Open access, freely available online Health in Action How the Collaboration Is Responding to the Asian Tsunami Prathap Tharyan*, Mike Clarke, Sally Green

planning, providing, and receiving review on the effects of debriefi ng [3]. care in affected regions? Would these The Cochrane review had not found resources prove useful and, if so, which evidence that brief single-session of the groups involved in disaster debriefi ng reduced psychological management should make use of them? morbidity but showed, instead, that limited evidence from one trial The Need for Evidence-Based indicated a signifi cantly increased Interventions in Disaster risk of PTSD at one year in those he powerful earthquake- Management receiving debriefi ng (odds ratio 2.88 triggered tsunami that devastated A commonly used strategy in the wake [95% confi dence interval 1.11–7.53]) Tthe coasts of many countries in of traumatic events is brief “debriefi ng”, [3]. Because of this review, we urged two continents bordering the Indian both voluntary and mandatory. offi cials and nongovernmental Ocean on 26 December 2004 killed The aim of debriefi ng is to reduce organisations to desist from offering more than 280,000 people, displaced immediate psychological distress as brief, single-session debriefi ng. more than 1 million, and affected the well as to prevent the development of This message about debriefi ng lives of around 5 million more [1]. psychological disorders, notably post- was incorporated into the content Unprecedented media coverage, in traumatic stress disorder (PTSD). of counsellor training workshops turn, triggered a worldwide outpouring In the wake of the tsunami, many along with evidence for interventions of empathy, fi nancial aid, and pledges of teams rushed to the Nagapattinam aid; the mobilisation of resources; and district, one of the worst hit areas of Citation: Tharyan P, Clarke M, Green S (2005) How the concerted action from governmental Tamil Nadu, the state in India with the Cochrane Collaboration is responding to the Asian and nongovernmental organisations largest number of casualties from the tsunami. PLoS Med 2(6): e169. and international agencies such as the tsunami. These teams offered forms Copyright: © 2005 Tharyan et al. This is an open- United Nations (Figure 1) and the of brief debriefi ng to survivors in each access article distributed under the terms of the village before rushing on to the next of Creative Commons Attribution License, which permits World Health Organization. However, unrestricted use, distribution, and reproduction in some of the well-meaning responses the 73 tsunami-affected villages in the any medium, provided the original work is properly were not without drawbacks. There district. cited. are concerns that the unregulated, Prathap Tharyan was part of a team Abbreviation: PTSD, post-traumatic stress disorder uncoordinated, and poorly sustained summoned by the government of Tamil activities of independent visiting health- Nadu to provide psychosocial support. Prathap Tharyan is Professor of Psychiatry at the Christian Medical College in Vellore, Tamil Nadu, care teams or individuals will undermine The team checked the evidence and India, and Coordinator of the South Asian Cochrane local health-care efforts [2]. found a relevant Cochrane systematic Network. Mike Clarke is Director of the UK Cochrane Centre in , . Sally Green is Six months after the tsunami, the Director of the Australasian Cochrane Centre at attention of the media has largely Monash Institute of Health Services Research, Monash shifted to other more pressing issues, University, Clayton, Australia. The views expressed Box 1. Countries Affected by the in this article are those of the authors and are not leaving many unanswered questions Tsunami That Qualifi ed for Free necessarily the views of the Cochrane Collaboration. about the appropriate response to such natural disasters. Is there a Access to the Cochrane Library Competing Interests: Prathap Tharyan is an editor with the Cochrane Schizophrenia Group, a reviewer comprehensive list, prioritised and • Bangladesh and co-reviewer with other Cochrane collaborative organised, of the health and social • India review groups, and Coordinator of the South consequences of disasters? Do people Asian Cochrane Network. These are not paid posts, • Indonesia but he has received funding from the Cochrane have ready access to regularly updated Collaboration and from John Wiley and Sons to host evidence-based resources about