiting for resources from the outside. Following the news that a disaster has occurred, the mental health authorities of the region need to start organizing programs of assistance and linking to community leaders to obtain data about the event.

 

After the first days, when the issues of survival, shelter, food, and water are the priorities, mental health issues present themselves as needing attention. These issues will continue for a longer period of time than expected by most communities (Green, Grace, Lindy, Gleser, Leonard, & Kramer, 1990). The following list presents a summary of the key issues that will need to be addressed when organizing and delivering a public health response to mitigate the mental health consequences of a disaster. If plans for preparation training of mental health teams are identified during the threat phase, then the activities necessary to implement the program are ready to go dur­ing the impact phase. It is expected that the mental health teams are orga­nized trained and can be deployed to the geographic area of the disaster, they will link with the organized, locally prepared groups and leaders. They need to be self-supporting in relation to shelter, food, transportation, and security. The following are activities that have been found helpful in assisting survivors of disasters in coordination with the local groups.

 

Outreach

 

These activities aim to provide emotional support during the acute period following a disaster and can be organized in shelters or congregated groups in devastated communities. Outreach assists survivors in expressing and understanding disaster-caused stress and grief reactions, aiding individuals to return to a state of equilibrium and function. Information is given to clarify that their reactions and behavior are normal and expected to result from the abnormal situation in which they suddenly find themselves (Cohen, 1982).

 

Assist Families during Burials

 

When death occurs following a disaster, families constitute a population at risk and in need of preventive mental health services (Kohn & Levav, 1990). The degree of loss, which may include loved ones, property, community, employment, and familiar surroundings, may be overwhelming. The effect of these multiple traumas in each individual is difficult to evalu­ate, but it is widely believed in clinical practice that the number of traumatic events has a relation with the difficulties in coping exhibited by the individual.

 

Prevention workers can also help in places where the dead are being kept (e.g., morgues) or near the common burial trenches where victims are sometimes buried as a result of fear of epidemics. Collaboration with a spiritual or religious representative is important in assisting survivors, especially when the body cannot be found or rescued.

 

Assisting Survivors in Shelters

 

Intervention procedures include the assessment of the survivors in shel­ters. The shelter mental health worker will have to evaluate the condition of he survivors and their ability to deal with problems and cope with the chall­enges of the crowded environment. A triage method to apportion resources needs to be developed, guided by the ratio of needs to the number of help­ers. Interventions must be planned in terms of immediacy versus delay, depending on the emotional status of the survivor and the capacity of the workers in the shelter.

 

Intervention objectives for the survivors in a shelter include helping them achieve physical comfort and an increased capacity to organize their living area, as well as support to resolve problems with their surrounding survivors. The worker will mobilize available resources to help the survivors reorder their environment as the days (or weeks) go by, alleviate emotional frustrations that emerge at the slowness of the public assistance, and cope with the difficulty in waiting for the reconstruction phase with the promise of new homes.

 

One of the most difficult tasks for workers is supporting survivors who ire dealing with the difficulties of living in shelters with minimal privacy, few comforts, lack of facilities for cooking or washing clothes, and fear of losing their meager possessions. Helping people to feel relatively comfortable in such a setting is an important goal. People of all ages reside in these places and each age group’s needs may require different categories of resources, knowledge, and skill from the assigned worker. Therefore, programs to assist children have become a major component of the activities for workers in shelters. The objectives of these programs are to assist the children in recuperating and adapting to the trauma and a new living situation, is well as to support the parents in their efforts to deal with their own lives and exert their parental roles.

 

Secondary Prevention

 

Triage decisions during outreach activities identify the families that will need crisis intervention. This interactive process can be defined as “an active intervention technique that restores survivors’ capacity to cope and handle stressful situations and provides structural assistance for restoring and reorganizing their unfamiliar world” (Cohen, 2000). Collaboration, edu­cation, and consultation with medical emergency personnel dealing with wounded survivors will assist in the recovery toward a healthy outcome (Cohen, 1987).

 

Emergency personnel and mental health workers will need well trained and constant support as long as the program of assistance lasts. Techniques such as debriefing, defusing, and critical incident assistance have been found to have merit in preventing the signs of burnout in disaster personnel (Hartsough, 1985; Kenardy et al, 1996; Mitchell, 1986). Different investigators who have raised question sover their effectiveness have reviewed this preventive measure (Barron, 1999)

 

Tertiary Prevention

 

A percentage of the population will be struggling not only with the effect of the disaster but also with a myriad of health and mental health problems that preceded the disaster. The need for referral or long-term professional services may be needed. Both mental health services and physical chronic illnesses can be found in this population (Shalev, Bonne & Eth, 1996; Ursano, Fullerton & Norwood, 1995).

