Raquel E. Cohen, M.D., M.P.H.*

 Frederick L. Ahearn, Jr., D.S.W.**



The intent of this chapter is the exploration and analysis of socio-psychological phenomenology associated with the long-term consequences of a natural disaster--earthquake. The authors, through personal experiences, social and professional interactions, following the disaster in Managua in research studies of professionals, view modes of behavioral adaptation of survivors. Inferences are drawn as to whether internal and external consequences and influences of the events following a disaster may produce short and long-term emotional disorders. Earthquake victims must deal with different degrees of stress over time. These Stresses produce effects in emotions and behavior related with characteristics of the intra-interpersonal situation within their support systems.  Stress is caused by: 1) the disaster itself; 2) the problem that are presented in daily interaction needed to obtain important psychosocial resources; 3) Internalized memories of the disaster; and 4) Stress that is the result of on-going physical and social changes in the immediate environment. It is our contention that years after the catastrophe, a segment of the population will manifest consequences of stress that continue to be re-activated by multivariate stimuli and will manifest itself through social and individual psychological disorganization.


Review of Literature

The state of the art in disaster studies is extensive. Scientific studies of disaster behavior have confirmed the fact that a natural disaster has profound psychological implications for its victims. (Parad, 1976) The extent of destruction, the number of persons killed, and the duration of the catastrophe may affect the intensity and the scope of psychological impact. (Fritz, 1957)  Most studies of disaster-related behavior are organized in terms of time sequence. While there are variations peculiar to each author, the general format usually refers to pre-impact, impact, and post-impact phases. Our attention is addressed to the last phase, that is, the social individual disorganization resulting from complex forces affecting the lives of the individuals.

The post-impact period begins when the individual comes in an environment which is altered in one or several crucial aspects. During the aftermath of disaster, people may be afflicted with a tormenting memory of the event or with an intensive fear of its reoccurrence. (Wolfstein, 1975)  For the majority, the first overt emotional expression occurs during the reaction period, sometimes called the period of recoil. At this time, there is a need to be with others in order to ventilate feelings related to the shocking sense of loss and perhaps loneliness. (Tyhurst, 1951) When an individual's reaction is delayed, he may demonstrate under-activity, helplessness, aimless wandering, dazed apathy, or mute, motionless behavior. (Healy, 1969)

The post--traumatic period follows the period of recoil. This period may last the remainder of a person's life and includes the period of rehabilitation. The behavioral reactions attributed to this period include: temporary anxiety and fatigue states, psychotic episodes, recurrent catastrophic dreaming, "Traumatic syndrome" or "post-traumatic neurosis", the more severe and prolonged reactions, become apparent during this phase. (Tyhurst, 1951)  Victims may express insomnia, digestive upsets, nervousness, and other such results of emotional tension. (Healy, 1969)

There may be long range emotional effects resulting from disaster.  Lifton studied the long term behavioral reactions of the victims of the Hiroshima bombing. (Lifton, 1967)  Survivor responses were interpreted in relation to five general themes - the death imprint, death guilt, psychic numbing, nurturance and contagion, and formulation.  The seriousness of long range impairment from disasters is disputed by some. One author,

for instance, maintains that the studies of several hundred past disasters have not demonstrated that psychological problems result. (Morris, 1973)  Another indicates that severe psychological disturbances from a disaster are infrequent. (Drayer, 1957)

            Recent evidence from the West Virginia flood at Buffalo Creek provides more weight to the psychological impairment from disaster argument. Church, in treating victims of the 1972 flood, witnessed serious depressive reactions, paralyzing fear, terrible nightmares, and a profound sense of guilt for having lived when others had died. (Morris, 1973)  Similarly, Erikson has reported severe psychiatric impairment of the Buffalo Creek victims long after the disaster. (Erikson, 1974)  The author noted the loss of community and individual identification brought about by the use of mobile homes. In other words, relocation, especially one that leads to prolonged or permanent displacement can be said to be "a second disaster" which leads to severe symptoms of emotional trauma. (Wallace, 1957)

Fried has described the variety of long term symptoms associated with relocation. These include anger, a sense of helplessness, somatic distress, and a tendency to idealize one's former home. He describes a grief process in the loss of one's place of residence. (Fried, 1963)

One final but interrelated concept is helpful to our discussion and that is the idea of social or community disorganization. It has been stated that community is disorganization as a result of disaster may adversely affect the mental health of a given community. (Leighton, 1959)  As the social system of a community, is destroyed or severely damaged, psychological stresses are produced for the individual to adapt to the changes-many times unsatisfying and not meeting his needs.  This added demand taxes his psychological mechanisms and emergence of fluctuating somatic or psychological

symptoms increase the burden of coping.

