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Improving psychosocial survival in complex emergencies
HEALTH AND HUMAN RIGHTS
Health and human rights
Improving psychosocial survival in complex emergencies
A
ssistance programmes for waraffected populations, such as refugees and internally displaced people, have increasingly focused on ensuring “positive human rights”, as defined by the International Covenant on Economic, Social, and Cultural Rights. These rights include access to medical care and public health services. During the past two decades, evidence on the major causes of mortality and morbidity has informed the development of public health strategies for complex emergencies, embodied in an international humanitarian charter and minimum standards for disaster response.1 The underlying rationale is the universal right to physical, mental, and social wellbeing. The need to address the mental health of war-affected populations has been increasingly recognised, especially in recent European conflicts such as in the former Yugoslavia, where in 1995 there were 185 mental health projects run by 117 organisations.2 Mental health professionals vigorously debate the relation between exposure to war trauma and resultant adverse health effects. However, unlike mortality, malnutrition, and infectious disease morbidity, mental disorders are difficult to measure in population studies; hence, there are few robust data for their prevalence in war-affected populations. Additionally, there are inadequate comparison data on the prevalence of these disorders in stable, low-income countries.
Many mental health programmes have provided counselling services focused on the prevention and treatment of post-traumatic stress disorder, a diagnosis described only since the 1980s, and based largely on tools developed in a western cultural context. These services have been criticised for focusing on the medical disorders of individuals and failing to recognise that war and displacement are collective experiences that warrant community responses.3 Moreover, the effectiveness of routine counselling after trauma is still debated, even in the west. Some researchers urge aid agencies to focus on supporting the adaptive responses of communities to deal with widespread grief, anger, loss of identity, and helplessness.4 These emotions are normal human reactions that are most commonly addressed through religious and cultural rituals, attention to continued economic survival, and family cohesion. Ensuring a lasting peace is probably the most effective external intervention to support community restoration. Others may include support for rituals (such as reburials, see p 869), employment, restoration of governance, and a process to ensure justice. Whether or not exposure to war significantly increases the incidence of mental disorders, all populations contain people with mental illness. The presence of mentally dysfunctional family members can only exacerbate the ordeal of people whose lives have been thrown into turmoil by armed conflict.
Public health programmes are often initially overwhelmed by the task of reducing morbidity and mortality from infectious diseases, malnutrition, and injuries. Thus, a phased approach to mental health would include an assessment of mental illness using culturally appropriate tools; a study of community coping mechanisms; support to community adaptive systems; and home-based care of the mentally ill through local community-based organisations. Programmes that are not evidencebased and that focus on medical strategies to manage individual disorders might cause more harm (by disrupting community recovery) than good, and so repeat many of the mistakes made earlier by emergency relief programmes in dealing with physical illness mainly through clinic and hospital-based interventions. Mike Toole Centre for International Health, Macfarlane Burnet Institute for Medical Research and Public Health, GPO Box 2284, Melbourne 3001, Australia (e-mail: [email protected]) 1
2
3
4
The Sphere Project. Humanitarian charter and minimum standards in disaster response. Geneva: Sphere Project, 1998. Agger I, Mimica J. Psychological assistance to victims of war in Bosnia-Herzegovina and Croatia: an evaluation. Brussels: ECHO, 1996. Summerfield D. A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Soc Sci Med 1999; 48: 1449–62. Silove D. The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework. J Nerv Ment Dis 1999; 187: 200–07.
Reburial ceremonies for health and healing after state terror in Zimbabwe
C
ivil war raged in the western half of Zimbabwe from independence until 1987; 10 000–20 000 people are estimated to have died,1 and much of the population was exposed to violence (survey for Catholic Commission for Justice and Peace, Amani Trust 1998, data available from authors). Entire communities are still struggling to come to terms with the past (http://globetrotter.berkeley.edu/people/Eppel/eppelcon2.html, accessed August, 2002). Amani Trust, Matabeleland, Zimbabwe, is a non-governmental organisation that rehabilitates survivors of torture and organised vio-
lence in the western half of the country. The group came to communities expecting to offer counselling services in keeping with the western expectation that post-traumatic stress disorder or mixed anxiety and depression would be the most prevalent disorders.2 However, recognising the importance of treating the problems that the survivors themselves identified led us to follow organisations and workers in Guatemala, Mozambique, Angola, Rwanda, and South Africa. These groups have moved away from one-on-one psychotherapy to use traditional community conflict resolution, belief systems, and public truth
THE LANCET • Vol 360 • September 14, 2002 • www.thelancet.com
telling to restore social fabric after community destruction.3-5 The subversion of community values as a result of violence is felt differently in cultures where individuals see themselves mainly as members of communities, rather than as individuals in the western sense. Destruction of the cohesiveness of communities has led to apathy, depression, and an unwillingness to assume leadership roles. At the same time, it is vital to recognise the resilience and power of victims to carry on and to rebuild their lives. Local leaders insisted that we held talks in community meetings rather 869
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Health and human rights
Improving psychosocial survival in complex emergencies
A
ssistance programmes for waraffected populations, such as refugees and internally displaced people, have increasingly focused on ensuring “positive human rights”, as defined by the International Covenant on Economic, Social, and Cultural Rights. These rights include access to medical care and public health services. During the past two decades, evidence on the major causes of mortality and morbidity has informed the development of public health strategies for complex emergencies, embodied in an international humanitarian charter and minimum standards for disaster response.1 The underlying rationale is the universal right to physical, mental, and social wellbeing. The need to address the mental health of war-affected populations has been increasingly recognised, especially in recent European conflicts such as in the former Yugoslavia, where in 1995 there were 185 mental health projects run by 117 organisations.2 Mental health professionals vigorously debate the relation between exposure to war trauma and resultant adverse health effects. However, unlike mortality, malnutrition, and infectious disease morbidity, mental disorders are difficult to measure in population studies; hence, there are few robust data for their prevalence in war-affected populations. Additionally, there are inadequate comparison data on the prevalence of these disorders in stable, low-income countries.
