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THE PUBLIC HEALTH CONSEQUENCES OF THE TSUNAMI IMPACT ON DISPLACED

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					THE PUBLIC HEALTH
CONSEQUENCES OF
   THE TSUNAMI:
    IMPACT ON
DISPLACED PEOPLE




   Male, Republic of Maldives



          Volume I
                            For further information please contact:




                                   11, Route du Nant d'Avril
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                                         Switzerland
                                   Ph: + (41 22) 783 1080
                                   Fax: + (41 22) 783 1087
                                    Email: admin@icmh.ch




Copyright reserved

The contents of this material may not be reprinted, either as a whole or in part without the
written consent of the International Centre for Migration and Health.
April 2005
                                    PREFACE

Few natural disasters have attracted the attention of governments, UN agencies and
non-governmental organisations as the Tsunami of 26 December 2004 did. Never
before has so much international attention focused on a disaster or so much financial
and other resource support been pledged and actually delivered to respond to a
disaster. But the response, which was unprecedented in terms of both its speed and
size, may well have been predicated not only on the scope of the disaster, but also on
the concern that natural disasters seem to be occurring with greater frequency and
affecting more people than ever before. Natural disasters affect people in a variety of
ways. They are the cause of widespread injuries and massive death. They destroy
families, family life and family health, and they disorganize and displace communities
in profound ways. In many cases the impact of natural disasters on socio-economic
development is such that they seriously impede any reconstruction efforts that come
afterwards.

Understanding the dynamics of natural (as well as man-made) disasters and their
impact on society is essential if countries are to prepare for future emergencies and
take the steps needed to mitigate their impact. Nowhere is this more evident than in
the case of public health. The Tsunami has been yet another vivid reminder that in
causing mass death and injury, forcing millions of people from their homes, and
leaving vast areas of countries uninhabitable, natural disasters also create public
health challenges that many countries (both rich and poor) are often unable to
overcome without assistance. They provoke new situations characterised by
overcrowding, poor water and sanitation, insecure food and poor nutrition. They
create conditions in which health in general and reproductive health in particular is
constantly threatened and in which mental health and psychosocial well being is
challenged in previously unheard of ways.

The Tsunami was responded to promptly and by well-meaning people, but many of
the responses now appear to have been lacking in insight and sensitivity. Essential
services for pregnant women, for example, were late in coming and some of the ways
in which relief workers responded to the psychosocial needs of people appear to have
neglected local and cultural defined ways of coping. And although the scale of
humanitarian relief operations was unprecedented, there is also growing evidence that
poor coordination and communication led to inevitable waste and duplication.

This report, Volume I of The Public Health Consequences of the Tsunami: Impact on
Displaced People, provides an overview of the problems that were faced by people in
the Indian Ocean and the ways in which public health in the areas affected by the
Tsunami was impacted. It is intended as a contribution to the debate as to how
countries and the international community can and should come together in the future
to prepare for future natural disasters.

Dr Manuel Carballo
Executive Director ICMH
and Project Director
                               ACKNOWLEDGEMENTS

ICMH was present throughout the relief effort in the countries of the Indian Ocean,
and in taking up the question of how the Tsunami is affecting public health, and
especially the health of displaced people, ICMH brought together experts from the six
most affected countries and elsewhere to review what had been learned. First of all in
March 2005 it brought together a small technical group in Geneva to propose how the
analysis might be structured. The group consisted of Dr Mohamed Abdelmoumene1,
Prof. Monique Begin2, Dr Issakha Diallo3, Mr Gangyan Gong4, Dr Aldo Morrone5, Dr
Harald Siem6, Dr Shih Chin-Shui7 and Dr Manuel Carballo8.

In preparation for the meeting that followed, ICMH organised the preparation of
country reports from the six most badly affected countries and in April it organised a
meeting of 18 national and international public health scientists in Male. The interim
report of that meeting was published in late April and disseminated among UN
agencies, humanitarian relief agencies and donors. This new report includes the six
country reports that were prepared for the Male meeting and which since then have
been edited.

