Foreword. After the tsunami: mental health challenges to the community for today and tomorrow.

From the Department of Psychiatry and Behavioral Science, Duke University Medical Center, Durham, N.C. Presented at the symposium “After the Tsunami: Mental Health Challenges to the Community for Today and Tomorrow,” which was held February 2–3, 2005, in Bangkok, Thailand, and supported by an educational grant from Pfizer Inc. Corresponding author and reprints: Jonathan R. T. Davidson, M.D., Director, Anxiety and Traumatic Stress Program, Department of Psychiatry and Behavioral Science, Duke University Medical Center, Durham, NC 27710 (e-mail: [email protected]). n December 26, 2004, a powerful earthquake rocked the ocean floor off the coast of northern Indonesia, O abruptly displacing a 15,600 square mile area of the floor some 50 to 70 feet upward. The earthquake, measuring 9.0 on the Richter scale, triggered a massive tsunami that propagated across the ocean’s surface at speeds of up to 500 mph, reaching the nearest shores in a matter of minutes and arriving up to 8 hours later at coastlines some 4,000 miles distant from the epicenter. Devastation was massive as waves measuring 10 to 40 feet in height enveloped shores and surged up beaches, leveling vegetation, buildings, and entire villages before receding back into the ocean. In the minutes, hours, and days after it struck, the tsunami caused more casualties than any other in recorded history, killing over 280,000 people in Indonesia, Thailand, Malaysia, Myanmar, India, Sri Lanka, and many other countries located on the rim of the Indian Ocean and the Bay of Bengal. Notable for its scale of devastation, for the sheer numbers of people caught up in the resulting chaos, and for the global humanitarian response that followed, the Asian tsunami is an extreme example of disaster. During the days and weeks following the tsunami, the intensive global media coverage vividly documented the physical consequences of the tsunami’s destructive power. From the air, we saw turbulent, sullied shorelines, aerial views of entire villages leveled, and acres of bare land stripped of vegetation. At eye level, close-ups of bloated and twisted corpses trapped among the debris fought for new airtime with images of bulletin boards of missing persons and makeshift morgues. News reports of the harried and urgent activities of medical teams, morgue workers, and relief operators reinforced the world’s perception of the physical costs of the tsunami and society’s best efforts to address them. By comparison, the psychological and psychosocial effects of the tsunami went relatively unnoticed. Identifying these effects presents a far more subtle challenge, but one that must be met if their long-term consequences are to be adequately recognized and mitigated. Thus, in the postdisaster setting, comprehensive programs of recovery and rehabilitation need to address such difficult questions as How has the tsunami affected the mental health of survivors? What psychiatric and psychosocial resources are available? How should they best be used? What are the ongoing needs of affected communities? Who is especially vulnerable? and What needs to be done in the future by way of disaster planning and mitigation for mental health? Acknowledging the dreadful devastation inflicted by the Asian tsunami, this disaster nevertheless presents an opportunity to characterize the destructiveness of mass trauma for individuals and societies not as a function of the physical consequences but as a function of the psychosocial effects. If left unchecked, the social scars and instability that are inevitable outcomes of disaster have the potential to cause a human toll that is in many ways more substantial than the physical disfigurement that is apparent to all. Long after the dead have been buried, villages and towns rebuilt, and infrastructure replaced, psychiatric distress and psychopathologies developed as a consequence of initial exposure and loss, and exacerbated through everyday stressors encountered in the postdisaster environment, have the potential to reduce quality of life and unnecessarily prolong human suffering with a resultant delay in community recovery.