In Bam, restoring homes and hope

Iranian officials are placing new priority on the mental health of survivors of December's earthquake.

The Iranian mother survived the Bam earthquake, but she needs more than a new house, food, and running water. She also needs to talk and cry, to cope with the extraordinary trauma that has battered families here.

"How can I sleep? I am always thinking of that day, when my brother woke up and my husband didn't," Mariam Ibrahim Ebadi tells a group of a dozen women brought together as part of a novel counseling program spearheaded by Iran's health ministry and UNICEF.

Her voice lowering, Ms. Ebadi tells of clutching her two young children to her as the earthquake roared. "I could hear them scream: 'Daddy is not here!'"

The Dec. 26 quake killed at least 43,000 - a sizable portion of the local population - and turned three-quarters of this ancient city to rubble, including its 2,000-year-old citadel, the largest mud-brick complex in the world.

As survivors begin rebuilding, officials are putting new priority on mental health to generate hope. They aim to touch half the population, but say success ultimately will hinge on government and relief efforts to restore normal life.

"A person who is hopeless and sees everything destroyed, goes to the edge of a precipice," says Abbas Zamiyad, a psychiatrist and codirector of the Health Ministry's mental health project. "We bring them back, talk to them, and give them hope, but if they turn around and see nothing - no home, no job, no future - we are just postponing their death."

Dr. Zamiyad says the government is "not fast enough to respond, and that affects the root of what we are doing." Still, eight weeks after the devastating quake, the government and aid groups are slapping together prefabricated houses, installing latrines and showers in zones around the city, and working to reestablish broken underground irrigation channels to protect Bam's famous date harvest. Twenty-seven temporary schools have been established so far for the 20,000 students expected to return to the classroom. On the streets, trucks carrying fuel and water, as well as rubble, rumble through as motorcycles zoom by.

UN and relief agencies give Iran high marks for moving swiftly, if not entirely efficiently, to ask for outside help and throw its own resources into the crisis.

"There will always be criticism, but if you consider where we started, and where we've got to now, it's gone well," says Pete Sweetnam, head of the US-British relief agency Mercy Corps, and a 20-year veteran of refugee and humanitarian efforts. "This has been fast- moving, and people's expectations have been raised by the government."

Already, 4,000 Bam survivors have taken part in several weekly group sessions directed by a psychiatrist and a therapist. Zamiyad fields 10 two-person teams a day and wants to double that.

Health Ministry figures reported to the UN show that 700 people are receiving one-on-one counseling, and that 210 psychologists and psychiatrists are being trained, along with 45 Education Ministry counselors and 130 teachers. Some 12,000 brochures about post-traumatic stress disorder (PTSD) have been passed out. "[Survivors] are in mourning reaction now, depressed, and feeling hopeless about the future," says Zamiyad. "If we can give them hope we can stop PTSD. But to give hope, we must show them something."

This is the first disaster in which Iran has undertaken a broad mental health effort. It stems from a pilot project during a much smaller earthquake in western Iran in 2002.

Just weeks before the Bam temblor, health officials began trauma training with UNICEF to deal with just such an event. Now the idea is being applied exponentially. "I'm optimistic about the quality of the response; the [mental health] strategy is quite good," says Jan Kleijburg, a Dutch officer with UNICEF.

The key, however, will be rebuilding. "For those who have seen natural disasters, Bam is still a shock," said Mark Malloch Brown, head of the UN Development Program, after a visit last week. "There are huge factors that have not yet been thought through, because people are dealing with the emergency."

Now Tehran must settle on its master plan as UN and relief agencies turn to rebuilding. While donors are ready to focus on restoring the citadel and earthquake-proof rebuilding, Mr. Malloch Brown says it is "very unlikely this is going to be turnkey financing, where donors ... give Iran a city of 100,000."

Still, there are increasing signs of hope emerging from block after block of rubble, where residents have set up tents on roads for shelter, and daily pick through the debris to salvage household items, or start to rebuild.

The carpet used for the women's session was pulled from beneath a collapsed roof and washed, host Hamida Moradzadeh says proudly. The plastic plates, laden with a few oranges and cucumbers for visitors, were salvaged, too.

"Our spirit has changed because we can talk," says Ms. Moradzadeh, her 2-year-old daughter sitting in her lap. When [people] come here, we know someone is thinking of us."

Besides talking about coping with the loss of loved ones, though, these women also complain about the lack of jobs, and what they see as inconsistent government efforts to help.

For Ebadi, whose late husband's tailoring shop went up in smoke when the earthquake sparked an electrical fire, there are few choices. She says she is irritable with her children, who have been reluctant to go back to school with so many classmates and teachers gone.

"Since I lost my husband, I felt mentally very weak. When I am alone, I cry, and my children see my tears," Ebadi says. "From the moment we wake up, we sit in our tents doing nothing, staring at each other and not talking."

The ability Bam survivors have shown to reengage has proved a strong lesson for Sayed Abolfazl Ghoreishi, a psychiatrist from Kerman. "Hundreds may be physically wounded, but thousands have had their mental health disturbed," says Dr. Ghoreishi.

For many, the greatest hurdle is coming to terms with the loss of children. Iranian flags often mark graves of entire families, which may consist of no more than names etched in concrete.

At Bam's sprawling cemetery, at dusk, Mohammad and Fatemeh Abdollahi let their tears flow to mourn the deaths of their teenage son and daughter: "You left so soon - to whom should I tell the saddest story of my heart?"

Yet horror is settling into a yearning for normalcy. The usual milestones that mark grieving in Iran - tearful ceremonies at three, seven, and 40 days after death - were largely lost among mass burials and other lifesaving concerns.

"Because this was such mass trauma, everyone had the same experience, and got through these stages quicker," says Ghoreishi. "Many are ready for stability, and want schools, houses, and jobs."