- Email: [email protected]
Vicarious grief and response to global disasters
Comment
Vicarious grief and response to global disasters
www.thelancet.com Vol 366 August 27, 2005
How does vicarious grief compare between dramatic catastrophic events and chronic human disasters that are experienced daily around the world? Because of their chronicity, and despite their enormity, tragedies such as AIDS, malaria, and tuberculosis do not seem to resonate at an individual level in the same way as sudden dramatic with 25 million in sub-Saharan Africa alone. AIDS kills more than 8000 people a day or one person every 10 s.9 In 2004, WHO reported over 3 million deaths from AIDS, including 500000 children under the age of 15 years.9 An estimated 1·7 million people died from tuberculosis in 2003, including nearly 20% coinfected with HIV.10 Malaria accounts for 1–2 million deaths annually, claiming the life of an African child every 30 s.11 In total, about 6 million people die of AIDS, tuberculosis, and malaria each year—over 16 000 preventable deaths a day.12 Yet, ubiquitous chronic tragedies do not seem to move people in the same way as those that are sudden or dramatic. Besides the acute and intense media attention that the latter receive, there is the issue of imagination. Whilst most westerners can readily evoke images of sudden disasters, the prospect of dying from a chronic illness in the sub-Sahara lies beyond imagination. Another aspect of postdisaster vicarious grief is lending or giving aid. Giving money or blood can help alleviate disaster-focused stress, and establishes a sense of cohesion with a community joined in tragedy.13 Patterns of philanthropy, however, appear to support the distinction between imaginable versus unimaginable disaster scenarios. For instance, Giving USA estimates that by the end of 2001, US$1·88 billion was received by the major relief funds for 9/11.14 To date, international donors have pledged more than $5 billion towards tsunami relief.8 Contrast this with the $200–300 million a year that the world spends on malarial control, or the $1·2 billion total funding available for tuberculosis control in the high-burden countries12 The annual funds spent on programmes for HIV/AIDS prevention, care, and support in low-income and middle-income countries are $1·8 billion.15 The UN estimates that these countries would need $7–10 billion annually to mount a successful programme against the AIDS epidemic—according to the UN Secretary General, this sum represents 1% of the world’s yearly military spending.15
Rights were not granted to include this image in electronic media. Please refer to the printed journal AP
What shapes our response to global disasters? Most of what we know about grief comes from studies that track individual reactions to personal loss.1 These studies mainly identify characteristics of bereavement and how it changes over time. Events, such as the tsunami at the end of last year in southern Asia, evoke a worldwide response whose phenomenology is not nearly as well understood. Whilst several investigators have examined psychological impairments in those directly affected, less is known about the nature of postdisaster vicarious grief within the broader global community.2–5 Disasters that evoke widespread response have several notable features, beginning with global visibility. The likelihood of vicarious grieving is proportionate to what the disaster literature describes as indirect or secondary exposure to coverage in the mass media.3 Exposure to details about the disaster increases the likelihood of being preoccupied with intrusive thoughts about victims, and postdisaster distress.3,4 The Asian tsunami was marked by sudden, unanticipated, random, and numerous deaths—characteristics associated with lingering and pronounced grief reactions. Other factors related to protracted grieving include multiple violent deaths, or deaths involving mutilation, such as the 9/11 terrorist attacks in the USA.6,7 The very nature of these dramatic events disrupts our collective sense of stability and predictability, resulting in what some have described as a “shattering of the assumptive world”.7 This disruption of psychological homoeostasis can influence individual or community reactions, evoking fear, anxiety, vulnerability, and ultimately, a sense of feeling less safe. Identification with the victim is another powerful mediator of response, predisposing to disaster-focused distress. After 9/11, vicarious victims were described as those who perceived real or imagined similarity to actual victims; they identified with victim experiences, despite being physically removed from the scene of the falling towers, or having no direct connection with any of the victims.5 This sense of identification appears to be connected to the disaster setting itself. It is easy to imagine being in an office tower, aeroplane, or on a beach; it is perhaps the ordinariness or imaginability of these predisaster settings that heightens identification with actual victims.8
Collecting money in Kathmandu, Nepal, Jan 2, 2005
697
Comment
A better understanding of postdisaster vicarious grief is important, because the psychology affecting individual reactions may guide community or global responses. Understanding vicarious grief has public-health and publicpolicy implications, because how we perceive and process these losses might partly influence how resources are allocated. Whilst abject poverty, disease, or persistent environmental crisis may not capture headlines or resonate in the same way as the more dramatic calamities, they are the chronic and hideous silent tsunamis of our time.
