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Tokyo Guidelines


TOKYO GUIDELINES FOR TRAUMA AND RECONSTRUCTION
Formulating New Principles and Practices
for the Recovery of Post-Conflict Societies

by
Richard F. Mollica, MD, MAR
Associate Professor of Psychiatry,
Harvard Medical School
Director,
Harvard Program in Refugee Trauma

and
Yasushi Kikuchi, EdD
Professor of Social Anthropology
Institute of Asia-Pacific Studies
Waseda University

Introduction

The end of the twentieth century has seen an increase in societies devastated by mass violence. The world has also witnessed natural disasters of extraordinary proportions, such as the Great Hanshin-Awaji (Kobe) earthquake. Problems of violence and natural disaster and resulting trauma affect millions of people worldwide and will be central issues in the next century .Yet assistance in these “complex humanitarian emergencies” has remained largely unchanged or unchallenged since the end of World War II. One dilemma for international policy makers is that they do not have a scientific methodology for assessing the cultural, political, and social meanings of trauma in the lives of civilian populations and how these traumatic experiences alter the everyday lives of the affected individuals. Little empirical research assessing outcomes is conducted and humanitarian goals are often subordinated to political agendas. Although the magnitude of the problem is becoming clearer, methods for prevention and reconstruction of damaged societies have remained elusive. As a consequence, the enormous burden of human suffering and loss of social and economic productivity remains hidden behind a veil of neglect, ignorance, and denial.

The Harvard Program in Refugee Trauma (HPRT) of the Harvard School of Public Health and Waseda University’s newly created Institute for Asia-Pacific Studies (WIAP) recently received funding from the Japan Foundation Center for Global Partnership to organize a symposium addressing these issues. Taking place in May 1997 in Tokyo, this meeting brought together innovative thinkers to address the issues of economic and social recovery of communities extensively damaged by human and natural disaster. Equal time was given to the Bosnia-Herzegovina and Croatia, Cambodia, and Kobe, Japan. The participants gave brief lectures and participated in moderated discussions with the audience. The exchange of ideas exploring the political, cultural, and social meaning of trauma focused on the following themes:

  • The impact of violence and natural disaster on personal, social, and community development;
  • Scientific knowledge on the effect of mass violence and natural disaster on physical, psychosocial, and socioeconomic behavior;
  • The role of the medical and mental health system in recovery and reconstruction of traumatized populations; and
  • New policies for economic and social reconstruction of societies affected by mass violence and natural disaster.

The following conclusions and recommendations are the result of this exchange of ideas. A small working group drafted the guidelines and modified subsequent drafts based on the feedback from the symposium participants.

1. Definitional Issues
1.1 The sequelae of trauma of individuals need to be defined and should include assessment of their health and mental health conditions, functional status, economic productivity and knowledge of the culture.
1.2 The impact of trauma on the ability of family, local community and, ultimately, national groups to affect the short-term and long-term recovery processes has been poorly defined.
1.3 Reconstruction should be redefined to include recognition that it is a complicated and broad- based process which requires more than simply repairing the infrastructure and restarting the economy of a country devastated by mass violence or natural disaster.

2. Ethical Decision Making
2.1 In the emergency phase to reconstruction continuum, field staff are often compelled to decide the “least worst” choice.
2.2 Organizations need to prepare their staff for ethical crises which arise because they are expected to remain neutral despite the fact that aid may be cynically manipulated by interested parties.
2.3 Organizations need to elucidate their ethical or moral “bottom line” for deciding whether to continue a relief or development operation.
2.4 Every professional and volunteer organization should clearly communicate standards of professional behavior to staff in ethical guidelines expressed through training and supervision.
2.5 Organizations should create institutionalized mechanisms for providers and recipients of relief services to engage in constructive dialogue and resolve conflicts.

3. Evaluation and Assessment Issues
3.1 For traumatic outcomes, a definition of “caseness” as a measurement of disability linking health and mental health to socioeconomic and sociocultural behavior has not been described.
3.2 Little analysis has occurred of the long-term impact of humanitarian assistance and development programs on traumatized populations.
3.3 Measurements have not been developed to assess the cultural efficacy of reconstruction activities. All recovery efforts should allocate resources to evaluate the cultural efficacy and socioeconomic success of implemented projects.
3.4 Funders and other interested parties should encourage organizations to scientifically evaluate their initiatives and try new approaches as well as abandon ineffective programs.
3.5 The potential benefit of media involvement in the relief to reconstruction continuum is still largely unknown and needs to be evaluated.
3.6 The relationships between tribunals and other reconciliation processes to reconstruction are unknown and need further study.

