The medium and long-term health impact of disasters

This advisory report addresses two questions placed before the Health Council of the Netherlands by the Secretary of State for Health and Welfare:

1. What is known about the prevention, diagnosis, progress and mid-to-long term prognosis of health problems further to a disaster? 
2. What is known about the effectiveness (in terms of both response and long-term efficacy) of professional healthcare and counselling services following a disaster?

In producing this report, the Commission has chosen to observe the legal definition of a disaster, viz. “an event which leads to the disruption of normal societal interaction on such a scale that coordinated government interventions become necessary”. This report is exploratory in nature; it is not to be regarded as a ‘manual’ setting out how the government should act following a disaster. The motive behind the State Secretary’s questions is that the government wishes to be sufficiently well informed to be able to implement a policy which will help to reduce the health problems experienced by victims.

While the problems experienced by disaster victims used to be regarded as an inevitable ‘fact of life’, they are now interpreted in their medical and psychological context. Recent years have seen a significant shift in thinking with regard to disasters and the victims of those disasters. In the past, the problems experienced by victims were largely seen as an inevitable ‘fact of life’, which should be accepted as such. Today, those problems are recognized as being medical and/or psychological in nature. Moreover, public sympathy for the victims of disasters has increased, as has attention for the necessity of coming to terms with the consequences of a serious incident, a process which may indeed require some assistance. These societal and sociological aspects must be taken into account when determining disaster response policy.

Disasters can cause well-documented physical and psychological complaints, as well as medically unexplained physical symptoms. The victim of a disaster can suffer direct physical injury, infection, radiation poisoning or other toxicological effects. There may also be psychological complaints caused by the shock of the disaster or its aftermath. In addition, a disaster is followed by an increase in the number of medically unexplained physical symptoms, being those with a physical manifestation but no clear physiological cause. The symptoms displayed may include persistent headaches, fatigue, stomach complaints and muscular pain. These form an important category of post-disaster ailments, and one on which the scientific world has yet to reach any consensus. Moreover, the domain of medically unexplained physical symptoms has yet to be clearly defined.

The physical damage caused by a disaster can take many forms. The nature of the immediate adverse impact on a disaster victim’s physical health is closely related to the nature of the disaster itself. There may be burns, damage to the airways due to the inhalation of smoke or other hazardous substances (‘inhalation trauma’), fractures, and symptoms caused by infection, radiation or intoxication. Generally, the treatment of this immediate physical damage is the first aspect to receive attention following a disaster. Some people may suffer serious physical disfigurement, which can also have far-reaching psychosocial implications.

The most common long-term reactions to a disaster are anxiety disorders, depression, ‘persistent recollection’, substance abuse and medically unexplained physical symptoms. Estimates of the prevalence of these reactions vary widely. In western countries, some 20% to 50% of disaster victims are thought to suffer one or more such effects. However, this is not to say that any increase in the psychological disorders which fall into the recognized classifications (depression, anxiety, post-traumatic stress syndrome, addiction) has been observed, although such an increase has been noted in certain groups. They include the mothers of young children, evacuees, migrants, people with a prior history of psychological or psychiatric problems, and adolescents.

There is no clear link between the nature of psychological or medically unexplained physical symptoms and the nature or cause of the disaster. In western countries, disasters which are caused by human commission or omission seem to give rise to greater negative health impact than natural disasters. There are no indications that certain types of disaster are more often responsible for some syndromes of physical complaints than for others.

Most victims succeed in regaining their emotional balance without professional assistance. Direct involvement in a disaster makes substantial claims on a person’s adaptability and resilience. People vary greatly in terms of the way in which they will respond to a disaster. Many will suffer stress – sometimes extreme – during both the disaster itself and its immediate aftermath. This may be regarded as a normal reaction to an abnormal situation. In many cases, any resultant health problems will be temporary in nature. Most people are indeed very resilient and will ‘bounce back’ within a reasonably short period.

Most people regain their emotional balance within eighteen months, but some experience health complaints of a more long-term nature. In general, health problems are most acute in the period immediately following the disaster. Other than actual physical incapacity, these problems usually subside within eighteen months. However, in 20% to 25% of victims, the complaints will persist for many years, and in some cases longer than ten years. These victims suffer serious long-term problems. The more serious the complaint in the short term, the greater the likelihood that it will persist beyond the usual recovery time.

The etiology of psychological and medically unexplained physical symptoms is determined by multiple factors. The factors which influence the emergence and persistence of psychological and medically unexplained physical symptoms can be classified into three groups. There are the ‘predisposing’ factors (i.e. the differences in personal susceptibility to psychological imbalance), the precipitating factors (external circumstances which prompt the emergence of health complaints in susceptible persons) and the ‘perpetuating’ factors (those which cause the complaint to persist and stand in the way of recovery).
Significant predisposing factors include a history of psychological imbalance (depression, anxiety disorder, post-traumatic stress syndrome), lower socio-economic status, and the lack of an adequate social network.
The most significant precipitating factor is likely to be the sudden and inescapable nature of the disaster, and its immediate effects in terms of injury, perceived danger to life, uncertainty regarding the fate of loved ones, and the loss of one’s home and property.
Perpetuating factors are linked to the nature of the disaster, the nature of the person concerned and the social and societal setting. One disaster-related maintenance factor is long-term evacuation, while personal factors which stand in the way of prompt recovery include low self-esteem and ineffective coping strategies, such as a tendency to ignore problems or to blame others. Other maintenance factors include involvement in long and complicated compensation claims, belief in conspiracy theories, and feelings of anger or suspicion directed towards the government. Societal factors which promote recovery include attention, acknowledgement and respect, adequate financial support and prompt reconstruction and repair of the physical damage caused by the disaster.

