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Lima, Bruno R.
Primary mental health care for disaster victims in developing countries
h [electronic resource] /
Bruno R. Lima.
Boulder, Colo. :
b Natural Hazards Research and Applications Information Center,
p. 203-204 ;
Reprint. Originally published: Farnham, Surrey, England : Foxcombe Publications, in: Disasters, v. 10, no. 3 (1986).
Includes bibliographical references (p. 204).
[Tampa, Fla. :
University of South Florida Libraries,
n Digitized from copy owned by Natural Hazards Center, University of Colorado at Boulder, in a joint project with the Louis de la Parte Florida Mental Health Institute (FMHI) Research Library's disaster mental health initiative.
x Psychological aspects.
University of Colorado, Boulder.
Natural Hazards Research and Applications Information Center.
t Natural Hazards Center Collection
HAZARD HOUSE '"""',",M ...o\... \ \\k(4..c.',,,::bc".c..r",eo..."4.t,,,-..
NaturalHazardsResearchandApplicationsInformationCenterCampusBox482UniversityofColoradoBoulder,Colorado80309-0482PRIMARYMENTALHEALTHCAREFORDISASTERVICTIMSINDEVELOPINGCOUNTRIESBrunoLima1986QuickResponseResearchReport#13... rt f the Natural Hazards This Information Center's ongoing Researc S. Quick Response Research Report enes. http://wWN colorado. edu/hazardsInstitute of BehavioralScience#6 (303) 492-6818
DISASTERS '---REPRINT.INTERNATIONAl DISASTER. INSTITUTE .85Marylebone High Street, LondonWIM3DE,U.K.PublishedbyFoxcombe Publications, Underhill Lane, Lower Bourne, Farnham, Surrey
REPORTS AND COMMENTPrimarymentalhealthfordisaster victims developing countries* care.zn203reportweremadewhenthe aut,hor wenttotheareaeleven daysafterthedisaster,as aconsultantforthePanAmericanHealthOrganizationtotheDivisionofMentalHealthoftheColombianMinistryofHealth.THECASEOFARMEROBrunoR.LimaDepartmental'PsychiatryandBehavioral Sciences JohnsHopkinsUniversity BaltimoreMD21205. U.S.A.INTRODUCTIONDisasters. known to have significantmentalhealthconsequences(KingstonandRosser, 1974),arefrequentoccurrences in developingcountries(Kroeger, 1976), with heavyhumancasualtiesandpropertylosses.Ontheotherhand.primarycare,themainstrategyforattainingWHO'sprogrammaticgoalof"healthfor all bytheyear2000," incorporatesmentalhealthasoneofits essential components. Inroutineclinical practice, ithasbeenfully recognizedthatmentalhealthservices in developing countries have tobeprovidedatthis levelofcare, assixteen percentofadultprimarycareattendershaveemotionaldisorders (Climentetal..1980),andspecializedmentalhealth resourcesareblatantlyinsufficient tomeettheirmentalhealthneeds(Harding.1978). ArecentWHOcollaborative stlKiy in seven developingcountrieshasshownthatprimarycareworkerscanbetrainedtocarryouteffectivementalhealthinterventions(WHO.1984), highlighting theadequacyandthepotentialoftheirrole.Thereforeinsituationswherethefrequencyofmentaldisordersislikely toincrease-suchas indisastersthe primarycareworkerwillnaturallybearthegreaterresponsibility for identifying,managingandreferring patients whopresentmentalhealthproblems. Nonetheless.110attentionhas been paid to the roleofprimarycare workers in deliveringmentalhealth todisastervictims in dcvdoping nations.anareathatneeds to bethefocus ofgreater researchandtraining cff(Jrts. Thevolcaniceruption of November 19S5 which destroyedthesmall town ofAnnen). inColombia.hasprovidedanopportunity for exploring thcse issues.Theobservationssummarizedinthis *Funded by thePanAmericanHealthOrganization. f)isa.\"/('r:;1 10/3/1986Armero,with apopulationofapproximately30,000,hada 160-bedgeneralhospitalanda psychiatric hospital. Both hospitals were lost inthetragedythatkilled over 22.000 peopleandleft 10.000 homeless,abouthalfbeinginjured.Thepsychiatrichospitalhad5,000 yearlyoutpatientvisits and ninety beds.representingeighty-sevenpercentofthestate'spsychiatric beds. Overthepastten years, ithadbeenupgradedfrom acustodialinstitutionthatoperatedwithanoccupancyrateof205%intoanefficient hospital withana\'erage lengthofstayoftwenty-six days.Thecurrentpsychiatric facility is a twenty-bed unit in a general hospital located tifty miles away.ThisdisasterofNovember 1985 highlightsthementalhealth roleoftheprimarycareworkers for a varietyofreasons:I.thesurvivors, mostly farm workers with a smallrepertoireofskills for alternative gainfulemployment.representtheusualattendersofprimarycareservices;II.amajorregional psychiatric resource has been lost,andmanyofits professionalstaffdied in the tragedy;III.therearemanypeople intemporarycamps.in verypoorliving conditions. whosehealthneedsarevariedandcomplex, still preoccupied with immedi:ite basic problems.butlackingclearlonger-term plans;\'.thethreatofneweruptionsorearthquakescontinues.addingto thepost-traumaticstressandrenderingthe survivorsandthe generalpopulationextremely anxious, Eventhreeweeksafterthe tragedy.primarycareworkers already reportedahigherfrequencyof anxiety anddepressionamongtheir patients. as well asofphysicalcomplaintsofprobablepsychophysiological origin.suchasheadachcsandbackaches.In