ICMH wishes to thank all the people who made the meeting and the two reports
possible. In particular it is grateful to the participants of the meeting for their
contributions to the discussion. Special thanks also go to those who prepared the
country reports: Professor Lalit Nath, Dr Reggie Perera, Dr Philip Stokoe, Dr Melania
Hidayat, Dr Pimonpan Isarabhakdi, Mr Ahmed Afaal and Mrs. Joyce Jett-Ali. ICMH
also wishes to thank Dr Abdul Azeez Yoosuf of the Maldives Department of Health
Services, Professor Paul Sherlock of Oxfam UK, Drs Joseph Prewitt Diaz and
Satyabrata Das of the American Red Cross (India) and Dr Matthew Huei-Ming Ma of
the National Taiwan University Hospital for their contributions to the process.

The Taiwan International Health Operations Center made the project possible through
a grant to ICMH, and was also responsible for providing technical relief assistance to
some of the countries affected by the Tsunami.




1
  Former Minister of Health, Algeria; Former Deputy Director WHO
2
  Professor, School of Health Sciences, University of Ottawa,Canada
3
  Director, Advance Africa Program, USA
4
  Research Associate, ICMH, Switzerland
5
  Director, Institute for Clinical and Scientific Research, San Gallicano, Italy
6
  Senior Advisor, Directorate for Health and Social Affairs, Ministry of Health, Norway
7
  Director, Department of Health, Taiwan (R.O.C.)
8
  Executive Director ICMH, Switzerland
                                              Male meeting report April 2005                                                    1

                                              Table of Contents
                                                                                                                          Page
List of Participants........................................................................................................2
Introduction ..................................................................................................................4
Tsunami and natural disasters .....................................................................................5
Populations at risk........................................................................................................5
Scope of the 2004 Tsunami .........................................................................................5
Magnitude of the 2004 Tsunami...................................................................................6
Who was affected.........................................................................................................6
Impact on livelihoods....................................................................................................6
Gross economic losses ................................................................................................7
Impact on human resources.........................................................................................7
Impact on infrastructure ...............................................................................................7
Mortality........................................................................................................................8
Gender bias in reported mortality.................................................................................8
Factors affecting gender bias.......................................................................................9
Difficulties estimating mortality.....................................................................................9
Missing people ...........................................................................................................10
Displaced people........................................................................................................11
Housing of displaced people ......................................................................................11
Overcrowding and physical health .............................................................................12
Psychosocial characteristics of displacement ............................................................12
Host communities and physical health.......................................................................13
Host communities and psychosocial issues...............................................................13
Resettlement and health ............................................................................................14
Response to psychosocial issues ..............................................................................14
Psychosocial responses.............................................................................................15
Pre-existing vulnerable groups...................................................................................16
New vulnerable groups ..............................................................................................16
Nutrition......................................................................................................................17
Reproductive health ...................................................................................................18
Loss of commodities/supplies ....................................................................................19
Reproductive health kits.............................................................................................19
Communicable diseases ............................................................................................19
Factors affecting low incidence of communicable diseases.......................................20
Communicable diseases in the future ........................................................................20
Perception of disease threat ......................................................................................21
Water and sanitation ..................................................................................................21
Water - sanitation coordination ..................................................................................21
Media .........................................................................................................................22
Role of religion ...........................................................................................................22
Role of the military .....................................................................................................22
Legal issues ...............................................................................................................23
Donor response..........................................................................................................23
Disaster preparedness and planning .........................................................................24
The bio-shield.............................................................................................................24
Conclusions and recommendations ...........................................................................25
Appendix 1 – India Country Report ............................................................................28
Appendix 2 – Republic of Indonesia Country Report .................................................39
Appendix 3 – Republic of Maldives Country Report...................................................44
Appendix 4 – Somalia Country Report.......................................................................52
Appendix 5 – Democratic Socialist Republic of Sri Lanka Country Report ................59
Appendix 6 – Kingdom of Thailand Country Report...................................................71
2                                     Male meeting report April 2005



