Healing hurt minds and hearts
Care during natural disasters includes empathy
Dr N.N. Wig

THE recent devastating earthquake in Gujarat has shaken the whole country. Seeing heart-rending pictures on the TV or reading stories in the press, one is left numb with shock and grief for the victims. Thousands have perished in this calamity. Hundreds of thousands others, who have survived, are struggling to restart their lives again. Many have lost their close relatives, their houses and their belongings. Many of them have been seriously injured.

How does one begin life again in these circumstances? How to cope with such a terrible situation? Numerous help-giving agencies, both governmental and non-governmental, have reached Gujarat to provide help. After the initial rescue work is over, the main concern is how to help the survivors in rehabilitation. Food, clothing and shelter are perhaps the first priorities. The medical teams are concerned with saving as many lives as possible and then repairing the broken limbs and other injuries. Efforts are on to avoid large-scale epidemics due to polluted water and food. In these circumstances, one medical aspect which is often forgotten is the mental health-care of the survivors.

Broken houses and broken limbs are easy to see but broken hearts and broken minds are not so visible and therefore these are easily forgotten. But the tragedy of mental health sufferers is as real as that of those with bodily injuries. Sometimes people argue that psychological reactions are "normal" in a catastrophe. But then, bruises, injuries and fractures are also in a way "normal" when a building falls on someone. We do take care of physical injuries. In the same way we have to take care of emotional injuries.

Psychological symptoms are very common among the survivors. Fortunately, in most of them they are transitory and settle down in a few days. However, in 15 to 20 per cent of the population, the symptoms are serious and last for a long time, disrupting life's routine and causing considerable suffering.

1. The immediate reaction to disaster: Such psychological reactions are most disturbing. One has suffered physical injuries, got exposed to extreme danger, witnessed death of dear and near ones, or seen mass deaths and destruction. During a disaster one experiences, the feeling of helplessness. There is often the feeling of guilt associated with the conflict of saving oneself or saving others. Maladaptive psychological reactions during a disaster include paralysing anxiety, uncontrolled flight reaction and group panic. For example, in the Gujarat earthquake, the fear of another earthquake was so powerful and common that a large number of people slept outside in the open for many days.

2. Emotional reaction after the "event": Different emotional reactions may occur after a disaster. In the beginning, many people feel numb. Some may even feel elated or relieved that they have been saved but soon the enormity of the tragedy becomes obvious. The effects of mental stress start showing. Post-disaster reactions include an intense feeling of anxiety, accompanied by "flashbacks" or frightening memories of painful experience. Nightmares are usual in which the person wakes up with a frightening dream and the feeling of panic. The suffering individual remains tense all the time, fearful that something terrible may happen again. He or she tries to avoid any reference to the events of disaster. Other common symptoms are the loss of sleep, poor appetite and social withdrawal. Some persons become very sad and depressed, losing interest in all activities. Various kinds of bodily symptoms also appear.

Psychological reactions after a disaster, though very troublesome, usually clear in a few weeks. However, in two types of cases the symptoms last for many months and even years. These are (a) prolonged grief reaction and depression after the death of close relatives and (b) Post-Traumatic Stresses Disorder (PTSD). In the case of PTSD, a person continues to get "flashbacks" of painful events; the mood is anxious, irritable and depressed. In addition, there may be multiple bodily symptoms like headache and giddiness. The patient complains of poor sleep, bad dreams, poor concentration and inability to work. Such symptoms can last for a long time.

The following points are important while planning mental health care during disasters:

(a) No one who passes through the experience of a disaster remains emotionally untouched by it. Disaster stress and grief reactions are normal reactions to an abnormal situation.

(b) Victims of disaster need to express their emotions. It is important that the sufferers get an opportunity to express painful feelings of grief, fear, guilt, anger, helplessness, shame, etc. The helpers must provide such emotional support both at the individual and group levels.

(c) As far as possible, mental health care should be provided through the existing helping agencies. It is better to avoid the use of mental health labels but care should be provided through the existing general health services.

(d) Mental health professionals can best help by sensitising the doctors, nurses and social workers to the mental health needs of the affected population. They can further help by training these workers in recognition and management of common mental health problems encountered during disasters. Finally, mental health professionals can help by providing direct treatment to those who are seriously affected by psychological symptoms. Such mental health services must be organised in the community close to where people live.

(e) Social and cultural support systems are crucial to the recovery and rehabilitation of those affected.

