Lessons Learned

There are several lessons that can be learnt from the Nairobi bombing and the responses to it.

In Managing Disasters, Things Can and Do Go Wrong

As the Kenyans responded to the disaster in their own way, the American people who were the principal target of the attack were having problems of their own. The distance and time differences were to prove problematic. The response was occasionally chaotic and marred by a host of planning and logistical failures, especially in the area of military transportation. The Foreign Emergency Support Teams (FESTs) arrived in Nairobi and Dar es Salaam about 40 hours after the bombings, having experienced delays of 13 hours. There was disjointed liaison between the State Department, as the lead agency, and the Defence Department, FBI and other agencies. The personnel selection of the FESTs was ad hoc and not ideal. Medical and other emergency equipment was not always ready and available for shipment [8].

The chaos was not limited to the air and directly affected the medical care given to the survivors. Kenyan medical professionals at the Nairobi Hospital where the wounded Americans were receiving care claimed that US Air Force medical personnel were insensitive. This misunderstanding was to multiply against the background of allegations of looting at the embassy by Kenyans, who in turn accused the marines of protecting the Embassy grounds at the expense of the lives of Kenyans. Even as the digging in the rubble for survivors continued, sharp words were exchanged between frustrated well-meaning people united in their grief in the face of this tragedy.

As was to emerge later, there was confusion within the ranks of the seemingly organized American team. With the large influx of people from Washington and elsewhere into Nairobi, there were the inevitable coordinating problems with some personnel having to be reminded at times that the Ambassador was ultimately in charge [8].

The Role of Media

The role of media in disasters is well documented. In the Kenyan case, the media proved to be an invaluable asset [9]. In the early stages of the tragedy they provided factual information on what had happened, provided an outlet through which people could vent their feelings and discuss issues arising, and provided an avenue for messages of reassurance and education on the psychological effects to be expected following a tragedy of this magnitude.

Medical personnel in many cases shy away from the media. This can create a vacuum that gets filled with speculative messages. A key lesson from the Nairobi experience was that the media could play a positive role in disaster response. Another was that attention does need to be paid to the media personnel, who, like other people, also suffer the psychological effects of exposure to traumatic scenes [9].

The Importance of Effective Leadership

Kenya, like the rest of the African continent, was at the time a deeply traumatized country, by both natural and man-made disasters. Floods and politically motivated violence, had led to many deaths and much destruction to property [2].

This was the first time that Kenyans responded to any disaster with a mental health component. It was critical to have clear and decisive leadership, which was provided by the Kenya Medical Association.

Dealing with Different Reactions

Tragedy has a way of uniting people. In the Nairobi case there was initially great solidarity and courage demonstrated, with many pledges of help. Anger and harsh loud words blaming others were also notable. Chaos and confusion, especially in the early stages, were there in plenty. Terrorism destroys the sense of cohesion and safety and creates terror in the individual, in communities and in nations.

Anger gripped the people of Kenya, at first directed at Muslims, Arabs and any other groups thought to be even remotely connected with the terrorists. The Americans were the next ''obvious'' targets, firstly for being there, and secondly for their insensitivity to the Kenyans' needs and feeling in the face of the attacks. These are ''normal'' reactions to terrorism as the community searches for a scapegoat to heap its anger and frustration on.

The Honeymoon Effect of Disaster Response

This honeymoon phase has been described in disaster responses and was experienced first-hand after the Nairobi bombing. Immediately after the disaster there was an enormous and sympathetic response, both locally and internationally, and offers of help came from many parts of the country and abroad. Many offers of money and materials were made, most in the glare of cameras. Few kept their promises, not because they did not intend to, but because, before they could, other priorities engaged their attention.

The public did not forget the offers and kept calculating its value expecting that the project teams were suffocating under the weight of donations. Sadly, that was not the case.

Health care workers dealing with disaster need to be aware of this honeymoon phase, and to include it in their planning.

Research

Without research results, hypotheses cannot be tested, and well-intentioned approaches become confused with knowledge. Part of the heroic recovery effort was to collect data on those affected by the blast in order to inform treatment strategies in the short and the long term.

In the ideal world, researchers would have had to wait until survivors had finished with vital traditional activities like funeral rites. The sudden and unanticipated nature of the disaster followed by chaos severely challenged research planning. The team was driven by the realization that methodologically sound data are required to understand the mental health effects of terrorism in the region and to inform planning in the event of future disasters. The large convenience sample studied was predominantly educated professionals who witnessed the attack firsthand.

The analyzed sample consisted of 2,627 subjects. Of this group, 47% were female, 62% were married, and the mean age was 33.6 years (SD 9.7). 64 of the women were pregnant. 46% had completed secondary school and 40% had had some college education. The mean number of children per respondent was three (SD 2.1). 96% of the sample was Christian; the next largest religious group was Muslims, making up 2.5%. In all, this was a predominantly well-educated group of adults responsible for the care of many thousands of people.

Factors associated with post-traumatic stress syndrome (PTSS) (our approximation of post-traumatic stress disorder, PTSD), were: female gender, unmarried status, less education; being outside during the blast, seeing the blast, injury, not fully recovering from injury; feeling afraid, helpless, or threatened at the time of the blast; not talking with a friend or workmate about the blast; bereavement; experiencing or anticipating financial difficulty after the blast, inability to work because of injury, and receiving material or financial assistance. Notably, there was no significant association with PTSS symptomatology for age, number of children, religion; assessment of hospital care or immediate medical response; receiving counseling, or the relationship of the person mourned. The data show a strong link between injury and PTSS (p< 0.0001).

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