List of Participants
                                                            Dr Matthew Huei-Ming MA
Mr Ahmed AFAAL
                                                            Assistant Professor
Deputy Chief Coordinator
                                                            Department of Emergency Medicine
Health Relief Unit
                                                            National Taiwan University Hospital
Ministry of Health
                                                            No 7 Chung-Shan South Road
Male 20-03, Republic of Maldives
                                                            Taipei, Taiwan 100
Email: afaal@health.gov.mv
                                                            Email: mattma@ntumc.org
Dr Satyabrata DAS
                                                            Prof. Lalit M. NATH
Acting Country Manager
                                                            Voluntary Health Association of India
Maldives Tsunami-Earthquake Task Force
                                                            E-21 Defence Colony
American Red Cross
                                                            New Dehli 110024, India
1 Red Cross Road
                                                            Email: lalitnath@vsnl.com
New Dehli-11001, India
Email: sdas@amcrossfieldin.org
                                                            Dr M.A.L.Reggie PERERA
Email: satyabrata71@yahoo.com
                                                            Health Systems Management Specialist and
                                                            Senior Associate
Dr Melania HIDAYAT
                                                            Health Policy Research Associates (Pvt) Ltd)
NPO – Reproductive Health
                                                            268/3, R.S. Perera mawatha
UNFPA Jakarta
                                                            Dalugama
7th floor Menara Thamrin
                                                            Kelaniya 11600, Sri Lanka
Jl. M.H. Thamrin, Kav 3
                                                            Tel: + 94 11 291 0198
PO Box 2338
                                                            Email: reggie@dialogsl.net
Jakarta 10250, Indonesia
Email: mhidayat.unfpa@un.or.id
                                                            Dr Joseph O. PREWITT DIAZ
                                                            Delegate, Psychological Support
Dr Pimonpan ISARABHAKDI
                                                            Tsunami-Earthquake Task Force
Institute for Population and Social Research,
                                                            American Red Cross
Mahidol University
                                                            1 Red Cross Road
Phuttamonthon 4 Road,
                                                            New Dehli – 110001, India
Phuttamonthon District
                                                            Tel: + 91 11 2331-1402/03/04
Nakorn Pathom 73170, Thailand
                                                            Mobile: + 91 11 2331-1977
Email: prpib@mahidol.ac.th
                                                            Email: jprewitt@amcrossindia.org
Dr. Mohamed Aseel JALEEL
                                                            Professor Paul SHERLOCK
Senior Registrar
                                                            Senior Humanitarian Representative Public
Obstetrics and Gynecology
                                                            Health Division
Indhira Gandhi Memorial Hospital
                                                            Oxfam UK
Kan’baa Aisaarani Hingun
                                                            274 Banbury Road
Male 20-02, Republic of Maldives
                                                            Oxford OX2 7DZ, United Kingdom
E-mail: Boi_jr@hotmail.com
                                                            Tel: + 44 (0) 1865 313 813
                                                            Mobile: + 44 (0) 778 611 0045
Mrs Joyce JETT-ALI
                                                            Email: psherlock@Oxfam.org.uk
Consultant
Relief & Development Organization
                                                            Dr Philip STOKOE
Mogadishu, Somalia
                                                            Director Operations Aceh
Email: oj@jettal.com
                                                            UNFPA Banda Aceh
                                                            Jl. Elang No. 1, Kp. Ateuk Taman Makam
Mr Ahmed KHALEEL
                                                            Pahlawan
Director, Maternal and Child Health
                                                            Banda Aceh, Nanggroe Aceh Darussalam
Ministry of Health
                                                            23241, Indonesia
Department of Public Health
                                                            Email: pstokoe.unfpa@un.or.id
Male 20-03, Republic of Maldives
Email: akhaleel45@hotmail.com
                                                            Dr Abdul Azeez YOOSUF
                                                            Director General of Health Services
Mr Ibrahim KONE
                                                            Ministry of Health
WHO
                                                            Male 20-03, Republic of Maldives
MTCC Tower, 5th floor
                                                            Email: dghs@health.gov.mv
PO Box 2004
                                                            Email: azeez_yoosuf@hotmail.com
Male 2004, Republic of Maldives
Tel: + 960 322 410, 327 519, 313 564
Email: ibrahimkone@who.org.mv
                                       Male meeting report April 2005                                 3




ICMH SECRETARIAT

Dr Manuel CARBALLO
Email: mcarballo@icmh.ch
Dr Rashid SHERIF
Email: drrashidsherif@yahoo.com
Mr Bryan HEAL
Email: bheal@icmh.ch

International Centre for Migration and Health (ICMH)
11 route du Nant d’Avril
CH-1214 Vernier (GE), Switzerland
Tel: + 41 22 783 10 80
Fax: + 41 22 783 1087