Thus, we see that community disorganization becomes interactive with expressions of individual disorganization. As community structures, institutions, and social groupings are altered, the individual may be affected in a downward spiral involving economic opportunities and/or burdens. Individuals are members of families, churches, schools, civic and economic organizations and as these disintegrate or dissolve due to lack of leadership and support, it is the individual who manifests the overt consequences and suffers from the process. (Elliot and Merril, 1961)  In like

manner, the disappearance of physical forms-such as, familiar buildings, streets, or surroundings-produce a sense of loss, fear, and anxiety.

In review, there is some evidence that the post-impact phase of disaster may produce differing levels of emotional impairments and that personal disorganization may be greatly influenced by the degree of community disintegration experienced over time by the disaster victim. On selected aspects of the Managuan earthquake, we found additional evidence to support these theories.


Managua: Three Years Later

            Before the earthquake, Managua, a beautiful city, was clustered on the banks of Lake Managua. It is the capital of the largest, Central American country, which is populated by approximately 400,000 of the 2,000,000 people in Nicaragua.  The city moved from the bank of the Lake toward a classical Spanish plaza surrounded by the cathedral where the major religious ceremonies took place; the National Palace; and the National Theater. Ringing the core of these impressive buildings were the central commercial, governmental buildings, and institutions. The residential areas were nearby and offered citizens the attraction of moving rapidly from work to home and recreation activities. The city was compact: its highly centralized geographical distribution was closely correlated with the traditional and cultural lifestyles of the family activities.  Most citizens could walk to the plaza where- the focus of their political and social activities took place. 

The 1972 earthquake completely destroyed this central core area of Managua and heavily damaged the surrounding residential areas. What existed was destroyed or heavily damaged so that it was not habitable for several years. Managua was destroyed by three violent tremors the evening of December 22, 1972 and the early morning of December 23, 1972.  Eighty percent of the structures in the city were destroyed, including all the hospitals with their equipment.  The possibility of professionals organizing rapid medical help was severely limited. Fires, which raged for several days, were unable to be contained because of the lack of firefighting equipment which was trapped under the fallen buildings.  Streets were impassable and communications by phone or telegrams were destroyed.  Almost everyone in the city suffered property loss, many losing all their accumulated possessions of long years of arduous work. Loss of life was high, with the death toll reaching an estimated 10,000 individuals. Another 20 thousand residents were severely injured and required medical attention which was not immediately available.  Most Managuans had family or friends who died in the devastation and who had to be buried in group graves or as part of multiple funeral ceremonies.  An estimated fifty percent of the capital population was dislocated by the earthquake resulting in extreme overcrowding in neighboring towns and villages.

In the past three years, following the earthquake, the post disaster impact could be characterized by severe change in life style. These were associated with the destruction of the city; the knowledge, experience, and the memory left of this event; the loss of life of dear ones; and the painful relocation experiences and loss of employment. 


Physical Changes as They Impact on Psycho-Social Adaptation

The geographical familiar structure of Managua was changed by the many new subdivisions and new activity centers located five to twelve kilometers from the old center. The socio-physical Managua no longer exists. The citizen's concept of the city is rooted in the past, and, today, represents an unfamiliar, albeit, safer, area of residence. If someone asks, "Where's Managua?", most would have difficulty in giving a clear description.  If someone suggested, "Let's go downtown", the response would be confused and influenced by a sense of sadness at trying to reconsider where downtown might still have been. The central plaza concept - the gathering place of young and old –disappeared as so many of, the social guideposts of the past.  There is no central area today as Managua is a series of dispersed neighborhoods, each with its own commercial shopping area.  Today, identification is with the neighborhood group, a brand new site--physically and psychosocially--different to adjust.

Managuans still use old reference points in giving directions, although these may no longer exist. Even though old reference points have been destroyed by the earthquake, they are commonly used, oftentimes creating confusion to the listener, if the original reference point, for instance, a church, has been rebuilt at a different location. Physical changes of the neighborhood get superimposed on the familiar internalized memory of the known places and remembered as buildings standing still in the past. 

The infrastructure of Managua, its parks, churches, clubs, bars, and schools were destroyed. Each of the social structures were the vehicle for citizens to participate in certain types of activity influencing behavior, customs and a continuation of tradition. Now, three years later, there are many replacements of these structures, some rebuilt, others new and unfamiliar, but in many cases, they are located further in distance. Community supports have been altered and residents search for ways to adopt and accept new or renewed forms of finding expression for work and recreation. Children attend different schools, families go to brand new churches, and fathers frequent a remodeled bar. The rapidity and completeness of the new physical and geographical changes have had deep impact on these families.

