Mental health services for victims of disasters in developing countries: a challenge and an opportunity.

In the past few years, significant progress has been made in knowledge about the psychiatric and psychological consequences of disasters. At the same time, as Raquel Cohen shows us in her article, the mental health interventions and services necessary to meet the specific needs of victims of disasters have become well known. The importance of ensuring the provision of mental health care to victims of disasters is today largely accepted. However, the implementation of these services is a difficult task in many countries. The development of mental health services and interventions for these populations is a particular challenge in developing countries, where mental health resources are scarce and usually concentrated in large institutions, and where responses to disaster situations face many other obstacles. What can be done to meet this challenge? The Pan American Health Organization (PAHO) has dedicated significant efforts toward disaster relief for more than 20 years in Latin America and the Caribbean, and recently has been systematically integrating a mental health component in these efforts. PAHO's experience shows that, even in countries with very few resources, the development of mental health services for victims of disasters and the preparation of countries for disaster situations can be significantly improved by the use of particular strategies. The strategy most commonly employed in the past has been the dispatchment of international mental health teams to the locale of the disaster. While this strategy has proved useful in meeting the immediate needs of the country, especially when well integrated in the larger relief plan, it has not helped the countries prepare fully for future disasters. To attain this latter objective, additional strategies are needed. The first is the formulation of a national plan to address mental health in the context of disasters, or the integration of a specific disaster response component in the national mental health plan. This plan should clearly define: a) the agency responsible, in a disaster situation, for developing a rapid assessment of the psychosocial needs of the affected population, defining priorities and coordinating actions; b) the roles of non-specialized personnel (primary care professionals, school teachers, community agents, among others) in providing psychosocial care to the victims of disasters, and the mechanisms to ensure their participation; c) the services (psychiatric hospitals, general hospitals, community- based services, emergency teams, non-governmental organizations) responsible for providing direct psychiatric treatment to affected persons and how these services are integrated into the general response plan; d) the mechanisms to provide intensive mental health training to professionals and community agents in disaster situations; e) the mechanisms to educate the community and promote its participation in the process of social recovery. Another important factor in the development of mental health services for victims of disasters is the existence of a strong mental health unit in the Ministry of Health. This unit must have the technical resources and the political support needed to formulate and implement mental health plans, and to coordinate activities developed jointly with other sectors. Training and education are fundamental strategies in preparing countries to provide psychosocial care in disaster situations. Disaster response strategies should be integrated into training curricula for psychiatrists, psychologists and other mental health professionals, and training materials for professionals and other participants that can assist with psychosocial interventions in disaster situations should be produced. International cooperation is particularly important in this area. In the Region of the Americas, PAHO sponsored a recently published manual on mental health for victims of disasters and guidelines for trainers (1,2). PAHO in 2001 organized two workshops on mental health interventions in natural disasters and situations of war and is finalizing guidelines on this issue. These initiatives integrate the new strategies with the old: training of experts that can intervene in emergency interventions in the future, and dissemination of knowledge and building capacity at the country level. Research remains a priority in this field. Since the reviews of research on the epidemiology of psychiatric and psychological consequences of disasters were done by Kohn and Levav in 1990 (3) and by Bromet and Dew in 1995 (4), significant advances were made in this area. However, still there is a lot to be done in the future. In collaboration with Brown University, PAHO has supported research on the mental health consequences of Mitch hurricane, in Honduras. This project is a prospective study of the psychiatric and psychological disorders in a large community-based sample, which has survived a life-threatening natural disaster. There is a well-defined control group, and modifying and predisposing factors are examined. Preliminary results confirm that the state of disaster seriously affected the mental health of the population (22.1% of the population were identified as psychiatric cases, 18.3% had major depression and 11.1% post-traumatic stress disorder). They also show that factors such as the level of exposure, socioeconomic status, and previous mental disorders are significantly associated with the level of psychological distress. All the above-mentioned measures are critical in strengthening the capacity of countries to provide mental health care to the populations in disaster situations. However, to ensure sustainable capacity, they must be part of a national strategy aimed at the development of community-based mental health services. In fact, the existence of a network of community services is the best guarantee that in a disaster situation a rapid and effective intervention will be implemented to meet the mental health needs of the population. The development of mental health services for victims of disasters in developing countries is, therefore, a stimulating challenge, demanding the participation of several sectors at the country level and the contribution of international cooperation. At the same time, as has been demonstrated in several countries, it is a great opportunity to raise awareness of the importance of mental health and to improve nation-wide mental health services. The public discussion of mental health and the mobilization of mental health resources in the aftermath of September 11, 2001 events provides the most high-profile example, but other recent disasters in Latin America, e.g. the earthquake in El Salvador in 2001, and the fire in Lima, Peru in 2002, had the same effect of creating new interest for mental health and new opportunities for initiatives in this field. Let us build on these experiences to minimize future tragedies and maximize mental health services potential in developing countries.