a follow-upconsultationsixmonthslatcr, it was notedthat the need formentalhealth care had increased with ncwproblemssuch as severe depression. chronicanxiety. :llcohol anddrug-abusc. violence.maritalproblems anelmaladaptive behavior. Thescproblemshavc clearlyoutstrippedthc already limited specialized mental health reS'llJrces. transfcrringto tbe gencral health sector. and particularlyto theprimaryhealth worker. tile responsibility for mectingthem,Patientsarc seen in the two health centers located in ncarb\' townsarc staffedbya generaldoctorand auxiliarywith;1\\'eekly psychiatric consultation.The mcntalhealth training ofprimar\'careworkers in developing countries has included the managelllentl)rconditions secn in routine clinical practicc. such as tirst-aid inIIcuropsychiatric emergel1cies;maintenancetrcalnlentorthe chronically mel1tally ill; advicc and sllpport to high-risk
204 families; referralofmentally ill people in anonacuteorunclearstateto thenearesthealth facility; familyeducationaboutpsychosocial developmentandtheneedsoftheelderlyandhandicapped;supportandeducationofthementallyillaboutself-care;andcollaborationofcommunity leaders in activities aimedatprotectingandpromotingmentalhealth(Hard inget aI.,1980). Attention needs to be paid now tothe specialmentalhealth needsofdisastervictimsandto thestructuralandproceduraladjustmentsrequired from the primary case worker to meet them.Importantareas in disastereducationandtraininginclude: knowledgeofdisasterbehavior (e.g. crisis/stress, lossandmourning, coping andadaptation);skills inthe ofdifferenttreatmentmodalities (crisis counselling,grouptherapy,short-termfocused therapy, psychopharmacology); understanding of thedisasteraid system (e.g. shelter, medical <:are. home repairs. financial assistance) and ability to utilize available familyandcommunity resources (Cohen and Ahearn. 1980). Inordertoadjustservice delivery to meet thedisaster \idims biopsychosocial needs. a varietyoractivities must hede\cll)ped in the areasoftraining. education. n:search and planninginprimary mental health care.Training anded ucational activities shouldconcentrateonthe develop mentof the necessary methodologiesadaptedto adisastersituationandtothespecific contentsthatneed to be learned. For example,trainingshould include the uscofmanualsandfocus on the recognitionandtreatmentof freq uent psych iatric problems seen in disasters. such as depressionandanxiety. Research should ascertain the frequencyofpsychiatric problems seen in primary care clinics located in thedisasterarea,andthe primary care l\orkers deficienciesinidentifying and managing patients with emotional problems and in referringthemto the specialized mental health sector.Thedatageneratedwillhighlight the specific areasatwhichtraining.programs should be targeted. A collaborative research projectisbeing carriedoutin the disaster area by the Johns Hopkins University, the University Lrveriana in Bogota and the DivisionofMental Healthofthe Colombia MinistryofHealth to address these specific questions. From a planning viewpoint. the roleof the specializedmentalhealth sectorinthe comprehensive care ofdisastervictims should beof training, educationandconsultation to theprimarycare workers,ratherthandirectREPORTS AND COMMENT. service delivery. Ideally, a small nationalorregionalmentahealthteamspecialized indisastersshould develop ttt capability fortrainingthementalhealthteamlocal to th\ disasterareato provide basictrainingandcontinuingsupporttothefront lineprimarycareworkers. who will inturnprovidedirectmentalhealthcareto victims, familiesandcommunities.Thelocalmentalhealthteamwill remain available for evaluationand/ortreatmentofreferred patients with psychiatric problemsthataretoo complex to behandledattheprimarycarelevel.butactual mental healthcarewillbedelivered to thedisastervictims by the primarycareworkers.Itis expected thatthe lessons to be learned frl1m the Armero tragedy willenhancethe primarycare worker's roleindeliveringmentalhealthcareindeveloping countries. and willpermita faster flexible and comprehensi\e respOllseofthe health system to the nlltltiplicity111' biopsychosocial problems disaster victims present. REFERENCESCliment C.E.et al.,Mental health in primary health care:WHOChronicle34,231-236(1980). Cohen R.E.andAhearnJr. F.L..Handhook/;)/".\1ell/el/ Health Careo/DisasterVictims.Johns Hopkins Uni\wsit\. Baltimore (1980). "HardingT.W..Psychiatry inrural-agrarian s,'cieti/ PsychiatricAnnals8,302-310(1978),HardingT.W.et al ..Mental disordersin primary health care: A studyoftheir frequencyinfour countries.Psychological Medicine10, 231-2-11 (1980). Kingston W.and Rosser R ..Disasters. Effects ()n mental and physical state.J.Psvchosomatic Reseurc!r 18, -1j7---lSo (1974). Kroeger E.K., Disastermanagementin tropil:al countries.TropicalDoctor6,147-151(1976). World HealthOrganization(WHO). Melltal health care indeveloping countries: a critical app('aisalor research lindings.WHOTechnical Report Series (lYH(19H4l.fJiSl/st,.,.s/ I().. \IlJS(1