Many new neighborhoods have been built, providing housing but these changes have produced a variety of added stresses. First, the economic increase in the cost of housing has risen rapidly so that families have had to downgrade some of the comforts that they used to enjoy. Prices of new homes or rentals have doubled in price since the disaster. Secondly, new neighborhoods do not provide the social interaction among friends and neighbors which existed, presenting new needs to reshape emotional bonds. Because of suspicion and sometimes fear of new neighbors, the usual social pattern is to attempt to maintain old ties, ties that are no longer neighborhood based, but that require long and tiring trips. Thirdly, as there is lower social interaction in the neighborhoods, there is little sharing, increased competition and ambivalent experiences for mutual social support.

Residents who return to their former neighborhoods do not face all the stresses of residents in the new settings.  Homes that were able to be remodeled and reinforced were many times preferred than moving to new places.  Many old neighbors have returned, but there are new neighbors changing the characteristic of the familiar surroundings. The physical surroundings are familiar on one hand, but the faces and voices of stable relationships have changed. This new housing arrangement appears to have affected social interactions as manifested by the sitting in groups in front of homes and interchanging neighborhood gossip. These customs permitted families to congregate, friends and relatives to visit, and provided strong social and emotional support for group members. Now, this custom is difficult to maintain in the city and does not appear to be practiced as often as in the past.

Community and social changes caused by the disaster have placed severe stress on families, for lost members and sadness experienced by the distant inter actions with displaced relatives affect the moods of many citizens.  Such family disruptions, with fewer or more members, are influencing some of the traditional characteristics of the extended family system that existed in stable Managua. Phenomenology that is familiar to the industrial cities where the paternal authority, their roles and tasks that were supportive in the past, now are vague and controversial. As families lost members and moved from strong knit neighborhoods, the social support to familiar authority weakened. Young adolescents, especially the middle and upper classes, are challenging traditional authority by rapidly altering the dating customs, increasing their identification with "modern" modes of behaving and using alcohol and drugs more liberally. It appears that conflict between parent and child has accelerated and intensified more rapidly than might be expected over values, norms, and authority.

With the dispersal of the new city in its job and employment opportunities, distances to and from the:-e essential services have added another stress to daily life. No longer can residents walk to work but must, instead, rely on public transportation or private cars. Now, the roadways are severely clogged because they were not built for the large-traffic increase that has occurred and for the driving habits that were developed when cars were used more for leisure than for daily working routines. There has been an increase in moderate and serious vehicular accidents. Time spent in traveling has risen. Where a ten to fifteen minute walk or bus ride was the norm, it is not uncommon to require one or, more hours.  This has had an effect on the time-honored custom of the mid-day meal where all the family members return home and important familial interaction occurred. Due to time pressures, this custom is rapidly disappearing with a large portion of the male population staying in the city during the day. This has resulted in that it must be handled by females at home with the children.


Psychosocial Changes as They Impact on Roles, Functions, and Behavior

            Physical and social change produced personal psychological crisis and required new modes of behavioral adaptation. As known and familiar physical structures violently disappeared or were destroyed, new ones were slowly built, influencing in time and space societal norms, values, and customs. New structural arrangements--that is, institutions, social groupings, physical environment-evoke differing individual adaptation. Individual behavior is influenced by personal interacting skills which in turn affects the quality of relations between individuals. The quality of this relationship bares an important support on coping adaptation, as identified by the individual himself. These complex interactions of psychological and social influences on individuals adapting to the post traumatic effects of a disaster, need to be evaluated and continued to be studied through long years to ascertain the post traumatic effects as manifested by adaptation and healthy outcomes. We agree with Kai Erkison (1974) who singles as a subsequent trauma following a disaster "the deepening awareness ' that the fabric of community life has been irreparably destroyed." As a significant impact on coping and stress following a disaster, it continues to be a reminder of the disaster and the consequences which intensified the daily difficulties and normal disappointments that exists in personal life. Many families that were not touched directly by the earthquake were unable to escape this community shift and changes and were also caught in the aftermath of the social and physical disruption.