the • Kenya a meeting of the South Asian Cochrane Network and from the Cochrane Collaboration to attend annual interventions relevant to such disasters? • The Maldives colloquia. Mike Clarke is employed as Director of Is there a mechanism by which these • Malaysia the UK Cochrane Centre and to work on systematic resources could be made available reviews. This employment depends on the value • Myanmar (Burma) placed on the work of the Cochrane Collaboration to policy makers making decisions and systematic reviews. Sally Green is employed as about the allocation of resources and • The Seychelles Director of the Australasian Cochrane Centre and is a member of the Cochrane Collaboration Steering interventions, as well as to people • Somalia Committee. • Sri Lanka The Health in Action section is a forum for individuals *To whom correspondence should be addressed: or organizations to highlight their innovative • Tanzania [email protected] approaches to a particular health problem. • Thailand DOI: 10.1371/journal.pmed.0020169

PLoS Medicine | www.plosmedicine.org 0483 June 2005 | Volume 2 | Issue 6 | e169 and it may become a valuable resource for coping with the aftermath of other disasters and health-care emergencies. The relevant reviews should provide a valuable one-stop resource for people making decisions about health care in the future. Disseminating the evidence. The tsunami affected many countries where access to the Cochrane Library, which is available by individual or national subscription through Wiley InterScience (http:⁄⁄www.interscience. wiley.com/cochrane), is limited. The Cochrane Collaboration and John Wiley and Sons, the publishers, recognised the need to make Cochrane reviews more available and, so, agreed to provide free “one-click” access to all contents of the Cochrane Library for people in affected countries (Box 1) for a six-month period from February to July 2005 (http:⁄⁄www. DOI: 10.1371/journal.pmed.0020169.g001 thecochranelibrary.org). Governmental Figure 1. The United Nations Population Fund Sends Aid to Those Affected by the Tsunami and nongovernmental agencies and Dr. Sanantha Wajewardena, the chief pharmacist at the Training Hospital in Galle, Sri institutions as well as individuals Lanka, and two other pharmacists (background) unpack a shipment of essential safe- involved in health planning and birthing supplies and surgical equipment supplied by the United Nations Population health care in these countries now Fund to replace equipment that the hospital lost in the tsunami on 26 December 2004. (Photo: Joanne Ornag) have access via the Internet to one of the best single sources of evidence on that were supported by the results of E-mail discussion list and regular the effects of interventions likely to be systematic reviews and randomised teleconferences aiding discussion and useful in their efforts at no cost. controlled trials [4–6]. Recent surveys planning of initiatives. Further details, Evidence aid: Summaries of of parts of the Nagapattinam district including a full list of the members evidence-based interventions. Members suggest that PTSD is not a signifi cant of the working party, are available of the working party, aided by others mental-health problem among adult at http:⁄⁄www.cochrane.org/docs/ in the Cochrane Collaboration, survivors of the tsunami. asiancrisis.htm#response. are preparing concise evidence Similarly, other evidence-based Prioritisation of reviews of relevant summaries of systematic reviews interventions, such as the distribution health-care interventions. A disaster of topics of high priority. These of insecticide-treated bed-nets [7], have of this magnitude raises the spectre summaries cover interventions relevant helped in the prevention of outbreaks of epidemics of infectious diseases to infectious diseases, injuries and of and dengue. Well-meaning and many other potential health- wounds, rebuilding of communities but misdirected and sometimes harmful care problems. The working party, and infrastructures, mental health, interventions could be prevented if in consultation with all Cochrane nutrition, rehabilitation, and those making decisions about the nature entities and around 200 individuals pregnancy and childbirth. They are of responses had access to reliable and from affected countries listed as available at http:⁄⁄www.cochrane.org/ up-to-date evidence of what works and contributors to the work of the docs/tsunamiresponse. If a summary what does not. Cochrane Collaboration, and