Living With Fear

The morning of Dec. 26 began like so many others along India's eastern coast, with the sounds of kids playing on the beach. Like thousands of children in the coastal hamlets of Tamil Nadu and Andhra Pradesh, Rajan, 10, was surprised by the giant waves that suddenly swept the shoreline. "I ran up a mound with a few others but saw our hut getting washed away," he says. He lost his parents and is now in the care of volunteers. He's so frightened of the sea he doesn't even want to cast a glance eastward. His sleep is usually interrupted by nightmares, and he spends most of his time staring vacantly.

On the island of Andaman, in the Bay of Bengal, Rizpo, a 25-year-old member of one of the world's few surviving primitive tribes, has maggot-infested infections in her thighs and a deep, pus-filled cut over her left eye. She lost 13 members of her family in the disaster. She cannot recall what happened to her when the tsunami struck. She vacillates from a stoic silence to uncontrollable weeping. At regular intervals, she mutters her tribe's words for "dead" and "water," mainly to herself.

Nightmares, memory loss, listlessness, weeping, terrifying images that replay in the mind--these symptoms are perfectly normal for survivors of traumatic events. In most cases they last only a few weeks or months. For many tsunami victims, though, a return to normal will be hard to achieve. Many must get by without parents, family and even villages lost in the disaster; very few will receive psychological treatment. For this reason, psychologists fear that symptoms will persist in nearly a third of the survivors. In these sufferers of what psychologists call posttraumatic stress disorder, or PTSD, the mind may continue to replay the event, triggering panic attacks. Some will go emotionally numb or suffer severe anxiety or depression. Rarely have so many people been at risk for mental illness.

What this means is that mental health will be a high priority in the coming weeks. Psychological support is already the most frequent request made to aid workers in Sri Lanka's refugee camps, reports Australian Red Cross delegate David Overlack. Relief organizations like Medecins Sans Frontieres and the Red Cross have been sending psychologists to train local health-care workers in counseling--and to identify those likely to need more help. But no one knows how many people they will reach.

At greatest risk may be children between 8 and 15, who are old enough to understand what has happened. Kids in refugee camps say they do not want to return to their old houses, even if they were to be rebuilt. As many as 40 percent of these children will develop PTSD, predicts Harvard Medical School health-care analyst Ronald Kessler. The social consequences look grim. PTSD victims are more likely to turn to drugs and alcohol for comfort, and to develop medical problems of all kinds. And "brain drain" can only be aggravated as painful associations give educated people another reason to flee.

Next to children, mothers may be most likely to develop PTSD, evidence shows. Women accustomed to male-headed households can feel overwhelmed when they find themselves alone, yet be reluctant to ask strangers for help. Aid worker Senthil Babu in Nagapattinam, 260 kilometers from the Tamil Nadu capital, Chennai, says simple things like a lack of underwear and sanitary napkins can make a difference. "It really hurts for women to ask for these things, and this is so humiliating that they are just sinking deeper and deeper into a suicidal depression." Men who now can't provide for their families also lose their sense of dignity and purpose. Like the children, many fear the sea they've known forever. After an engineering unit of the Indian Army repaired some large sboats, soldiers went out to sea with fishermen to bolster their confidence.

The good news is that for most victims the simplest of treatments--talking through the event--is enough to keep shock from turning into PTSD. The local health-care workers trained by MSF and others will help, not least by educating people about what to expect. In the natural course of trauma, symptoms should decline in about three months. "It helps to know you're not crazy," says Lisa Najavits, of the National Center for PTSD in Boston. To stay sane, "people need to be told not to lie in bed all day and [not] to drink or use drugs to escape the emotional pain." The best therapy is to reestablish confidence among victims in their own ability to cope. The miracle is that most of them will.