              Back from left : Dr M.H. Ma, Mr I. Kone, Dr J. Prewitt
              Middle Row from left: Mr. A.Khaleel, Dr P. Sherlock, Dr L. Nath, Dr S. Das, Dr R.
              Sherif, Dr P. Stokoe, Dr R. Perera
              Front Row from left: Mr B. Heal, Dr P. Isarabhakdi, Dr M. Carballo, Dr M. Hidayat, Dr
              A.A. Yoosuf
4                             Male meeting report April 2005




Introduction
                                                  but unless the evolution of these
The 9+ Richter-scale earthquake that              public health aspects is understood in
occurred off the coast of Northern                a timely fashion it will be difficult to
Sumatra on December 26, 2004                      prepare longer term strategies to
triggered one of the greatest human               assist people and prepare for any new
disasters and international relief                disasters in the future.
efforts in recent history. As many as
180’000 people are estimated to have              From 22-24 April a group of public
been killed and at least 1,633,000                health experts from Indian Ocean
people were displaced in the                      countries and elsewhere met in Male,
countries that were hit by the                    Republic of Maldives, to present
Tsunami. The humanitarian relief                  country reports, review what is
operation that followed brought over              already known, what lessons are
660 countries, agencies and NGOs                  emerging, and what should be done
together in one of the largest                    to better understand and respond to
humanitarian operations ever seen.                the needs of people and prevent and
                                                  mitigate any future natural disasters
Natural disasters affect people and               in the region.
communities in complex ways. In
the case of the Tsunami disaster, the             This interim report of the
impact will be felt for years to come             proceedings will be followed by a
and the demographic and socio-                    longer report that will include the
economic profile of the regions                   country reports and more discussion
involved may never be the same                    about next steps.
again. How and to what extent the
public health implications of the
Tsunami will continue to affect the
people of those regions is not clear,




                                         European Commission Joint Research Council (JRCEC), 2005
                              Male meeting report April 2005                                             5



Tsunami and natural disasters                     The Tsunami was yet another
                                                  reminder that the type of housing
The term Tsunami comes from the
                                                  people live in and the location of
Japanese term for tidal wave and is
                                                  their housing can often determine the
the accepted international term to
                                                  extent to which people are exposed
describe radially spreading, long-
                                                  to danger from natural phenomena
period gravity waves caused by
                                                  such as floods and landslides. It was
"large-scale sea-surface disturbances
                                                  also a reminder that poverty is all too
of an impulsive nature" such as
                                                  often one of the underlying
earthquakes, massive landslides into
                                                  characteristics that defines both the
the sea, and collapse of sea
                                                  type of housing and its location. It is
volcanoes. The speed and impact of
                                                  also evident that as population
Tsunamis depends on a number of
                                                  increases and as the historical
factors including the depth of the
                                                  tendency for people to concentrate in
water and the slope of the shorelines
                                                  and around specific areas of
the waves come into contact with.
                                                  employment also grows, more and
Tsunamis have been historically rare
                                                  more people will be affected by
events, however, and are only one of
                                                  disasters if and when they do occur.
many natural phenomena such as
floods, earthquakes and typhoons
that frequently cause large-scale                 Scope of the 2004 Tsunami
disasters. In 2003, 142 natural and               The epicenter of the earthquake that
238 man-made disasters of varying                 caused the Tsunami was about 22
severity were recorded in different               kilometers off the western coast of
parts of the world. Of the 40 worst               northern Sumatra. Its force and
natural disasters recorded between                positioning precipitated a series of
1970-2003 earthquakes and floods                  multiple tidal waves that hit
were by far the most frequently                   coastlines across the Indian Ocean in
occurring events.                                 intervals of 5-40 minutes and

   World Wide Disaster Trends




                             Figure 1 World-wide disaster trend from year 1970 to 2003 (SwissRe, 2004)

                                                  traveled as far as the eastern coast of
Populations at risk                               Africa. The European Commission
                                                  Joint Research Council (JRCEC)
In principle everyone is at risk of
                                                  estimates that the total land/sea area
being affected by natural disasters
                                                  affected by the earthquake was
when they occur, but some people
                                                  approximately 41,509 Km2.
are clearly more at risk than others.
6                            Male meeting report April 2005