5 6 7
8 9
10
11
Harvey Max Chochinov Manitoba Palliative Care Research Unit, CancerCare Manitoba, Department of Psychiatry, University of Manitoba, Winnipeg, Canada R3E 0V9 [email protected]
12
13
I declare that I have no conflict of interest. 1 2 3
4
Parkes, C. Bereavement: studies of grief in adult life, 3rd edn. Philadelphia: Taylor & Francis, 2001. Rubonis AV, Bickman L. Psychological impairment in the wake of disaster: the disaster-psychopathology relationship. Psychol Bull 1991; 109: 384–99. Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA 2002; 288: 1235–44. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. JAMA 2002; 288: 581–88.
14
15
Wayment HA. It could have been me: vicarious victims and disasterfocused distress. Pers Soc Psychol Bull 2004; 30: 515–28. Rando T. Vicarious bereavement. In: Strack S, ed. Death and the quest for meaning. Northvale, New Jersey: Jason Aronson, 1997: 257–74. Rando T. Complications in mourning traumatic death. In: Corless I, Germino B, Pittman M, eds. Dying, death and bereavement: theoretical perspectives and other ways of knowing. Boston: Jones and Barlett Publishers, 1994: 253–71. Nolan S. Federal tsunami aid hits 425 million as cash woes hurt African AIDS fight. Globe and Mail Jan 11, 2005: A:1. World Health Organization Regional Office for South-East Asia. HIV/AIDS: facts and figures. March 17, 2005: http://w3.whosea.org/EN/Section10/ Section18/Section348.htm (accessed May 5, 2005). World Health Organization. Global tuberculosis control—surveillance, planning, financing. 2005: www.who.int/tb/publications/global_report/ 2005/summary/en/index.html (accessed May 6, 2005). World Health Organization. Malaria is alive and well and killing more than 3000 African children every day. April 25, 2003: http://www.who.int/ mediacentre/news/releases/2003/pr33/en (accessed May 5, 2005). Global Fund to Fight AIDS, Tuberculosis and Malaria. HIV/AIDS, tuberculosis and malaria: the status and impact of the three diseases. 2005: www.theglobalfund.org/en/files/about/replenishment/disease_ report_en.pdf (accessed May 3, 2005). Schuster MA, Stein BD, Jaycox L, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med 2001; 345: 1507–12. American Association of Fundraising Counsel (AAFRC) Trust for Philanthropy. Charitable giving reaches $212 billion (Giving USA 2002, The Annual Report on Philanthropy for the Year 2001). June 20, 2002: http://www.aafrc.org/press_releases/trustreleases/charitablegiving.html (accessed May 5, 2005). Alagiri P, Collins C, Summers T, Morin S, Coates T. Global spending on HIV/AIDS: tracking public and private investments in AIDS prevention, care and research. 2001: http://www.kaisernetwork.org/health_cast/ uploaded_files/Global_Spending.pdf (accessed May 6, 2005).
Reproductive decisions in HIV-infected individuals There is growing recognition of the reproductive decisions faced by HIV-infected women and men worldwide. One national study of HIV-infected individuals in the USA found that as much as 28% of participants wanted children in the future,1 and cohorts of HIV-infected women from sub-Saharan Africa, Europe, and North America show that many HIVinfected women choose to have children after learning of their infection.2,3 Despite the increasing attention to the health-care needs of HIV-infected women and men in resource-limited settings, most notably about antiretroviral therapy, support for reproductive choice in HIV-infected individuals in these regions has lagged behind. Although the use of contraception by HIVinfected women in developing countries has been described by some policymakers as an imperative within HIV treatment services,4 there has been little consideration of the range of different issues that HIVinfected individuals face in making reproductive decisions (table). 698
There are few medical concerns that should affect HIV-infected women’s reproductive choices. Pregnancy seems to have little influence on the progression of HIV disease, because the transient decline in maternal immunocompetence observed during gestation (regardless of HIV status) appears to resolve after delivery, and these changes are greatly outweighed by the immunological benefits that accompany antiretroviral therapy.5 Contraceptive options should be minimally affected by a woman’s HIV status; the principal exceptions to this choice are intrauterine device and surgical sterilisation, both of which might be considered with caution in women with advanced HIV disease.6 Furthermore, the potential teratogenicity of the non-nucleoside reversetranscriptase inhibitor, efavirenz, means that effective contraception is strongly recommended for women taking this drug.7 Although there is no evidence to suggest that any contraceptive method reduces the efficacy of HIV therapies, oestrogen-containing contraceptives (including combined oral contraceptives and www.thelancet.com Vol 366 August 27, 2005
Vicarious grief and response to global disasters
www.thelancet.com Vol 366 August 27, 2005
