The staggering death count from the Asian tsunami — 114,000 and rising — overwhelms us. Yet disease and mental health problems will kill and sicken several times this number, experts say.
What can we expect to see over the coming days, weeks, and months? How can we cope with our own feelings? What should we say to our children? WebMD asked several experts:
—Randall D. Marshall, MD, director of trauma studies and services for the New York State Psychiatric Institute, New York State Office of Mental Health; and associate professor of clinical psychiatry, Columbia University College of Physicians and Surgeons. Marshall has expertise in the diagnosis and treatment of posttraumatic stress disorder (PTSD), and has studied and written about the role of psychological trauma in anxiety disorders, psychotherapy of traumatized individuals, and the biology of PTSD.
—Phyllis E. Kozarsky, MD, professor of medicine and director of the Travel Well Clinic in the division of infectious diseases at Emory University School of Medicine. Kozarsky specializes in clinical tropical medicine and travelers' health. With the CDC, she conducts international surveillance of travel-related morbidity and emerging infectious diseases.
—Nancy Cahir, PhD, a child and family therapist in Atlanta.
Tsunami Aftershocks: Disease
Tsunami survivors now face three serious problems: lack of food, lack of clean water, and poor or nonexistent sanitation. Aside from the very real threat of death from hunger and thirst, these problems mean desperate people will be forced to consume contaminated food and water.
"We have to look forward to tremendous problems with foodborne and waterborne diseases: dysentery, cholera, hepatitis A, typhoid fever, and diarrheal diseases," Kozarsky tells WebMD. "Children are going to be very vulnerable to diarrheal disease and cholera. Those can kill very rapidly if support isn't there. Probably there are large numbers of children who can't find their families. And we know hospitals and clinics were destroyed also. There may not be any structures for people to go to for health care."
This is far more than enough. But it's not all. Long before the tsunami, most of the affected areas suffered from mosquito-borne diseases — malaria and dengue fever in particular. The waves have receded, but they've left huge pools of stagnant water in their wake.
"Think of the explosion of mosquito populations and the explosion of malaria and dengue fever," Kozarsky says. "Those are huge items in a population where there may be a tremendous number of homeless people. These numbers may make the mortality seem low. If you say OK, in the tsunami we lost 70,000 people, disease may take a toll as great as that."
Tsunami Aftershocks: Mental Illness
Experts are only beginning to appreciate the mental health toll of huge disasters. Intense studies of recent disasters — including Hurricane Andrew in Florida, the 9/11 attacks, and the 1988 Armenian earthquake — provide startling numbers. A large proportion of survivors, Marshall says, will suffer major depression or posttraumatic stress disorder. Many more will get stuck in the worst part of the grieving process, a phenomenon known as complicated grief.
"The mental health consequences of disaster are alarming," Marshall tells WebMD. "For adults with the worst exposure — those who feared for their lives, or narrowly escaped losing life, or dealt with the most horrific aftermath such as having to bury loved ones — the PTSD rate could be 30 percent in adults and 50 percent in children."
The scale of this mental health tsunami is difficult to imagine. Marshall's estimates are based largely on studies of industrialized nations. Studies suggest that the mental health consequences of a disaster are even more severe in developing nations. Even in the best of times, these people have scarce resources.
"What we cannot estimate now is how many survivors witnessed the horrific aftereffects of the tsunami," Marshall says. "It is expected that probably the majority of those people will recover if their social support systems are more or less intact. But when entire communities are affected, social support systems are devastated."
Tsunami Aftershocks in America
Those indirectly affected by disasters do not, of course, suffer anything like those in harm's way. But we are affected.
Few among us are not deeply moved by the tsunami disaster. Fewer still feel no empathy for the survivors' plight. And the awful scenes of human grief make us remember the losses we've suffered in our own lives and the disasters we've survived.
"If you can afford to help, it can actually make the giver feel better, to feel you have made some contribution to the recovery effort after the tsunami," Marshall says. "Forty percent of Americans made donations after 9/11. People said that was the way they coped. Being part of the world effort to reach out to these poor people helps us, too."
Whenever and wherever there's a disaster, people have one need in common: other people.
"For those very disturbed by the tsunami and experiencing a lot of distress, the most important way to deal with this is to really talk about it with other loved ones and friends and family and your local neighborhood community," Marshall says. "When one is extremely distressed, there is a remarkable comfort in the presence of other people."
Some of us will need more.
"There will be people who find themselves replaying images of the tsunami in their minds, or imagining over and over again what it would be like to be swept out to sea and drown," Marshall says. "There will be those who will reexperience their own trauma because the tsunami triggered that memory. Often that can be temporary. But it is important for someone experiencing something like that to try to control that in their own mind. Try distraction, try talking to someone else. Don't sit alone with these frightening images and dwell on it. It can pass, but if someone stuck with these images, it may be good to seek professional consultation."
Tsunami Aftershock: What to Tell the Kids
Very little children don't need to be made aware of frightening events that will only scare them. But at a surprisingly tender age, children usually find out when something is wrong.
"A 4- or 5-year-old will pick this up. You can't shield kids from this kind of thing," Marshall says. "So if the child is in school, you might ask whether they are worrying or thinking about the tsunami. You might be surprised that they are, even if they aren't talking about it."
Lying to them or trying to deceive children is the wrong approach, says child psychologist Cahir.
"Kids are smart and know what they see. Don't try to lie or deceive or make believe it didn't happen or downplay it. Children do feel naturally sad and upset about these situations," Cahir tells WebMD. "Parents should be supportive but encourage kids to talk. Yes, it is sad and tragic and hurts to look at the pictures. But it helps to talk."
Marshall, too, counsels honesty but warns parents to avoid any gruesome details.
"You want to give it a positive spin for a child," he says. "For older children, you can explain what a tsunami is. If you are in a part of the world where these things don't happen, you want to emphasize that and point it out. For younger children, reassure them that their momma and poppa will keep them safe no matter what."
Cahir and Marshall both recommend letting children participate in any charitable giving the family makes.
"Talk with your children about what one can do to help," Cahir advises. "Send cards or emails — think about people who survived and their need for help."
Some children — those who have been abused or who have lost their families in other disasters — may feel more of a sense of tragedy, Cahir says. Such kids may need extra support.
SOURCES: Randall D. Marshall, MD, director of trauma studies and services, New York State Psychiatric Institute, New York State Office of Mental Health; and associate professor of clinical psychiatry, Columbia University College of Physicians and Surgeons. Phyllis E. Kozarsky, MD, director of the Travel Well Clinic, Division of Infectious Diseases; and professor of medicine, Emory University School of Medicine. Nancy Cahir, PhD, child and family therapist, Atlanta.