Magnitude of the 2004 Tsunami                      resorts in and around Phuket
                                                   Thailand, there was also a massive
The force of the waves created by the
                                                   loss of life among national and
earthquake varied geographically. In
                                                   international tourists, but the disaster
Indonesia waves over 10 meters in
                                                   was a reminder that it is invariably
height traveling at up to 500 km/hour
                                                   the poor who are at greatest risk
deposited millions of tons of mud
                                                   when natural disasters occur.
and heavy debris as far inland as
12 km, and in Thailand, Malaysia,
Sri Lanka and India tidal waves                    Impact on livelihoods
traveled as far as 4 km inland.                    In addition to loss of life the
Although the waves had lost some of                Tsunami caused massive social
their force by the time they reached               devastation; houses, schools and
the eastern coast of the Maldives and              health facilities were destroyed, and
then Somalia several hours later they              in most of the affected communities
still measured 3-4 meters in height                people lost all their personal
when they made landfall. Given the                 possessions. In doing so it pushed
low elevation of the Maldives, with a              hundreds of thousands of survivors
maximum land height of 1.5 meters,                 into or below the poverty line and
the impact of 3-4 meter high waves                 may have done much to reverse
was still extensive.                               many of the economic and social,
                                                   and hence health, gains achieved by
Who was affected                                   countries in the region in recent
                                                   years.
The countries affected by the
Tsunami were all developing
countries with populations already
living in poverty before the disaster
occurred.      The Maldives, for
example, had been taken out of the
“least developed country” category
just six days before the Tsunami
struck. Throughout the region most
of the people who were most
seriously affected were low-income
families whose livelihoods revolved
                                                                                Carballo, 2005
almost entirely around fishing and
small-scale agriculture. The vast
majority lived in poorly constructed               In the Maldives where many
houses paralleling the coastlines.                 islanders kept their savings at home
There were nevertheless important                  and not in banks, these too were lost.
exceptions, and in the case of tourist             The loss of fishing boats and
                                                   equipment was often compounded
                                                   everywhere in the region by a fear of
                                                   returning too soon to the sea and by
                                                   rumors that fish might have come
                                                   into contact with (if not eaten) bodies
                                                   washed out to sea. The impact of
                                                   this was to essentially paralyze the
                                                   fishing    industry      for     weeks.
                                                   Meanwhile,      fear    of     repeated
                       www.wbnc.com                Tsunamis and high media coverage
                            Male meeting report April 2005                                    7


of the devastation had much the same              reaching loss of health care
impact on tourism in Thailand, Sri                providers. In Indonesia, 357 out of
Lanka and the Maldives.                           the 634 health personnel in the
                                                  region died or are still missing;
Gross economic losses                             among these dead and missing health
                                                  workers were 30% of all the
Experience suggests that if and when
                                                  midwives in the affected zones. In
"impact-to-GDP" ratios exceed 40%,
                                                  the Maldives, where much of the
affected economies face serious
                                                  island health care system depended
difficulties of recovery and usually
                                                  on expatriate physicians and nurses,
require major external assistance if
                                                  many foreign staff left to go back to
they are to reconstruct. In Indonesia
                                                  their countries in the region to look
World Bank estimates place the
                                                  after families in Tsunami-affected
impact of the Tsunami on Aceh
                                                  areas. Everywhere the load imposed
province at around US$4.5 billion,
                                                  on health staff was exacerbated by
that is to say 97% of Aceh’s GDP.
                                                  loss of equipment and drug supplies
In the Maldives total losses and
                                                  and by the fact that they had to clean
damages constitute 62% of the GDP
                                                  and repair severely damaged
                                                  facilities. It is important to note that
                                                  health care staff were also exposed to
                                                  the same stress and fears as other
                                                  people and many of them had their
                                                  own local families to look after. This
                                                  weighed heavily on them and in
                                                  Thailand, Indonesia and Sri Lanka
                                                  where levels of mortality were
                                                  especially high, it was exacerbated
                                                  because health care personnel as well
                              Reuters, 2005
                                                  as police, military, relief workers and
and are expected to slow down the                 volunteers had to dig out and handle
country’s real GDP growth to around               large numbers of dead bodies.
1% of GDP for 2005, compared to
pre-Tsunami forecasts of 7.5%. In                 Impact on infrastructure
Sri Lanka the damages and losses are
placed at more than US$ 1.5.billion,              Health facilities were just as
which may be as much as 7.3% of                   vulnerable as all other public
the country’s total GDP and in India
losses are estimated to amount to
around US$ 1.2 billion. In all these
instances the health sector suffered
as much if not more than other
sectors did because of the impact the
Tsunami had on both public and
private health care systems and
because of the massive loss of
trained health care staff.                                              Perera, 2005 – Sri Lanka