How does vicarious grief compare between dramatic catastrophic events and chronic human disasters that are experienced daily around the world? Because of their chronicity, and despite their enormity, tragedies such as AIDS, malaria, and tuberculosis do not seem to resonate at an individual level in the same way as sudden dramatic with 25 million in sub-Saharan Africa alone. AIDS kills more than 8000 people a day or one person every 10 s.9 In 2004, WHO reported over 3 million deaths from AIDS, including 500000 children under the age of 15 years.9 An estimated 1·7 million people died from tuberculosis in 2003, including nearly 20% coinfected with HIV.10 Malaria accounts for 1–2 million deaths annually, claiming the life of an African child every 30 s.11 In total, about 6 million people die of AIDS, tuberculosis, and malaria each year—over 16 000 preventable deaths a day.12 Yet, ubiquitous chronic tragedies do not seem to move people in the same way as those that are sudden or dramatic. Besides the acute and intense media attention that the latter receive, there is the issue of imagination. Whilst most westerners can readily evoke images of sudden disasters, the prospect of dying from a chronic illness in the sub-Sahara lies beyond imagination. Another aspect of postdisaster vicarious grief is lending or giving aid. Giving money or blood can help alleviate disaster-focused stress, and establishes a sense of cohesion with a community joined in tragedy.13 Patterns of philanthropy, however, appear to support the distinction between imaginable versus unimaginable disaster scenarios. For instance, Giving USA estimates that by the end of 2001, US$1·88 billion was received by the major relief funds for 9/11.14 To date, international donors have pledged more than $5 billion towards tsunami relief.8 Contrast this with the $200–300 million a year that the world spends on malarial control, or the $1·2 billion total funding available for tuberculosis control in the high-burden countries12 The annual funds spent on programmes for HIV/AIDS prevention, care, and support in low-income and middle-income countries are $1·8 billion.15 The UN estimates that these countries would need $7–10 billion annually to mount a successful programme against the AIDS epidemic—according to the UN Secretary General, this sum represents 1% of the world’s yearly military spending.15
Rights were not granted to include this image in electronic media. Please refer to the printed journal AP
What shapes our response to global disasters? Most of what we know about grief comes from studies that track individual reactions to personal loss.1 These studies mainly identify characteristics of bereavement and how it changes over time. Events, such as the tsunami at the end of last year in southern Asia, evoke a worldwide response whose phenomenology is not nearly as well understood. Whilst several investigators have examined psychological impairments in those directly affected, less is known about the nature of postdisaster vicarious grief within the broader global community.2–5 Disasters that evoke widespread response have several notable features, beginning with global visibility. The likelihood of vicarious grieving is proportionate to what the disaster literature describes as indirect or secondary exposure to coverage in the mass media.3 Exposure to details about the disaster increases the likelihood of being preoccupied with intrusive thoughts about victims, and postdisaster distress.3,4 The Asian tsunami was marked by sudden, unanticipated, random, and numerous deaths—characteristics associated with lingering and pronounced grief reactions. Other factors related to protracted grieving include multiple violent deaths, or deaths involving mutilation, such as the 9/11 terrorist attacks in the USA.6,7 The very nature of these dramatic events disrupts our collective sense of stability and predictability, resulting in what some have described as a “shattering of the assumptive world”.7 This disruption of psychological homoeostasis can influence individual or community reactions, evoking fear, anxiety, vulnerability, and ultimately, a sense of feeling less safe. Identification with the victim is another powerful mediator of response, predisposing to disaster-focused distress. After 9/11, vicarious victims were described as those who perceived real or imagined similarity to actual victims; they identified with victim experiences, despite being physically removed from the scene of the falling towers, or having no direct connection with any of the victims.5 This sense of identification appears to be connected to the disaster setting itself. It is easy to imagine being in an office tower, aeroplane, or on a beach; it is perhaps the ordinariness or imaginability of these predisaster settings that heightens identification with actual victims.8
Collecting money in Kathmandu, Nepal, Jan 2, 2005
697
Comment
A better understanding of postdisaster vicarious grief is important, because the psychology affecting individual reactions may guide community or global responses. Understanding vicarious grief has public-health and publicpolicy implications, because how we perceive and process these losses might partly influence how resources are allocated. Whilst abject poverty, disease, or persistent environmental crisis may not capture headlines or resonate in the same way as the more dramatic calamities, they are the chronic and hideous silent tsunamis of our time.
