Morten Rostrup, MD, worked in Indonesia’s devastated Aceh province from January 6-24, 2005, providing medical consultations to thousands of people who survived the earthquake-triggered tsunamis and helping support the hospital in Meulaboh.
Emotional Scars, Physical Pain
When I arrived in Meulaboh on the western coast of Aceh, I started seeing patients right away in addition to assessing the situation. When I have the chance to speak to people in a medical consultation, I also get a much better impression of what the health situation is like.
We started with two mobile clinics in Meulaboh on January 7. With the clinics we visited different IDP locations that MSF had been alerted to. After a few days we had carried out consultations in five subdistricts. That first week we did some 1000 consultations, working seven days a week.
Everywhere we went, we saw the same health problems: infected wounds, skin infections, and a number of illnesses I believed to be psychosomatic — caused by the stress of what the patients had experienced in the tsunami. People were complaining of breathing problems, muscle pains, headaches, and a general numbness of the body. They seemed to be describing their emotional state as physical numbness.
When I examined them without identifying medical problems, I would ask them about their experiences. Did they see the tsunami? Did they have to swim? For how long had they had to fight for their lives? Had they lost any relatives or close family members? Had they lost their homes? It is of course terrible to lose all your possessions, but going through the experience of fighting for your life is especially traumatic.
One man told me that every night when he tried to go to sleep, he was kept awake by pain all over his body, although he felt fine when he kept moving. It was not physical pain he was feeling, but mental pain that manifested itself in physical symptoms.
Previously I’ve seen how people who have had to fight for their lives in a catastrophic situation can develop psychosomatic illnesses. Experiencing the feeling that death is imminent, especially over a long period of time, is extremely traumatic. The sudden violent death of close relatives is also a major trauma, as is losing young children.
To see others die without being able to help them is terrible. I met a man who had sought refuge from the tsunami by climbing a palm tree. From there he saw many people drown. There was nothing he could do to save them. Such an experience is an awful thing to go through.
Even worse are the cases where people were caught in the waves with family members, trying desperately to save them. One extremely depressed man told me about how he was holding on to his wife with his left arm and his child with his right. He was trying to swim and stay afloat. The man lost hold of his wife, and was unable to hold on to his child. He could only watch as his child floated away from him. By fighting for and saving his own life, he will always be haunted by the memory of not being able to save his wife or child.
I treated another patient who had lost all four of his children, his wife, and other relatives. “I am totally alone,” he told me, with astonishing calm. It was simply too much for him to take in, no way for him to relate to it. The only way for people to make sense of such an abnormal situation is to distance themselves from it.
An important factor that makes it a little easier to cope is collective grief. When you are not alone in having experienced the loss of your family or your home, there is collective suffering, which provides a kind of support. Even so, it is important to have outsiders to speak to. It is difficult to talk to your neighbor about what you have lost when that neighbor is also experiencing the same loss.
I felt pretty helpless when meeting patients suffering from psychosomatic illnesses. What can I do as a doctor in such a context? When there is nothing medically wrong with them, and with me not being a psychologist, what can I offer them?
I decided to take their symptoms very seriously and give each person a thorough medical examination. I would listen to their heart, their chest, and touch them where they told me they were feeling pain. I would then ask them questions about what had happened to them and then explain to them that I didn’t find anything wrong with them physically. That would at least give them the comfort of knowing that there was nothing wrong with their health.
To attempt to provide them with some comfort and put them at ease I would try to explain that what they were feeling was a very normal reaction to a completely abnormal experience. It was also important to simply be present with these people, and to have the time to talk with them and listen to them.
I was very pleased to have psychologists going with our mobile clinics. That allowed me to refer patients with this kind of symptoms to someone better equipped to help them. The psychologists suggested ways for the patients to help regain control of their bodies by touching or massaging the places where they felt pain. The numbness that they were feeling and describing was really a mental state.
No epidemics, little malaria
This disaster is very different from what I usually see as a an MSF doctor. Soon after I had arrived in Aceh, I realized that people’s physical health was generally not the major area of concern. We have not seen any classic epidemic outbreaks, and very little malaria. Initially I suspected that we were missing the disease in our clinical examinations, so we did a number of tests, all of which were negative. Out of 1500 consultations, we detected only 5 or 6 of cases of falciparum malaria and few cases of diarrhea.
In general, the health situation was quite good before the disaster. However, the Acehnese people were already living with stress because of the ongoing conflict in the province. Some might have suffered from psychosomatic illness before, but it all got worse after the tsunami.
Lack of time
Here in Aceh I have had the opportunity to delve deeper into the psychological aspects of providing treatment after a traumatic disaster. In the African settings I have worked in previously, we often lacked the time to address psychological problems in the same way. We were too busy trying to take care of people’s physical health needs.
I started to reflect on the trauma previous patients of mine must have gone through after fleeing war or being raped. Sometimes there’s so much mental trauma in a situation that it somehow comes to seem normal – which is absolutely not the case.
I feel a little helpless here in Aceh, hearing the stories and realizing that we arrived too late to help save many people. In a catastrophe as massive as this, your fate – if you managed to survive the initial event itself – is decided in the first 24-48 hours. Without immediate on-the-spot medical and surgical care, the severity of your injuries is what determines whether you live or die.
An enormous surgical capacity would have needed to be on the spot when the disaster struck – and make it through the tsunami intact – in order to have a medical impact on saving lives. For example, the doctors who were in Meulaboh when the tsunami struck worked around the clock for the first two days to save as many lives as possible, but they lacked personnel, equipment, and supplies. No outside help had reached them yet. They didn’t even have the capacity to carry away the bodies of the dead. It was all they could do to keep working in the emergency room, while dead bodies were piling up around them.
It is a terrible situation to be in; to know that you could have done more, saved more lives, if you only had more resources and supplies.
By the time MSF arrived in the Meulaboh hospital, it was barely functioning. There were emergency room surgical teams, but no one to follow up the patients in the post-operative ward. MSF helped open up the post-op ward and it soon expanded to 50 patients. We also helped take on the medical and pediatric wards. Half the staff had been killed or were missing and others were away caring for their own families or their own suffering. It took some time for the nursing staff to return, but it’s beginning to happen now.
The surgical support that arrived a few days after the tsunami provided care that avoided some amputations, and helped prevent further infections and septicemia. Still, we could have made a major impact if we had been there the first two days, but there was simply no way to respond quickly enough to such a massive disaster that came without any warning.
Now we need to make sure that the survivors are well taken care of. We need to get the primary health care system up and running again, make sure that there is good epidemiological surveillance allowing us to contain epidemics and control them quickly, should they occur.
We also need to look into how we can prevent people from developing symptoms related to post-traumatic stress, which will be a major hazard in the months to come. It can take months for these symptoms to develop. Mental health care must be a priority. It will be difficult to address the needs of the thousands upon thousands who have suffered so greatly.