Residents of Managua exhibited a variety of individual manifestations of disorganized behavior. Individual crisis was expressed as a reaction in the fact of the new reality. Beginning to reconstruct again, both the routine of life at home and having to adapt to the changes which had occurred, presented long and arduous efforts to find some solutions to problems of daily living. The net results in many of the families were manifested by changes of mood and appearance of physical or psychological symptoms. Physicians reported an increase of patients showing psychosomatic ailments. Older individuals expressed increased hopelessness and were not motivated to personally rebuild their homes. After all, they remembered the 1931 earthquake which had also destroyed Managua and these residents felt too old to start again. Children, too, were affected by their own experiences and the behavior of the adults that cared for them. Children had an increase of symptomotology that could be categorized as phobic symptoms, anxiety separation, and regressive behavior.  This added, in turn, another burden to parents who tried to seek psychological help for the children. (Cohen, 1976)

Another increased activity was expressed through the morbid preoccupation with the disaster news that continued for months in the newspapers and radio. They reported any earthquakes or tremors in the rest of the world and many traumatic episodes of personal disasters, like suicide or illness related to consequences of this disaster. In social reunions, the topic of the disaster invariably was linked to events and past dates. Feelings and fears appeared to need continuous ventilation. During the first year when the American team members worked closely with the professionals in Managua, they noted that the group used the professional relationship with the foreign colleagues ventilate some of their own unmet needs and manifested of late mourning processes. Frequently, after seeing patients all day, the professionals from Managua and the United States would get together to discuss experiences and this was used to ventilate heightened emotions relating to specific incidents during the events still remembered many months later.


Related Evidence

An analysis of the situation in Managua prepared for the Department of Public Health in 1973, presented evidence that the disaster had an influence on the psychological behavior of the citizens of that city. (Ministerio de Salud Publica, 1974) It was reported that the emotional problems and disturbances of the residents that had suffered effects of the disaster could be analyzed at three levels of individual and group behavior: 1) an increase in magical and religious thinking; 2) individual psychological changes in the function of the residents of Managua; and 3) psychosocial changes and disturbances. Referring to the magical religious thought, it was reported that one of the major findings was an expression of sense of guilt and seeing it as a punishment to the population for their behavior and as a just admonition by God so that they would reconsider their behavior and change. The characteristics of the psychological disorders were presented as belonging to all the types of known psychiatric disorders and increase in crisis disturbances. The psychosocial disturbances were identified as: A) changes in family relations taking the form as reactions of crisis by the increase in dependency needs of the young on their divorces, increase in the parents, and increase of inter-familiar fights related to the reduction of physical space in living conditions caused in the emergency in living; B) alterations in the relationships in work situations were manifested by low rendition of daily tasks, loss of initiative, fear of making decisions and low learning and teaching activities. Increased problems in labor relations occurred more often.

They single their problems of economy as a major influence on psychological disturbances, pointing out that the lack of occupation and employment in large sectors of the population would increase distress which in turn would have a reverberating influence on their production of goods in the country.

Six months after the earthquake, a random sample of refugees at "Las Americas" camp were surveyed as to levels of their perception of community and personal disorganization. (Check Pallais, 1974)  The researcher found a high degree of change in the pattern of living indicating social disorganization in the traditional family lifestyle. There were no clubs, parks, churches, or recreational services. In addition, there were few personal and social services, transportation and minimum employment opportunities. All this limited the opportunities needed for adult and children activities.

The following profile of individual disorganization was developed. Ninety-eight percent of the sample had lost their homes in the earthquake; seventy percent had lost their jobs; and five percent had lost a family member. Residents reported that living in that neighborhood was unpleasant. They did not know their neighbors and lacked social interactions with them. Fear was commonly expressed. Most said that their family and friends live some place else.  In fact, 79 percent of the sample indicated that their family structure was altered after the earthquake either by loss of members (death or relocation elsewhere) or by the additional family or relatives. Now, 82 percent reported that their lives were better before the disaster had affected them. Despite such discomfort living in the "Las Americas", the majority, that is 67 percent, did not want for fear of another disaster or because of unpleasant or traumatic memories.  They were trapped by circumstances beyond their power and felt helpless and hopeless to influence the direction of changes of lifestyle.

Today, this camp still exists housing an estimated 60,000 people in five different locations, but changes have occurred.  Now, there is an infrastructure of paved roads, public buildings, and services. The once barren land is covered by trees, flowers and gardens. In the study of residents three years later, many have been able to renew both friendly bonds with a small number of families and strengthen their family bonds with some of their relatives. This is unsatisfactory, but the common bond of the traumatic memory, the daily trips to the city looking for employment and the need to find recreation and social outlets have helped to develop a new social structure. The beginning social groupings enhanced by their awareness of the intra-dependence and commonality of needs have started to give emotional and social basis for the regroupings.