(f) The Press and television are now an important part of the disaster relief activities. It is the media which brings to attention the human side of the disaster. Unfortunately, the media often does not appreciate the psychological needs of the affected population. References to psychological symptoms when made in the Press are usually derogatory — e.g. victims acting crazy or people becoming mad or committing suicide and so on. It is important not to ridicule the mentally ill, but to understand their suffering. Mental health professionals must regularly intereact with the media to emphasise the mental health needs of the affected population during a disaster.

One feels happy to record that mental health professionals in India have responded positively to various disasters during the past 20 years. A beginning was made during the Bhopal gas tragedy in 1984. A team of mental health professionals through the Indian Council of Medical Research made some valuable studies and provided guidelines for mental health care in any future national emergencies.

Similar good work was done during the Latur earthquake in Maharashtra and the Orissa cyclone last year. The NationalInstitute of Mental Health and Neurosciences, Bangalore, has been a pioneer in organising many workshops on the subject.

According to the latest information, once again mental health professionals in Gujarat and neighbouring states are very active in organising the much needed mental health services for the victims of one of the worst earthquakes this country has seen.

Loss of sight in diabetics: hard facts 
Dr I.S. Jain

IN developed countries, diabetic retinopathy ranks number one amongst the various causes of age-related blindness like glaucoma and macular degeneration.

In India, which is a country at an interim stage of development, the blindness rate due to diabetic eye disease is on the increase because of the increase in the average span of life, better standards of living and better care of the diabetic.

To assess the magnitude of the problem, the Department of Ophthalmology at the PGI launched a project to screen the diabetic population attending the Diabetic Clinic and the Eye Out-patient Service, with the aim of knowing the prevalence rate of vision-threatening diabetic retinopathy.It was observed that retinopathy was present in 42.9% cases, out of which 15.2% cases had vision-threatening retinopathy. Our figures match closely those reported by Constable et al (1984) who found 43.4% and 13.9% respectively.

In a study conducted by our department and the Department of Endocrinology, the non-insulin dependent diabetes mellitus (NIDDM) is about 10 times more prevalent than insulin-dependent diabetes mellitus (IDDM). The knowledge of statistical data is an important element for the planning and evaluation of many activities in eye health-care for the prevention of blindness due to the disease.

Retinopathy in NIDDM cases was 16 times more prevalent than IDDM. As many as 45.5% of the IDDM cases had retinopathy and 27.3% of these had vision-threatening retinopathy. Grey et al (1986) also reported a prevalence rate of 43.4% of retinopathy, out of which 13.3% had sight-threatening retinopathy. In NIDDM 42.7% cases had retinopathy, out of which 14.4% of the cases had vision-threatening retinopathy.

The increased percentage of sight threatening cases in our series could possibly be due to their remaining undetected for long because of late ophthalmoscopic examination. It is a fact that in 75% of our cases retinopathy was diagnosed only by the ophthalmologist. Therefore, the importance of a complete ocular examination of every diabetic by the ophthalmologist cannot be overstressed.

The most important single factor in the development of retinopathy is the duration of diabetes and at present there is no way of preventing the development of retinopathy.

Non-ocular factors in the development of diabetic retinopathy include diabetic control, hypertension and renal disease. Recently, there has been a tremendous improvement in the overall prognosis of vision in diabetics by the early treatment of diabetic retinopathy by laser photocoagulation and several such studies are now available to support such an approach.

For us in India, in order to plan services for effective patient management, it is necessary to know the likely work load involved in terms of laser photocoagulation and vitreous surgery.

Both physicians and ophthalmologists should make every effort for the early detection and treatment of vision-threatening diabetic retinopathy to prevent avoidable blindness due to diabetes.

NIDDM — Non-insulin dependent diabetes mellitus

IDDM — Insulin-dependent diabetes mellitus.

Dr Jain, FRCS, DO, is Professor Emeritus at the PGI, Chandigarh, and the doyen of Indian ophthalmologists. (Telephones: 704550, Chandigarh; Panchkula: 560106 & 565629).

Q&A
Hand allergy can cause much discomfort
Dr S. Lavasa, a well-known allergologist, answers readers' questions

A Hands come in contact with countless objects and substances at home, at work and elsewhere.

A Certain plants, like primula and giant hogweed, are contact allergens.

A Detergents and alkalis affect mostly housewives and hair-dressers.

A Cromates in leather and cement cause allergy in shoemakers and bricklayers.

A Nickel affects mechanics, jewellers and those handling hardware.