members is not currently available but there of other agencies such as the World is a relevant Cochrane review in the The Response of the Cochrane Health Organization, Oxfam, and the Cochrane Library, a link takes people Collaboration publishers of BMJ’s Clinical Evidence, straight to that review. If a suitable Shortly after the tsunami, it was felt drew up a list of over 200 interventions Cochrane review is not available, that the Cochrane Collaboration, considered relevant to health care in links are included to other identifi ed as the world’s largest international the aftermath of the tsunami. sources of evidence, in particular, to organisation committed to providing These topics were further prioritised topics in the BMJ’s Clinical Evidence good evidence about health care and and grouped to ascertain which (http:⁄⁄clinicalevidence.com). with many members working in the interventions currently had an up- Do We Know Enough to Deal region, had a moral duty to help in to-date Cochrane review and which the global-relief and rehabilitation would need Cochrane reviews to be Effectively with the Consequences efforts. A working party was convened updated or even commissioned. This of Disasters? in early January 2005 of people in list will be modifi ed as further input Sadly, the answer is “No, not nearly the region and elsewhere, with an from other sources becomes available, enough”. Of the topics in the list of

PLoS Medicine | www.plosmedicine.org 0484 June 2005 | Volume 2 | Issue 6 | e169 the 200 or more interventions that are interventions should be implemented 3. Rose S, Bisson J, Wessely S (2002) Psychological debriefi ng for preventing post traumatic stress thought to be relevant to health care and on which new interventions disorder (PTSD). Cochrane Database Syst Rev after a disaster such as the tsunami, should be planned and evaluated 2002: CD000560. there is an up-to-date, good-quality [10]. These reviews, however, are only 4. National Institute for Clinical Excellence (2004) Post-traumatic stress disorder (PTSD): available for only a as good as the studies they review. The management of PTSD in adults and quarter of them. And, of these, not Adequate funding coupled with the children in primary and secondary care. all have conclusions that can guide necessary volunteers to prepare and Available: http:⁄⁄www.nice.org.uk/pdf/PTSD_ 2ndcons_niceguideline.pdf. Accessed 27 April practice now because of a lack of maintain systematic reviews of relevant 2005. relevant good-quality studies. interventions, as well as pragmatic 5. Ursano RJ, Bell C, Eth S, Friedman M, How, then, do we get the required randomised controlled trials to fi ll the Norwood A, et al (2004) Practice guideline for the treatment of patients with acute stress evidence? The tsunami was a reminder gaps indicated by these reviews, would disorder and posttraumatic stress disorder. Am that the divisions within and between complete the process initiated by the J Psychiatry 161(Suppl 11): 3–31. nations as well as attempts to close Cochrane Collaboration, and could 6. Stein DJ, Zungu-Dirwayi N, van der Linden GJH, Seedat S (2000) Pharmacotherapy our eyes and borders to problems well be one of the lasting legacies of the for post traumatic stress disorder (PTSD). abroad fl ounder in the face of the tsunami. Cochrane Database Syst Rev 2000: CD002795. 7. Lengeler C (2004) Insecticide-treated bed nets challenges posed by nature [8]. As the and curtains for preventing malaria. Cochrane world prepares to debate strategies for References Database Syst Rev 2004: CD000363. global equity in health care and the 1. World Health Organization (2005) Three 8. Abbasi K (2005) Death by tsunami and poverty. months after the Indian Ocean earthquake- BMJ 330: 0. DOI: 10.1136/bmj.330.7482.0-f millennium development goals at the tsunami: Health consequences and WHO’s 9. Labonte R, Schrecker T, Gupta AS (2005) A G8 summit in July 2005 [9], the lessons response. Available: http:⁄⁄www.who.int/hac/ global health equity agenda for the G8 summit. learned from the tsunami should not crises/international/asia_tsunami/3months/ BMJ 330: 533–536. en/index.html. Accessed 8 April 2005. 10. Clarke M (2004) Doing new research? Don’t be forgotten. Good-quality systematic 2. Lee ACK (2005) The tsunami and the dangers forget the old. PLoS Med 1: e35. DOI: 10.1371/ reviews form the basis on which of goodwill. BMJ 330: 261. journal.pmed.0010035

PLoS Medicine | www.plosmedicine.org 0485 June 2005 | Volume 2 | Issue 6 | e169