4. Emergency Phase to Reconstruction Continuum
4.1 The reconstruction process must be planned from the beginning of the emergency phase. In other words, recovery is nested within the earliest humanitarian response to trauma.
4.2 Knowledge about the natural history of the socioeconomic and sociocultural effects of trauma needs to be incorporated into planning for the emergency phase and subsequent humanitarian efforts.
4.3 Traumatized persons are often seen as powerless and needy and sometimes are forced into dependent situations which may have a negative long-term effect on their independent socioeconomic and sociocultural behavior. Standards of human dignity and human needs should be defined in a “gold standard” which planning organizations aspire to achieve in spite of limited resources and political agendas.
4.4 The emergency phase and subsequent reconstruction should be monitored by the implementers themselves in order to limit the possible and unintentional harm of humanitarian assistance.

5. The Importance of Altruism and Self-Help
5.1 Survivors of mass violence and natural disaster need to be given permission and empowered to do good by humanitarian and political authorities.
5.2 The international humanitarian assistance community needs more information about the capacities of traumatized populations to contribute to the reconstruction process. Scientific evidence clearly suggests that there is a surge of resourcefulness and mutual assistance early in the posttraumatic phase which can be utilized for recovery in spite of limited resources.

6. The Importance of Work
6.1 Trauma survivors will do whatever they need to survive. Although trauma survivors have been shown to maintain the ability to maximize survival in spite of high levels of psychosocial impairment, this productivity has rarely been harnessed in the recovery phase.
6.2 It is rare for individuals who have experienced traumatic events to limit their informal work activities (which we call “BIGS”) despite conditions of extreme adversity.
6.3 In contrast, an individual’s formal employment activity (“BEGS”) is usually constrained by the existing sociopolitical environment and available economic opportunity.
6.4 Until jobs become available through formal employment, promotion of income generation through informal work activities is an essential foundation of the recovery process.
6.5 Small funds for self-recovery by survivors should be allocated during the emergency and long- term reconstruction phases.
6.6 There is a moral responsibility to take care of those who cannot care for themselves. Some people will be unable to participate in either formal or informal work activities even if they are provided with opportunities. These individuals need special assistance.

7. The Importance of Home
7.1 Planning for a permanent residence for survivors needs to be a top priority in the emergency phase.
7.2 Displaced populations need to be involved in the decision-making process with regard to choices and options related to housing. Local recipient communities, which are sometimes ignored during repatriation, need to be consulted as to the suitability of living conditions for newcomers.
7.3 Promotion of neighborliness is at the core of any long-term solution to difficult housing issues. Rebuilding neighborhoods and local community environments must replace concepts of repatriation and reconstruction which primarily focus on physical locations, structures, and transportation issues.

8. Vulnerable Groups
8.1 Vulnerable groups have a high burden of traumatic outcomes. Three vulnerable groups are of particular concern: Adolescents, the elderly and the mentally ill.
8.2 Since adolescents are often coping with despair about their future opportunities, addressing their special needs can help reduce their involvement in the cycle of violence.
8.3 The elderly are particularly burdened with solitary death, despair, and isolation.
8.4 In the emergency to reconstruction continuum, individuals seriously damaged psychiatrically by trauma and those with prior mental illness in the pre-trauma phase often have no access to mental health services; these services should be provided.

9. The Role of the Mental Health System in Reconstruction
9.1 Using scientific methods developed over the past twenty years, the health and mental health system can provide clinical care in a culturally sensitive way to traumatized populations and subgroups such as rape victims.
9.2 Mental health providers can serve as public health educators supporting local responses to the general community such as through the educational system.
9.3 Health and mental health professionals should participate in the process of reconciliation by maintaining a nonpolitical role and serving all affected populations regardless of ethnicity , social class, or political world view.
9.4 Recognizing the enormous stress on reconstruction organizations and their staff, technical assistance and training can be provided to reduce “burn out.”

Bibliography
1. Colletta NJ, Cullen M. Violent Conflict and the Transformation of Social Capital: Lessons from Cambodia, Rwanda, Guatemala, and Somalia. Washington, DC. The World Bank; 2000.

2. Desjarlais R, Eisenberg L, Good B, Kleinman A. World Mental Health: Problems and Priorities in Low-income Countries.New York and Oxford: Oxford University Press; 1995.

3. Holtzman SE, Collin A. Post-Conflict Reconstruction: The Role of the World Bank. Washington, DC. The World Bank; 1998.

4. Leaning J, Chen L, Briggs S. Humanitarian Crisis: Medical and Public Health Response. Harvard University Press; 1999.

5. Mollica RF McInnes K, Sarajlic N, Lavelle J, Sarajlic I, Massagli MP. Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. JAMA. 1999;282:433-439.

6. Mollica RF. Invisible wounds: Medical researchers have recently begun to address the mental health effects of war on civilians. Scientific American. 2000;282:54-57.

7. Murray CJL, Lopez A. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. In: Murray CJL LA, ed. Cambridge: Harvard University Press; 1996.

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