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It is three months since Black Sunday and the post disaster rehabilitation efforts in India have entered the phase of reconstruction. The relief phase seems to be over with the departure of the media circus and many NGOs (Non Government Organizations), although the slow pace of rehabilitation and realization that recovery is still a long way off, for most, is only now slowly seeping in.
Over 12,000 people lost their lives in India, the Nagapattinam district in Tamil Nadu being the worst hit, as over 6,000 lives were lost, 2,000 of who perished in the pilgrim town of Vellankani alone. Pilgrims from all over had attended Sunday mass in the Vellankani Shrine Cathedral on the morning of the 26th and were strolling on the beach when the tsunami struck. Many others lost their lives while attending the fish markets operating along the coast where fishermen had set up shop on the beaches with their fresh morning catch.
Devastation spread inland for 2 kilometres from the coast, however the bizarre and contrasting after-effects of the disaster, can only be seen when one drives down this coast observing the normal lives of people who are living in those relatively unscathed coastal towns that line the highway, to the devastation and misery that is still apparent in the fishing villages and hamlets which dot the entire coastline.
Unlike the west coast of India where the continental shelf stretches many kilometres and thrives on a fishing industry based on trawling; the east coast has a shelf of only four to five kilometres, where fishing communities living in village settlements have for centuries made their livelihood from fishing out in the open sea, in boats that can basically be described as primitive catamarans constructed of 4-5 logs tied together with rope. Their villages now in ruins, surviving inhabitants must live in shelters which have been erected by the Government and NGOs for the next eight to twelve months, as plans are debated over community welfare and safety issues which must be taken into account in the construction of new homes around the coastline. Driven by fear of a repeat disaster, the distance planned for permanent resettlement was initially three kilometres from the coastline, however current considerations of construction within 500 metres from the beach is a matter of fierce debate.
The inherent problems of delaying reconstruction as refugees await resettlement include higher risk of epidemics and prolonged psychological and physical distress, as temperatures reach 40 degrees Celsius in one of the hottest periods this part of India has experienced in many decades.
In the initial aftermath of the tsunami, there was widespread distress and acute stress reactions. Virtually everyone we met two weeks after the disaster reported that they were unable to sleep at night and reported waking up with images of towering waves crashing down on them. Reliving the sensation of being hurtled through the air by the rushing waters and the sound made by the tsunami - a high-pitched whine likened by some to a speed boat, and by others to the sound made by a helicopter. That, mixed with the cries for help from children and loved ones, was also re-experienced, filling them with dread. For many these latter cries signified the restless souls of the many dead who were buried in mass graves nearby and many feared to sleep in the villages preferring the cramped and hot conditions of the shelters.
Although the psychological distress has started to subside and the normal grief period is still being experienced by those who lost loved ones and life possessions, people as a whole, appear to be making a slow recovery. Rituals and funeral rites have always been a way for people in these parts to deal with death of loved ones and these are traditionally helped in community mourning by the process of aid, confronting grief and loss, and eventual realization and acceptance of limits to the grieving process. Financial hardship has limited the extent to which these rituals can be held, but they continue to serve as important signposts of loss and reconciliation.
Survivor guilt was very evident in the initial weeks with many survivors expressing guilt and anguish at physically having let go the hands of children, parents and loved ones. One woman had given strict instructions to her oldest daughter to look after her two toddler siblings while the mother went to buy fish from the fresh catch of the day. To this day, she rues her instructions as her obedient daughter refused offers of help from neighbours as the waters surged into the village and all three children drowned. Grief for people like this mother is intense indeed, though we do feel that repeated sessions of empathetic listening and practical help provided to her will enable her to eventually pick up the pieces of her shattered life.
Subsequent teams that we have sent to the area over the past two months report that post-traumatic stress disorder (PTSD) does not appear to be a widespread problem among adults at present, though there are occasionally people who have been traumatized by the search for and burial of bodies, unable to sleep due to visions of the many dead and mutilated bodies that they helped to bury. One man we saw had buried 150 bodies by himself, the images of which replay constantly in a loop effect, causing great distress. Other men we met have resorted to alcohol to quell these troublesome images.
Children were the largest group of victims of the tsunami, along with women, the elderly and the disabled. For parents who lost children, reactions are varied. Those who had many children are less inconsolable than those who had few. Some mothers rue the day they listened to government family planning programmes and had accepted sterilization. Some men talk about re-marrying in order to find fertile women who can bear them more children, often referring to lost sons. For children who survived, schools have reopened and the resilience of children is apparent in noisy classrooms and smiling faces. Many still draw pictures of the tsunami when asked to do so, though one sometimes wonders whether this is what they have come to expect visitors like to see, rather than an attempt at catharsis; a bit of both, I suspect. Rumours still abound of earthquakes and impending tsunamis and there has been the odd stampede, occasioned by newspaper reports of earthquakes in the area, but this apprehension is also slowly settling down.