Many mental health programmes have provided counselling services focused on the prevention and treatment of post-traumatic stress disorder, a diagnosis described only since the 1980s, and based largely on tools developed in a western cultural context. These services have been criticised for focusing on the medical disorders of individuals and failing to recognise that war and displacement are collective experiences that warrant community responses.3 Moreover, the effectiveness of routine counselling after trauma is still debated, even in the west. Some researchers urge aid agencies to focus on supporting the adaptive responses of communities to deal with widespread grief, anger, loss of identity, and helplessness.4 These emotions are normal human reactions that are most commonly addressed through religious and cultural rituals, attention to continued economic survival, and family cohesion. Ensuring a lasting peace is probably the most effective external intervention to support community restoration. Others may include support for rituals (such as reburials, see p 869), employment, restoration of governance, and a process to ensure justice. Whether or not exposure to war significantly increases the incidence of mental disorders, all populations contain people with mental illness. The presence of mentally dysfunctional family members can only exacerbate the ordeal of people whose lives have been thrown into turmoil by armed conflict.
Public health programmes are often initially overwhelmed by the task of reducing morbidity and mortality from infectious diseases, malnutrition, and injuries. Thus, a phased approach to mental health would include an assessment of mental illness using culturally appropriate tools; a study of community coping mechanisms; support to community adaptive systems; and home-based care of the mentally ill through local community-based organisations. Programmes that are not evidencebased and that focus on medical strategies to manage individual disorders might cause more harm (by disrupting community recovery) than good, and so repeat many of the mistakes made earlier by emergency relief programmes in dealing with physical illness mainly through clinic and hospital-based interventions. Mike Toole Centre for International Health, Macfarlane Burnet Institute for Medical Research and Public Health, GPO Box 2284, Melbourne 3001, Australia (e-mail: [email protected]) 1
2
3
4
The Sphere Project. Humanitarian charter and minimum standards in disaster response. Geneva: Sphere Project, 1998. Agger I, Mimica J. Psychological assistance to victims of war in Bosnia-Herzegovina and Croatia: an evaluation. Brussels: ECHO, 1996. Summerfield D. A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Soc Sci Med 1999; 48: 1449–62. Silove D. The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework. J Nerv Ment Dis 1999; 187: 200–07.
Reburial ceremonies for health and healing after state terror in Zimbabwe
C
ivil war raged in the western half of Zimbabwe from independence until 1987; 10 000–20 000 people are estimated to have died,1 and much of the population was exposed to violence (survey for Catholic Commission for Justice and Peace, Amani Trust 1998, data available from authors). Entire communities are still struggling to come to terms with the past (http://globetrotter.berkeley.edu/people/Eppel/eppelcon2.html, accessed August, 2002). Amani Trust, Matabeleland, Zimbabwe, is a non-governmental organisation that rehabilitates survivors of torture and organised vio-
lence in the western half of the country. The group came to communities expecting to offer counselling services in keeping with the western expectation that post-traumatic stress disorder or mixed anxiety and depression would be the most prevalent disorders.2 However, recognising the importance of treating the problems that the survivors themselves identified led us to follow organisations and workers in Guatemala, Mozambique, Angola, Rwanda, and South Africa. These groups have moved away from one-on-one psychotherapy to use traditional community conflict resolution, belief systems, and public truth
THE LANCET • Vol 360 • September 14, 2002 • www.thelancet.com
telling to restore social fabric after community destruction.3-5 The subversion of community values as a result of violence is felt differently in cultures where individuals see themselves mainly as members of communities, rather than as individuals in the western sense. Destruction of the cohesiveness of communities has led to apathy, depression, and an unwillingness to assume leadership roles. At the same time, it is vital to recognise the resilience and power of victims to carry on and to rebuild their lives. Local leaders insisted that we held talks in community meetings rather 869
For personal use. Only reproduce with permission from The Lancet Publishing Group.