Topic: Disasters, terror and stress management

Regular general practioners follow-up of individuals affected by the tsunami.

Hjemdal, O. K. (2007). Fastlegenes oppfølging av de berørte etter tsunamien [Regular general practioners follow-up of individuals affected by the tsunami.] Norwegian only. (Rapport 1/2007).


The Tsunami disaster that struck Southeast-Asia and the Indian Ocean on September 26th is one of the most devastating natural disasters in modern time. Almost 230.000 people were killed, among them 84 Norwegians. During the first days following the catastrophe more than 3000 persons arrived at Norwegian airports returning from the disaster areas. Many of those returning had been exposed to serious strains and some of them also had lost family or friends. It therefore soon became a question of how best to attend to their medical and psychological needs.   

The Directorate for Health and Social Affairs decided on a decentralized approach, giving the Regular General Practitioners (RGPs) the main responsibility for the primary care and the assessment of needs for further assistance among those affected by the disaster. Based on the assumption that it would be necessary to actively call on seriously traumatised disaster victims, the RGPs were asked to try to get in touch with all those who had not by themselves contacted the local medical services. To determine which RGPs were involved and who they should contact, the local social security office’s register showing which persons was the responsibility of each RGP was compared with the police account of those who had returned from the disaster areas.

This way of organising the assistance to disaster victims was different from the procedures used in former disasters. The Directorate for Health and Social Affairs therefore wanted to know how the chosen approach had worked out and how the RGPs felt about the task they were given. The Norwegian centre for studies on violence and traumatic stress (NKVTS) was asked to conduct a survey among the RGPs to investigate these questions. A small questionnaire, consisting of only two pages of questions, was sent to the 1531 RGPs who had returned victims among the persons registered with them. The questionnaire included a general section with questions about the RGPs evaluation of the assignment, did she receive the list of persons to contact, how many of the individuals on the list did she reach etc. The RGPs should answer this section only once. The other section were comprised of several questions about each patient and the treatment they had been given. This section should be completed for each patient.

Only 480 of the 1531 doctors who received the questionnaire retuned the form even after a second written reminder. This gives a response rate of 31 percent. In addition to the answers from the RGPs the report is also based on answers from 899 tsunami victims about their experience with the RGPs and medical services after the disaster. The survey indicates that only half of the RGPs received the list of persons to contact. This can partly be explained by the local authorities having used other methods to get in touch with those who had returned. However, the rather complicated procedure used, involving the National Insurance Commission, the county governor’s administration, the local government administration and the local social security office, may also have been part of the reason why the lists never reached the RGPs.

The survey also indicates that more than 40 percent of the RGPs who did receive lists of persons to contact did not get I touch with any of the individuals on their list. This may partly have been caused by the lists being incomplete or faulty making it impossible to track the right persons. It is however reason to believe that a more fundamental view among the GPs, that it is the patient who should contact the doctor, and not the doctor who should call on the patient, also may have had some influence. It is also possible that reservations about the therapeutic effects of debriefing disaster victims made some RGPs decide not to follow the procedure proposed by the Directorate for Health and Social Affairs.

The survey cannot give an exact measure of how much these circumstances may have influenced the assistance given to the disaster victims. The results indicate however that the doctor’s attitudes toward the task they were given had an influential impact on how they acted. The doctors most enthusiastic towards the mission also were the ones most inclined to being active in contacting the persons on their list. 

The survey also gives a strong indication that the concerns some doctors may have felt about actively calling on their patients, were not confirmed by the victim’s reactions to being contacted. Almost none of those who were called upon by their RGPs gave a negative assessment of the assistance they had received, while among those who had to contact the doctors themselves and those who did not get in touch with their RGPs at all about 20 percent were dissatisfied. 

The fact that almost 50 percent of the doctors did not receive the lists, combined with the fact that a considerable fraction of the doctors who did receive them never contacted the persons on the list, may have the consequence that victims in need of treatment did not get any follow up from their RGP. To some extent this was counteracted by the fact that many victims who felt they were in need of help made contact with their RGP or other medical personnel themselves. There was however almost 10 percent of the victims who felt they suffered from some kind of health problems caused by the disaster, and one fourth of those who felt they might have a health problem, that had not had any contact with their RGP.

The RGP’s attitudes towards the tasks they were given does not seem to have had any impact on how they have diagnosed the patient’s problem and assessed their needs of assistance or the actual follow up they have given their patients. The victim’s opinion of the RGP’s assistance is to a large extent the result of what the doctor have not done, more so then an appraisal of the actual following up they have received. Those patients who were contacted by their RGPs are the most content, whatever treatment they have been given after the first consultation. Those who had to establish the contact with the RGP themselves are somewhat less content, while those who did not see their RGPs at all are the least satisfied. Among those who had been in contact with their RGPs there were only minor differences concerning how they felt about the assistance they had been given. Their opinion was more or less the same whether the following up had consisted of referral to special health care, further consultations with the RGP or if it had ended with the first contact. This might indicate that a majority of the disaster victims felt the assistance they received from the RGPs to be adequate in relation to their needs. 

The modest response rate and other limitations in the survey limit the possibilities to give precise advice based on this study about how to organise the assistance after future disasters. The study still gives an indication that the following aspects should be taken into consideration in the planning:

1. If the RGPs are to have a role in future disasters their role and tasks must be further clarified and defined and become integrated in emergency planning.
2. With large variations in the degree of exposure among those affected by the disaster a primary screening and assessment of needs should be done by those who first receives and register the disaster victims. Great effort must be put into securing the accuracy of the registrations.
3. The central authorities should establish a direct link to the RGPs. Accounts of which persons the RGP shall contact must be made out by the central authorities and sent directly to each RGP.
4. Experience has shown that disaster victims with severe psychological problems do not always seek medical assistance. When the RGP’s contacted the tsunami victims this did not bring about negative reactions from those contacted. This indicates that an active strategy should be chosen also in future disasters.