A If allergy goes untreated, it becomes chronic, resulting in dehydrated, fissured and nonfunctional hands. Patch-testing is a useful method to detect allergy for the prevention of disease.

A Rubber affects tyre-workers. Clothing containing rubber and elastic bands cause allergic reactions. It hurts.

A Latex allergy is common. It affects doctors, nurses and patients because of allergy to gloves.

Getting an x-ray to uncover the source of lower back pain does not reduce suffering, researchers report. In fact, in a new study, patients who had an x-ray, or radiography, reported more pain 3 months later than those who did not have an x-ray.

"There is no evidence that having radiography helps doctors to care for people with simple back pain,’’ according to one of the study’s authors, Dr. Mike Pringle, of the School of Community Health Sciences at University Park in Nottingham, UK.

"Indeed, the evidence is that the act of having an x-ray can, perhaps by appearing to increase the perception of severity, delay recovery,’’ he told Reuters Health.

Low back pain is a common medical problem, and doctors often x-ray the lower spine to diagnose the cause of the pain. In most cases, however, x-ray results do little to change the treatment of back pain, Pringle and his colleagues note in an article in the February 17th issue of the British Medical Journal. Most of the time, x-rays are performed to reassure patients or doctors, according to the researchers.

To test the benefits of x-rays, Pringle’s team conducted a study of 421 people with low back pain that had lasted for an average of 10 weeks. All patients received the standard care for low back pain, but half of the patients were randomly assigned to have an x-ray of their lower spine.

Three months later, back pain had improved on average in both groups, but patients who had been x-rayed were more likely to still be suffering from back pain and to have poorer overall health. These patients were also somewhat more likely to complain of more severe pain and to have their back pain interfere with their normal activities.

But even though x-rays did not appear to help relieve back pain, more than 80% of the patients in both groups said they would choose to have an x-ray if they could. — Merritt McKinney

For every soft drink or sugar-sweetened beverage a child drinks every day, their obesity risk appears to jump 60%, new study findings suggest.

About 65% of adolescent girls and 74% of adolescent boys consume soft drinks daily, most of which are sugar-laden, according to Dr. David S. Ludwig of the Children’s Hospital in Boston, Massachusetts, and colleagues.

``Currently, soft drinks constitute the leading source of added sugars in the diet, amounting to 36.2 grams daily for adolescent girls and 57.7 grams for boys,’’ the researchers write.

The study included 548 Massachusetts schoolchildren of various ethnic backgrounds who were aged 11 and 12. The investigators found that for every can or glass of sugar-sweetened beverage a child drank during the 19-month study, a child’s body mass index—a measure of weight related to height—and their chance of becoming obese increased 60%.

However, the authors note that their study ``was observational in nature’’ and does not prove that drinking sugar-sweetened beverages will cause a child to definitely become obese.

According to the report, published in the February 17th issue of The Lancet, one possible explanation for the link is that liquids do not satisfy the appetite in the same way as food. This situation, combined with the fact that children are not likely to limit their consumption of food at mealtime to compensate for the extra soft drink calories, has an overall result of the child taking in more calories than he or she burns off. — Keith Mulvihill

Sleepyheads and chronic snorers may have something in common: an increased risk of stroke. The finding is from a study presented here at the American Stroke Association’s 26th International Stroke Conference.

Dr. Adnan I Qureshi and colleagues from the State University of New York at Buffalo asked 1,348 adults about their sleep habits as well as their stroke risk factors such as smoking, high blood pressure and diabetes.

Six per cent of the participants had a previous stroke and 7% had partially narrowed carotid arteries, a condition caused by a buildup of fatty plaque in the neck arteries that can increase the risk of stroke.

Qureshi found that 14% of the participants who said they slept for more than 8 hours a night had a history of either stroke or transient ischemic attacks, which are ``mini-strokes.’’ But he said that less than 6% of people who sleep for only 6 hours a night had a stroke history.

Additionally, people who said they were sleepy during the day and had difficulty staying awake or who snored also had an increased risk of stroke.

Qureshi explained that daytime sleepiness and snoring are both symptoms of a condition called sleep apnoea—a disorder in which a person stops breathing for short periods during sleep, sometimes dozens or even hundreds of times a night. Most commonly due to upper airway obstruction, the condition can disturb sleep, leading to loud snoring, repeated near-wakening, and increased blood pressure. Sleep apnoea is associated with both obesity and high blood pressure. — Reuters