The Government response at the outset was swift and efficient. Each person was provided money and dry rations as well as utensils to cook food in. Three months on, relief rations are sometimes in short supply, however NGO’s are stepping in to fill the gaps in Government relief.
The present problem is lack of livelihood for most, as the fishermen’s associations haggle with the Government on the proportion of subsidy and loans to buy or repair boats and nets. The fishing association had initially resolved not to resume fishing for three months or until the Government aid to repair/buy boats and nets had reached everyone. This impasse was still unresolved at the time of writing in March, though it was hoped that it would be resolved in the following weeks. As it is likely to be a while before fishermen get their boats back, especially the bigger fibre reinforced boats and large trawlers and the process of getting back to work is still distant for many. It should take less time to provide catamarans and nets for immediate use and we are arranging with the village leaders of the smaller hamlets and the more isolated villages, who are less likely to be visited by NGOs or the media, to permit us to provide them with catamarans and nets to be operated as a community venture with shared ownership and pooling of the income from the catch to provide for widows, or those unable to fish for themselves.
The health problems at present are outbreaks of diarrhoeal diseases, cases of measles among young children, a few cases of jaundice among adults in each of the camps, possibly Hepatitis E, febrile illness and respiratory infections, especially in children. No deaths have been reported due to any of these from the camps. I am aware of four suicides possibly linked to the tsunami in the first month, but none since. There has been a worrying increase in alcohol consumption among the fishermen who are idle the whole day; they already had a high consumption of alcohol but this has increased significantly since the tsunami. The risk of increased STD and HIV are unknown at present; in disasters elsewhere, like after the super-cyclone in Orissa, this was an issue, but we are unsure whether this will pose a problem here.
There was a mass immunization against tetanus immediately after the tsunami which seemed like overkill at the time but, mercifully, no cases of tetanus have been reported. Wound infections have not been a major problem. These areas are not endemic for malaria or dengue although the situation is different in the Andamans and Nicobar islands.
The other problems are heat and sanitation in the camps. The drinking water comes from bore wells and in summer water is often a problem. A recent survey revealed that in some camps there is a potential for contamination of drinking water supplies by newly laid sewage lines. The shelters have tin roofs and the heat in some of them has been recorded to already be in the range of 38-40 degrees C. People are laying plastic sheets over the tin roofs since the locally used thatch is considered a fire hazard, but summer still promises to be hell.
The challenges facing us are numerous. There is an urgent need to speedily facilitate the resumption of fishing so that livelihoods can be reclaimed. For those farmers whose lands have been rendered unfit for cultivation due to salination, compensation and alternative livelihoods need to be considered. Methods to ensure better sanitation and clean drinking water to prevent waterborne diseases are necessary. One local NGO has successfully implemented a de-salination plant in one village and if this works over the long term, other such projects could be implemented. We need to provide wider immunization for children against measles and hepatitis. The Government is gearing up to tackle this. There is also a need to continue with the provision of dry rations to help families tide over the shortage of income until fishing or other means of resuming their livelihoods is returned to normal. Many NGOs have stepped in to support this and the Government is also making attempts to ensure that all compensation claims are honoured.
Finally we need to continue surveillance of vulnerable people over the coming months in order to pick up pathological grief states and identify those who are not showing signs of recovery from grief or those who develop PTSD. The overall goal has been to provide immediate psychosocial support, identify those most affected by the tsunami and who are therefore most vulnerable to psychological distress and morbidity, identify and train community level volunteers to provide these services in the long term and to strengthen existing health services to include provision of psychosocial care to those who need these services. To this end, a list has been prepared and sent to all Public Health Centres, of those at potentially high risk for psychological distress and suicide. Those include people who;
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have suffered multiple deaths in the family
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have lost a spouse
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have lost a child under the age of 20 years
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have lost their homes
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have reported loved ones as missing
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have previous mental disorder
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show symptoms of excessive grief or post traumatic stress or substance dependence
The methods of obtaining this information have been from Government records of compensation claims, from Primary Health Centre nurses who have been trained to recognise abnormal from normal responses, from asking residents of villages for symptoms of excessive distress in others in their area, and from community level and NGO volunteers.
There have been sporadic attempts at identifying and providing alternate sources of employment while normal sources of occupation are reclaimed. The men are unlikely to get involved in this enterprise as they are traditionally, and continue to be, averse to doing any work other than fishing, tending to their nets and their boats. The women are keen to get any sort of employment to supplement their income. However, in the remote villages that many of them live, alternate sources of employment are few. In some villages we have had limited success in finding alternative sources of income generation, although in one, a cooperative has been established among a group of women who have been provided sewing machines. These women will in turn teach other women how to use these machines gainfully. Similar efforts are underway in other villages but ultimately, these are fishing communities and unless they can return to commercial fishing, it promises to be a long, hot, summer and a longer road to recovery.
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