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by Nick Stockton

LESS THAN A month ago, the world fell down on Nepal. Soon after, thousands of aid workers descended to help pick up the pieces. And then, a week ago, the world fell down again. “When the second earthquake happened, people everywhere were saying the death prayer. There was a lot of screaming,” says Cindy Stein, who was working at a hospital in Kathmandu.

Stein’s organization, Real Medicine Foundation, came in to offer traditional relief—food, water, shelter, medicine. But it also delivered an often-overlooked component of disaster recovery: care for psychological trauma, in addition to the physical. Stein has no doubt that Nepal’s double tap earthquakes will leave a mark on the mental health of everyone who experienced them.

Everybody expects that survivors will be traumatized by a disaster. But few relief groups specifically address the mental toll of disasters—both natural and man-made. That’s because mental wounds are, in many ways, more difficult to treat than physical ones: They can’t be set right like broken bones, they can’t be inoculated with shots, and they can only be numbed for so long with pills. This makes mental care hard to plan for and hard to raise money for, because its indefinite successes and indeterminate timetables aren’t as appealing to the donors that fund disaster response.

It’s crucial, though, to address survivors’ mental health early and often. These people may not carry their wounds physically at first, but the problems do eventually manifest. If stress goes untreated, it can sabotage short term gains by letting PTSD, anxiety, and depression fester. And those can lead to more tangible threats, like diabetes, hypertension, and stroke.

“Mentally traumatized people have shorter, more sickly lives,” says Richard Mollica, director of the Harvard Center for Refugee Trauma, and a pioneer in bringing attention to the mental care of people who have lived through mass violence, civil war, torture, and natural disasters. “You may not die at first, but you will die 20 years after a catastrophe from diabetes and stroke.”

Disaster relief has been part of the American story since the early 1880s, when the American Red Cross cut its teeth helping the 14,000-some people displaced by Michigan’s Great Thumb Fire. In the 1920s, when shell shocked WWI veterans returned to the United States, they woke the public up to the invisible effects of war and disaster. But the disaster response community has focused its efforts on the logistics of food-water-shelter-medicine impact, without giving much attention to psychological trauma.

“A lot of people think mental health is a luxury add-on,” says Steven Reisner, a psychologist who focuses on post disaster mental health at NYU School of Medicine and Columbia University Teachers College. Only in the early 1980s did disaster response start to consider the fact that traumatic events can have lasting mental health consequences.

But even now, psychological disaster relief is mostly tokenism. The problem, says Mollica, is that relief groups tend to go into a disaster with a silver bullet mentality: “You give a shot, people get better.” But mental health can’t be treated this way (for that matter, neither can physical health). For one thing, treating mental health problems is harder than treating things that can be fixed with bandages, splints, scalpels, pills, stitches, and syringes. And because mental health is much less quantifiable than physical ailments, funding for mental aid can be more difficult to come by. “Donors love those sexy things like number of vaccines given, mouths fed, lives saved,” says Reisner.

Those problems are compounded because disaster relief groups often approach mental health care as separate from main humanitarian work. But Martina Fuchs, Cindy Stein’s boss at Real Medicine Foundation, says mental care can be given alongside basic medical care. “Mental health people have to be co-located with the medical people,” says Mollica. “They have to go in together as teams and sit in the same jeep, work in the same tent, be on the same issues from day one.”

That can be easier to do than it seems. “From what I have seen, it just takes a willingness to listen and acknowledge,” says Fuchs. This can come from nurses as they give vaccines, doctors who ask the community how they feel about the aid, or deploying psychologists along with normal aid.

“In Sri Lanka, after the tsunami, we did a very brief intervention where we just listened to people tell their stories,” says Fuchs. “We had mothers who had to make a Sophie’s Choice, letting go of one child to save another. That allowed them to cry for the first time.” These small releases can be important, because they build mental health into a response program, rather than making it a big challenge to be overcome on its own.

In Nepal, Stein starts every aid effort by holding town hall-style meetings, giving communities a role in their own recovery. Reestablishing a sense of livelihood in people is one of the most important first steps to take after a tragedy, says Mollica, and including them in aid efforts is a perfect way to do this.

The cultural consequences of trauma have been well documented. Psychological studies of Cambodia after the Khmer Rouge shows how the society has been scarred with high rates of PTSD, depression, and other mental diseases. “The entire society becomes traumatized,” says Stein.

These mental health crises continue long after the disaster has been washed out of the news cycle. “In Nepal, the mental health crisis will be two years from now,” says Mollica. And it will last into generations that come after the earthquakes. Mollica has seen the long-term effects of mismanaged Haitian relief efforts. “You see mentally ill people in chains, living in tents, after $8 billion. Haiti is a disgrace,” he says.

To stave off this crisis, relief organizations will do their best to include the Nepalese in their relief efforts, and to keep compassion in mind in the logistical rush. And Nepal could be the best possible place to experiment with this new model of disaster relief. In her community meetings, Stein says she’s seen a hunger from people for lifestyle improvements that will help change the long-term health trajectory in the region. Women have asked for more established health care systems, farmers want irrigation, and parents need education opportunities for their children. “Despite all that’s bad,” she says, “they have the self-awareness to say this is an opportunity to fix the things that were wrong with our country.” Perhaps the right aid can replace the fear and insecurity that comes after a disaster with confidence in the future.

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