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Wei Jiang, M.D.

Associate Professor

Internal Medicine / Psychiatry & Behavioral Sciences

October 31, 2008

One World, One Aim:

Promote Mental Health post

Catastrophic Disasters____Experience of the Duke Voluntary Medical

Team to the 5.12 Earthquake Zone in Sichuan, China

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Objectives

Brief review of the 5.12 Earthquake and

the physical consequences of the quake

Recount the experience of the Duke

Voluntary Medical Team serving thevictims of the earthquake

Discussion of rules of international aid inpromoting post disaster mental health

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Sichuan Province, China The

Heaven of the Country

Beautiful Mountain Scenery,Natural Preservations,

Home of Giant Panda,Modern Cities,

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2:28 pm. May 12, 2008 (ChinaTime)

A 7.9 Richter Scale

Earthquake Strikes Sichuan.

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Approximately half of the

2,400 studentsin the school

were killed

during the quake

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The Premier

Comforting parent-less children

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Chinese Government Updateearly September 2008

Magnitude: 8.1 Richter scale

Casualties: 79,800Missing individuals: 17,300

Displaced population:10 million

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Psychological Impact of Mass Disaster

The WHO estimates:

after disaster, the prevalent rate of mild-to-moderate and severe mental disorders areliable to increase to 20%, and 3-4%

respectively, among the affected population The rates are higher in population affected

by mass disaster; 30-50% of 2004 Asia

Tsunami were thought to suffer moderate-to-severe emotional distress

Davidson & McFarlane J Clin Psychiatry 2006;67

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Psychological Impact of Mass Disaster

Common psychosomatic problems post disaster:

Acute stress reaction

PTSD and subclinical PTSD symptoms

Depression

Anxiety

Various somatic symptoms

If the post traumatic mental disorders are not managedappropriately, they may last for the rest of the life in

many sufferers and adversely effect their physicalconditions and shorten their life expectancies

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Psychiatric Service in China

only 17,000 certified psychiatrists;

approximate 1/10 of psychiatrists to

patients ratio in developed country

They are located in psychiatric facilitiesand a few tertiary hospitals in large cities

No community based psychological /psychiatric care prior to the quake

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Sichuan is the largest province in China

with a population surpass 100 million 40,000 to 50,000 severely mental ill

patients in Sichuan who were not under

psychiatric care 3 months post quake

Quickly trained volunteers provided

psychological counseling for certain quakevictims

Psychiatric Service in China

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Forming a Medical Team to Help Out

To mainly provide psycho-psychiatric

treatment to survivors of the earthquake To provide professional assistance to local

health providers in caring for quake survivors

To understand the infrastructure of post-quake mental health rehabilitation and

acceptance of victims to mental health

service

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Because mental health being provided by

International aids is constrained by languagebarriers, members of the Duke team are all

Chinese speaking and knowing local culture

Green lights given by the Chinese Embassy inUS, Local Chinese governments of Sichuan

province, and the Ministry of Health Department

of China

Warm welcome and eager expectation sent from

Huaxi Hospital where we are assigned to work

Forming a Medical Team to Help Out

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The Journey of the Duke Team

Aug 23-24 RDU to Beijing to Chengdu

Aug 25-27 Inpatient service in Huaxi hospital

Aug 28 Bailing Town refugee camp

Aug 29-31 Red & White Town refugee camp

Sept 1 An Xian refugee camp

Sept 2 Preparation for training and lecture on inpatient

service

Sept 3-4 Training local and remote mental health providers

Sept 5 Rehabilitation center & ICU for severely injuredvictims

Sept 6 to Beijing; meetings

Sept 7 Meetings; then return to USA

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Hiking into the small village__Wu Gui Ping Village

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The Damage is Devastatingand the Victims are Resilient

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Psychosomatic Symptomsare Common

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Based on our observation, at least 50% of those

victims experience post disaster psychosomatic

symptoms and would benefit from psychologicaland/or psychiatric interventions.

Symptomatology wise, we observed mainly

various spectrums of anxiety symptoms andpsychosomatic manifestations are most

prevalent.

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Highly Skilled Experts but Too Few

to Meet the Needs of Numerous

Victims

Psych-psychiatric Intervention isWell Accepted by Local Victims as

Far as the Term of Psychiatry is

not Used

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How may International Aids Help on

Promoting Post Disaster MentalHealth in a Foreign Country?

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Differ from post disaster surgical intervention orinfectious disease control, mental health

rehabilitation post disaster is much more

complex

It requires involvement of many aspects such as

governmental support, financial resource, social-environmental conditions, and preference and/or

acceptance of victims, etc.

It therefore particularly requires verbalcommunication and understanding of local culture.

However, in reality, very limited number of trained mental

health providers is able to master the foreign languageand familiar with local culture.

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Despite we speak Chinese and know

local culture, to reach our goals, we needto:

Ascertain Effective Communication

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We were assigned to Huaxi Hospital, thebiggest hospital in Asia (>4,000 inpatient beds).

People we were going to collaborate with didnot know us, neither did we know them.

Although we were eager to help, our

presentation could be perceived as a burden andintrusion, especially in situation that the localhealth providers had been working very hard

since the quake and exhausted. To have to takeus in while not knowing how well we are, itsstressful.

Our Effective Tactics

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Be respectful, rather than suspicious

Be open-minded, politely requesting, rather than

veiled, impudently demanding

Be a team player do whatever its needed,

rather than a leader direct on others Be considering, validating, flexible,

accommodating, and perseverant

Be an active player and take initiatives

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Services provided by International teams in thequake zone thus far focused on trainings of promotingmental health rehabilitation.

Along with the progress of time and conditions, theneed for face-to-face supervision on difficult cases andconsultation and assistance on psychological processing

of the health providers become pressing.In an environment where mental health had not

been appreciated for years, dissemination and

penetration of it becomes more challengingAs a consequence, the demand for language

proficiency and communicating skills become evenstronger.

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Few teams have the luxury of

possessing all features, therefore:

Teaming up with Various Areas of

Expertise

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You are the best!

Aftermath Comments

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The importance of ensuring provision of

mental health to victims of disaster is todaylargely accepted

But implementation has been difficult in

many nations, including China

The pyramidal Effort of the MissionThe pyramidal Effort of the Mission

Th L th I tTh L th I t

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Care for single patientCare for single patient

Care for patients with local medical teamCare for patients with local medical team

Enhancing capabil ity of local medical professionalsEnhancing capability of local medical professionals

Establish communityEstablish community--based care systembased care system

Improvement / modification of infrastructures of the care systemImprovement / modification of infrastructures of the care system

The Larger the Impact,The Larger the Impact,the Heavier Work Load, and the Greater Challengethe Heavier Work Load, and the Greater Challenge

Aftermath Comments

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Provision of mental health post catastrophicdisaster is a long process which may last for

several years. Therefore, enormous challengescontinue in maintaining the provision.

International aids tend to flush in soon after

the disaster, then die down; rescue resourcesdeplete; and personnel fatigue.

N tt h biti i t ti l

Aftermath Comments

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No matter how ambitious an international

aid wishes to accomplish toward provision of

mental health service post disaster, what anindividual aid may offer solely may be quite

limited.

Nevertheless, the effort of organizingsuch an aid to travel to a foreign country is

tremendous and may overweigh the amount

of service the aid actually provide.

Aftermath Comments

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Therefore, international consortiashould be ideal in order to elicit and

mobilize expertise and financial resources.

By working together with centralized

coordination at a national or global level,the country suffers from a catastrophicdisaster, and consequently the world,

would have a better handle on disastermental health.

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G t f l

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Gratefulness

to the Victims

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Thank You