There is no evidence to support a causal link between media coverage of a disaster and health complaints, and such evidence is unlikely to be forthcoming given the difficulty of researching such a relationship. The media can play a significant positive role in providing information about the effects of a disaster. Nevertheless, it is not unreasonable to assume that media coverage which speculates on the causes of post-disaster health complaints is likely to extend the period in which those complaints are experienced. The Commission dismisses the contention that a disaster will always and inevitably give rise to long-term psychological or psychiatric complaints as ungrounded.

Good organization and quality of disaster management procedures is also important from the perspective of preventive healthcare. The manner in which rescue efforts and victim support services are organized in the acute phase of the disaster will do much to determine the extent of health effects in the middle to long term. There is also a direct proportional relationship between the number of fatalities caused by the disaster and the extent of psychopathological symptoms exhibited by the survivors. The sooner the survivors know exactly where they stand, and the sooner their safety is assured, the less significant the likelihood of long-term negative health impact will be.
The preventive effect of early psychological interventions has not been subject to adequate research, but it is clear that a single debriefing session has no preventive value. Interventions during the acute phase of a disaster are intended to reduce stress-related complaints and to minimize the likelihood of the victim developing post-traumatic stress syndrome. It is clear that a single ‘debriefing’ session, at which victims are encouraged to talk at length about the disaster and its emotional consequences, is not effective and may even be detrimental. This prompts the Commission to advise against the use of single debriefings, and to advise caution in the use of other interventions of a debriefing-like nature. There is little or no thorough research into the preventive effect of interventions other than debriefing during the acute phase.

The emphasis of psychosocial services immediately after a disaster should be on the promotion of natural recovery and self-sufficiency. The lack of evidence to support the effectiveness of interventions in the acute phase does not mean that no psychosocial care should be offered. The profession endorses the view that prompt and proper assistance can promote natural recovery and self-sufficiency, and hence safeguard the longer-term health of the victim. This can best be achieved by directly addressing the immediate needs of the person concerned, in the practical, social and emotional areas. In practice, this will entail offering a ‘listening ear’, helping to reunite victims with their loved ones, helping to resolve practical problems, and informing victims of the potential effects of the incident on their general health and well-being. First-line relief workers should also be able to identify those victims who require further therapeutic treatment, and must ensure that such treatment is available.

Prompt and adequate information can help victims to regain control of their lives. It is essential that the government, as the party responsible for information provision and risk communication following a disaster, is fully aware that creating any (further) uncertainty could seriously exacerbate the problems faced by the victims. Uncertainty with regard to one’s exposure to hazardous substances, for example, will lead to fear and anxiety, and provides a fertile breeding ground for rumour and speculation. Uncertainty, anxiety and speculation may cause and maintain psychological and medically unexplained physical symptoms. The government can avoid this by conducting its communication with the public openly and honestly from the very outset, even where some aspects are still not fully clear.

Effective treatments exist for depression, anxiety and post-traumatic stress syndrome. Although little research has been conducted into the treatment of these disorders in the context of a disaster, substantial research has indeed been conducted in other contexts. The Commission is of the opinion that the existing treatments are likely to be just as effective in the disaster context as in any other. Guidelines and protocols now exist for the treatment of depression, anxiety disorders and PTSD. As yet, there are no guidelines covering the treatment of medically unexplained physical symptoms.
The Commission recommends that the current policy with regard to aftercare services following a disaster should be continued. At present, the main features of this policy are integrated psychosocial assistance, an Information and Advice Centre (IAC) function, health research and monitoring, and the national centres of expertise: ‘Impact’ and the Centre for Health Impact Assessment of Disasters (CGOR). While there is insufficient hard evidence that this aftercare policy has helped to prevent health complaints in the medium to long term, the Commission nevertheless recommends that it should be continued since its value is supported by the scientific results achieved thus far.
Disaster victims often experience a multitude of (interrelated) problems, including those of housing, work, financial concerns, problems in the private sphere, and health complaints. It is therefore preferable to offer assistance in an integrated form. An Information and Advice Centre is well placed to mediate between the people with problems and questions on the one hand, and the social welfare and relief organizations on the other.
The IAC function is temporary in nature. Because it is difficult to predict how the requirement for information and advice will develop, it is necessary to establish suitable evaluation moments at the outset. It is also important to ensure that downsizing is possible when appropriate.
In order to conduct effective health research among disaster victims, there must be a system whereby the victims (direct and indirect) can be monitored on an ongoing basis. However, this type of research has certain drawbacks. Both clinical experience and research results to date suggest that it can increase the individual’s concerns about his or her health. This is a reason for exercising additional care when using this approach.

In the case of a disaster of such impact that the regular channels cannot cope, even with additional support, it is recommended that specific disaster-related assistance services other than the IAC should be implemented. The nature of the likely problems and health complaints caused by involvement in a disaster do not themselves call for specific disaster-related assistance, but the scope and extent of the assistance requirement may render it necessary to set up temporary teams or institutions. The exact period during which these bodies are active will depend on the nature and extent of the assistance requirement. The comments made regarding the flexibility of the IAC and the period in which it operates therefore apply here too.