 

Short-Term Phase

 

Primary Prevention

 

The program objectives for consultation, education, and assistance change during the weeks and months following the disaster. The acute phase is over, and now a new, postdisaster phase, which can last months, emerges with different problems facing the survivors. Mental health disaster workers can be trained to identify the new problems, assist with their expertise, and help the local teams. Mitigation of further deterioration of the capacity of survivors can be achieved during this phase if preventive measures are taken. One important program that emerges is the school program for children, parents, teachers, and administrators. Since these individuals are congregated in schools, the opportunity to assist them as a nuclear population appears very effective if they are educated about preventive mental health approaches (Green et al, 1991). Women, as heads of households, are an important group in underdeveloped countries. Workers can assist them in their function as caregivers and help them obtain resources to reconstruct their lives.

 

Secondary Prevention

 

Counseling Survivors

 

This process of assistance can help individuals who need it or ask for it following a disaster. The more information is shared with a community, the more they will become aware that there are methods to ameliorate their problems. Training personnel to have the capacity to counsel is one of the most active approaches in public health programs. University psychology and public communication departments could be very helpful in this phase.

 

Another group that will need guidance is that of the survivors who have lost their homes and are frustrated by the lengthy rebuilding schedule of the country. Housing is a perennial problem in many communities of Latin America, and after a disaster it becomes a source of deep emotional impact. It can lead to aggressive and unusual group behavior, including violent protests against the authorities. Group therapy programs can be organized and provided by communal leaders that incorporate traditional and religious customs. These programs can be incorporated into the usual gather rhythms of the community. This phase is beset by multiple problems, however, emerging from political agendas, diminishing international help and resources, increasing frustration, and disappointments resulting from broken promises. It will be helpful if emergency agencies are prepared for expected reactions that survivors may present some of these behaviors. They can make effort to ameliorate its effect by anticipating this phase and by preparing supportive and assisting programs. The public media can play an important role to support healthy messages to the community but will need the help from experts to guide them.

 

 

Long-Term Phase

 

Primary Prevention

 

A program of support services needs to be extended to the traumatized individuals for longer periods of time than generally is expected (Bland, O’Leary, Farinaro, Jossa & Trevisan, 1996). When agencies are aware that percentage of individuals at risk are unable to fend for themselves for a variety of reasons, their services can include assistance in finding shelter, employment, and health resources. This part of the preventive program is difficult for certain countries in Latin America because of the lack of resources. In general, international assistance is necessary for extended periods of time but is difficult to obtain. Many of the residual, chronic cases found in countries where no prevention programs have been developed remain homeless and poverty stricken, adding to the unproductive strata of society. Efforts to mitigate the effects of a disaster may lower the number of these individuals. Traditional, local approaches should be instituted to ameliorate he long-term effects of the trauma.

 

Secondary Prevention

 

Family assistance, either in groups or individually, should be provided to families that are still manifesting signs of struggling with problems left by the aftermath of the disaster. Support for these families could be sought in the additional or religious modality of their communities. Education remains a method of strengthening the capacity of helping groups, months or years later.

 

Tertiary Prevention

 

Most cases that are remaining months and years later present a variety of difficult problems, including mental or physical ailments. Although their numbers are small in relation to the total population that has turned to functioning in their community, it is a difficult population segment to ameliorate. In general, this group joins the chronic, unemployed citiz­ens of their community. Linking them to welfare, religious, or volunteer support systems remains the only solution in regions where there is a lack of chronic care.

 

Summary

 

This chapter has presented an overview of the occurrence of natural disasters in Latin America and their effects on individuals and communities. The morbidity and mortality produced by the recurring disasters affecting the Latin American region indicates a need to develop programs that can service hundreds of affected individuals. The organization and deployment service modalities that integrate health and mental health developed throughout the region lends itself to a rapid emergency response. A public health model is suggested to mitigate the effects of the catastrophic trauma. The procedures known to help individuals through the threat, impact, and short and long phases are identified. The historical knowledge accumulated, different types of disasters, and the awareness of human reactions to catast­rophic events are well known. The methodology and services docume­nted to be useful in the last 30 years worldwide support the approach to implement a public health modality to assist the traumatized populations in Latin American region.

 

Conclusion

 

The historical knowledge accumulated during catastrophic experiences— and the realization that disasters are unique but that the effects on individuals follow a similar sequence of coping patterns allows for the accumulation of knowledge that can be adapted to different regions of the world. The morbid­ity and mortality produced by the recurring disasters affecting the Latin American region indicates a need to develop assistance programs that can ser­vice hundreds of traumatized individuals. The organization and deployment of service modalities that integrate health and mental health services, a model used in many countries in the region, lends itself to a rapid emergency response if they include psychosocial approaches. The use of primary health centers supports a public health approach to assist postdisaster effects on trau­matized survivors. By offering education, consultation, and crisis intervention through the threat, impact, and short and long postdisaster phases, the possi­bility of mitigating the effects of the trauma can be achieved.

 

Although preventive plans may be written in national mental health emergency programs, many communities only begin to mobilize mental health assistance several weeks after the impact, because of the lack of resources. Many of the programs that should be instituted rapidly when the threat is imminent could be developed in countries where disaster occurs with frequency. These activities should be operationalized and institutional­ized within governmental systems in such a way that they do not change every time a new government takes the leadership of the country, but remain stable throughout the years.

 

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