                                                  buildings. In Indonesia, one of the
Impact on human resources
                                                  main referral hospitals, 4 district
Throughout all the affected countries             hospitals, 41 out of 240 clinics and
there was a significant and far-                  505 schools were destroyed by the
8                             Male meeting report April 2005




Tsunami together with many of the                   dead. Sri Lanka is the first of the
official records in these buildings. In             countries     in    the   region  to
the Maldives, where most health care                acknowledge that people still listed
facilities escaped major structural                 as missing are likely to have died,
damage, some facilities such as                     and has begun to report Tsunami
Mulee hospital serving an entire atoll              "dead and missing" as one statistic.
lost all their medical records as well              In Indonesia, national authorities
as all their equipment. In Indonesia,               have stated they will wait for a
Sri Lanka and Thailand the loss of                  period of 12 months from the time of
roads, train tracks and other                       the disaster to do the same.
communication lines incapacitated
early search and rescue efforts and
has continued to make the provision
of health care services difficult. In
Thailand, Indonesia and Sri Lanka
the number of bodies local health
care facilities had to deal with in the
days immediately following the
disaster rapidly overwhelmed the
capacity for mortuary space and
imposed additional logistical as well
as psychosocial burdens on staff.                                                    ABC, 2005



                                                    Gender    bias       in    reported
                                                    mortality
                                                    There is striking evidence that
                                                    Tsunami-related injuries and deaths
                                                    in most of the affected countries
                                                    were extremely gender biased. In
                                                    Aceh province (Indonesia) as well as
                                                    in parts of the affected regions of
                                                    India and Sri Lanka 80% or more of
                                                    all casualties were female.       An
                                                    Oxfam survey of four villages in
                          Ma, 2005 - Indonesia
                                                    Aceh Besar and North Aceh found
                                                    that only 189 out of 676 survivors in
Mortality                                           Aceh Besar were women and that
                                                    77% of all casualties in North Aceh
By 10 April 2005 the total number of                were women.        In India female
confirmed deaths as the result of the               mortality was three times higher than
Tsunami was over 170,000 and                        that of men and in some areas of Sri
according to some estimates close to                Lanka four times more women than
180’000, the vast majority of them in               men died in the disaster. Children
Indonesia. Mortality statistics in all              everywhere     were     also    more
the affected countries, however, can                vulnerable than adults, but it is not
still be expected to grow in the                    clear whether there were gender
coming weeks and months as more                     differences among them.
bodies are found and as people who
are still unaccounted for are declared
                                            Male meeting report April 2005                                      9


Factors affecting gender bias                                     mobility in the water, and in some
                                                                  communities women had little
A number of factors may help
                                                                  experience swimming even though
explain    the  gender    mortality
                                                                  they had always lived close to the
differences. The Tsunami hit the
                                                                  water. In Sri Lanka there have also
coastlines mid-morning on a Sunday
                                                                  been reports of women’s bodies
when women in many of the affected
                                                                  being found in tree branches
                                                                  entangled by the long hair they
                                                                  traditionally wear.

                                                                  Difficulties estimating mortality
                                                                  To date precise reporting on the
                                                                  number of people who died in the
                                                                  Tsunami has been made difficult
                                                                  because of the evolving nature of the
                                                                  disaster. The waves dispersed bodies
                                                                  over large areas of land and often
                                                Reuters, 2005
                                                                  under meters of mud and debris from
                                                                  which they continue to be recovered.
areas are traditionally at home. In                               The force of receding waves also
India wives were also on the shore                                dragged many people out to sea and
waiting to help receive and process                               into currents that swept them far
the day’s fishing catch, and in Sri                               away from the point of origin. For
Lanka the waves hit at a time when                                example, bodies of Sri Lankan and
women on the eastern coastlines                                   Indonesian nationals were washed up
                       Figure 1a. Number of deaths for selected Tsunami Affected Countries (TACs)


                  140000
                  130000
                  120000
                  110000
                  100000
                   90000
   Total deaths