Although the beginning of shared institutional services offered them a level of participation, these were not of the same quality and consistency as previously shared by their own extended family and neighbors.  The lack of common basic interacting institutions has made it difficult for them to meet their needs or to develop a sense of togetherness. Some of the organized groupings promoted by the Government to help in the socialization actions of the community, had been resented at first and had been the scapegoat group for many of the bitter and unhappy feelings of the community. These strong sentiments had decreased with the years, and there was a stronger feeling of solidarity and participation in their activities.

Another study of psychiatric patients at the National Psychiatric Hospital in Managua compared rates of illness before and after the earthquake and developed socio-psychological profiles of the 3,466 patients. (Ahearn, 1975)  It was found that the number of psychiatric admissions to the hospital increased 27 percent after the disaster.  There was an increase of inpatient and outpatient admissions each month with the largest percentage increase being the first three months following the catastrophe.

Cases of cerebral organic syndrome increased from 226 to 324 or 43 percent. The diagnostic sub-category which accounted for much of the increase was epilepsy.  Although it is not possible to say disasters cause epilepsy, it is thought that this may be consequent from head blows sustained during the earthquake.  Others feel that after a disaster the subsequent living arrangements created pressures so that families sought help for the epileptic member.

Retardation cases increased 42 percent after the earthquake, 55 cases to 78 cases. Here, again, it is felt that relocation of families led certain people to seek psychiatric person formally maintained in the home.

Patients diagnosed as neurotic increased a substantial 49 percent from 389 cases before the earthquake to 578 cases after.  The sub-categories which reflected this increase was neurosis with depression, neurosis with anxiety, and to a lesser degree, neurosis with dissociative hysteria and neurosis, other (unspecified) type.  These patients were for the most part females in their early thirty’s, with minimum education and equally likely to be married as single. The increase occurred during the first three months and from the ninth to twelfth months after the disaster.

After the earthquake, the number of psychotic patients increased at the hospital. The number the year before the disaster was 734 as compared to 858 the year after, an increase of 17 percent. The types of psychosis represented in the increase were schizophrenia, chronic type, schizophrenia, episodic type, and schizophrenia without specification. It was discovered that a number of former psychotic patients were readmitted to the hospital the first nine months following the earthquake.

Evidence from this study and the others cited above all document that moderate and severe psychological reactions occur after a disaster. It seems evident that relocation, adjustment to a new living environment, produces severe stress resulting in an increase in psychiatric disorder.


Implications and Conclusions

The composite experiences of the authors and their colleagues during the three years that they have been familiar with the activities and changes of lifestyle following the traumatic events' set into motion by the 1972 earthquake have confirmed many of the

findings reported in the literature. Observations and studies point to the incidents of social and individual disorganization as an after effect of disaster and to the correlation between these levels with behavioral and psychological adjustment.  Effects of functioning and patterns of coping mechanisms appear to continue through a number of years showing differing aftermaths which vary in intensity, impairment, and adaptation modality related to: 1) intra-interpersonal relations; and 2) physical, social and economical support systems. There needs to be a clear understanding of the relationships between social and individual disorganization through the study of multivariate phenomenologic approaches in the psychological and social fields. In terms of psychological help for individuals suffering the effects of disaster, it should be articulated and focused on what is happening in the community at large. The effects of relocation can be seen as a second crisis which intensifies the trauma precipitated by the disaster itself. This disruptive effect does not lie so much in the actual change of location but in the fact that relocation projects pulled the under feelings from beneath the neighborhood and leave the individuals emotionally unsupported. Priority should be directed toward building up, organizing and integrating the social structures in order to prevent or lessen psycho-psychological stresses. Regrouping the sense of unity and community identity to group ties fostered by the need to share culture and to share commonality of family bonding, should be central to governmental and public efforts after a disaster. Sudden and profound loss of personal property, disruption of friends and family, unemployment, lack of recreation and health facilities will remain a continuous source of stress which needs to be considered as part of the post traumatic events.  How many years this will last, how intense will it be will depend on the reconstruction effort?



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Note: The authors wish to express their gratitude to their professional colleagues of Andromeda who accompanied them to Managua; to the National Institute-of Mental Health, who, in part, funded the Andromeda and some of the research reported here; and to Simeon Rizo-Castellion, M.D., National Coordinator of Mental Health in Nicaragua for his assistance and guidance.

*Associate Professor - Department of Psychiatry, Harvard Medical School, Boston, Massachusetts

**Associate Professor - Community Organization and Social Planning, Boston College, Chestnut Hill, Massachusetts