5 6 7
8 9
10
11
Harvey Max Chochinov Manitoba Palliative Care Research Unit, CancerCare Manitoba, Department of Psychiatry, University of Manitoba, Winnipeg, Canada R3E 0V9 [email protected]
12
13
I declare that I have no conflict of interest. 1 2 3
4
Parkes, C. Bereavement: studies of grief in adult life, 3rd edn. Philadelphia: Taylor & Francis, 2001. Rubonis AV, Bickman L. Psychological impairment in the wake of disaster: the disaster-psychopathology relationship. Psychol Bull 1991; 109: 384–99. Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA 2002; 288: 1235–44. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. JAMA 2002; 288: 581–88.
14
15
Wayment HA. It could have been me: vicarious victims and disasterfocused distress. Pers Soc Psychol Bull 2004; 30: 515–28. Rando T. Vicarious bereavement. In: Strack S, ed. Death and the quest for meaning. Northvale, New Jersey: Jason Aronson, 1997: 257–74. Rando T. Complications in mourning traumatic death. In: Corless I, Germino B, Pittman M, eds. Dying, death and bereavement: theoretical perspectives and other ways of knowing. Boston: Jones and Barlett Publishers, 1994: 253–71. Nolan S. Federal tsunami aid hits 425 million as cash woes hurt African AIDS fight. Globe and Mail Jan 11, 2005: A:1. World Health Organization Regional Office for South-East Asia. HIV/AIDS: facts and figures. March 17, 2005: http://w3.whosea.org/EN/Section10/ Section18/Section348.htm (accessed May 5, 2005). World Health Organization. Global tuberculosis control—surveillance, planning, financing. 2005: www.who.int/tb/publications/global_report/ 2005/summary/en/index.html (accessed May 6, 2005). World Health Organization. Malaria is alive and well and killing more than 3000 African children every day. April 25, 2003: http://www.who.int/ mediacentre/news/releases/2003/pr33/en (accessed May 5, 2005). Global Fund to Fight AIDS, Tuberculosis and Malaria. HIV/AIDS, tuberculosis and malaria: the status and impact of the three diseases. 2005: www.theglobalfund.org/en/files/about/replenishment/disease_ report_en.pdf (accessed May 3, 2005). Schuster MA, Stein BD, Jaycox L, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med 2001; 345: 1507–12. American Association of Fundraising Counsel (AAFRC) Trust for Philanthropy. Charitable giving reaches $212 billion (Giving USA 2002, The Annual Report on Philanthropy for the Year 2001). June 20, 2002: http://www.aafrc.org/press_releases/trustreleases/charitablegiving.html (accessed May 5, 2005). Alagiri P, Collins C, Summers T, Morin S, Coates T. Global spending on HIV/AIDS: tracking public and private investments in AIDS prevention, care and research. 2001: http://www.kaisernetwork.org/health_cast/ uploaded_files/Global_Spending.pdf (accessed May 6, 2005).
Reproductive decisions in HIV-infected individuals There is growing recognition of the reproductive decisions faced by HIV-infected women and men worldwide. One national study of HIV-infected individuals in the USA found that as much as 28% of participants wanted children in the future,1 and cohorts of HIV-infected women from sub-Saharan Africa, Europe, and North America show that many HIVinfected women choose to have children after learning of their infection.2,3 Despite the increasing attention to the health-care needs of HIV-infected women and men in resource-limited settings, most notably about antiretroviral therapy, support for reproductive choice in HIV-infected individuals in these regions has lagged behind. Although the use of contraception by HIVinfected women in developing countries has been described by some policymakers as an imperative within HIV treatment services,4 there has been little consideration of the range of different issues that HIVinfected individuals face in making reproductive decisions (table). 698
There are few medical concerns that should affect HIV-infected women’s reproductive choices. Pregnancy seems to have little influence on the progression of HIV disease, because the transient decline in maternal immunocompetence observed during gestation (regardless of HIV status) appears to resolve after delivery, and these changes are greatly outweighed by the immunological benefits that accompany antiretroviral therapy.5 Contraceptive options should be minimally affected by a woman’s HIV status; the principal exceptions to this choice are intrauterine device and surgical sterilisation, both of which might be considered with caution in women with advanced HIV disease.6 Furthermore, the potential teratogenicity of the non-nucleoside reversetranscriptase inhibitor, efavirenz, means that effective contraception is strongly recommended for women taking this drug.7 Although there is no evidence to suggest that any contraceptive method reduces the efficacy of HIV therapies, oestrogen-containing contraceptives (including combined oral contraceptives and www.thelancet.com Vol 366 August 27, 2005