                                                                                                    Indonesia
                   80000
                                                                                                    Sri Lanka
                   70000
                                                                                                    Thailand
                   60000
                   50000                                                                            India
                   40000
                   30000
                   20000
                   10000
                       0
                           17-Jan 26-Jan 28-Feb 08-Mar 18-Mar 09-Apr         09-Apr   10-Apr
                                                  Reporting Date


often go the seaside to bathe.                                    on islands near Male in the Maldives
Personal stories also tell of mothers                             approximately eight weeks after the
and grandmothers who returned to                                  disaster and in the case of Indonesia,
beaches to search for missing                                     almost      3’000      km      distant.
children when the second wave                                     Throughout the region estimating the
struck. The clothing worn by women                                number of dead has also been made
in many of the affected regions may                               more difficult as a result of the
well have also impaired their                                     intense movement of migrant
                10                                             Male meeting report April 2005




                workers. Although many of these                                      occurred. On the whole, however,
                were documented migrants, many                                       the number of people declared
                others were probably not and today                                   missing can be expected to fall in the
                still remain "unknown". Figure 1                                     course of coming months as
                below provides an overview of how                                    authorities declare missing people as
                mortality statistics from countries                                  dead, or as missing people are found
                that suffered the highest mortality                                  among the hundreds of thousands of
                evolved over the past three months.                                  displaced people living in camps,
                                                                                     with host families and communities.
                Missing people                                                       Legal and administrative factors,
                                                                                     however, may serve to delay the
                Estimating the number of missing
                                                                                     process of declaring missing people
                people in disasters is always difficult.
                                                                                     as dead; two of the most important of
                In the case of some Tsunami affected
                                                                                     these factors concern land rights and
                countries it was complicated by the
                                                                                     inheritance and the need for pre-
                                                   Fig 2a. Number of Missing People: Indonesia

                140000
                120000
Total Missing




                100000
                 80000
                 60000
                 40000
                 20000
                                0
                                          17-Jan      26-Jan    28-Feb         08-Mar           18-Mar   09-Apr   09-Apr     10-Apr

                                                                               Reporting Dates

                                                                                       Indones ia

                                              Fig 2b. Number of Missing Persons in selected TACs

                                10000
                Total Missing




                                1000                                                                                       Sri Lanka
                                                                                                                           Som alia
                                    100
                                                                                                                           India
                                     10                                                                                    Thailand
                                                                                                                           Maldives
                                      1
                                            17-Jan 26-Jan 28-Feb 08-Mar 18-Mar 09-Apr 09-Apr 10-Apr                        Malays ia

                                                                    Reporting Dates


                fact that in some areas there were                                   defined "waiting times" to be
                few recent census data to build on.                                  respected before claims can be
                The in and out movement of migrant                                   settled. Figures 2a and 2b provide an
                workers also made it difficult to                                    image of how reported numbers of
                determine how many people were                                       missing people from selected TACs
                actually present when the Tsunami                                    evolved over the past three months.
                             Male meeting report April 2005                                   11


Displaced people                                   other areas while they themselves
                                                   stayed behind.
The United Nations defines displaced
people as: "Persons or groups of
persons who have been forced or
obliged to flee or to leave their
homes or places of habitual
residence, in particular as a result of
or in order to avoid the effects of
armed     conflict,    situations    of
generalized violence, violations of
human rights or natural or human-
made disasters, and who have not
crossed internationally recognized
State borders".       The scope of                                Associated Press, Jan 2005 – Sri Lanka
displacement as a result of the
Tsunami was massive; at least
1’796,357 and possibly many more                   Housing of displaced people
people had to move as a result of the              Patterns of accommodation of
disaster.                                          displaced people have varied
                                                   considerably between and within
     Country          Displaced                    countries. In Sri Lanka more people
                      people                       appear to have been taken in by
     India            647,599                      family and friends than housed in
     Indonesia        400,062                      temporary shelters, but tents and
     Maldives         21,663                       shelters have nevertheless been in
     Malaysia         8,000                        great demand and the load on
                                                   authorities to provide more of them
     Somalia          5,000
                                                   continues to be intense. In the
     Sri Lanka        519,063                      Maldives       solidarity    between
                                                   islanders made it possible to
By far the largest forced Tsunami-                 accommodate large numbers of
related displacement occurred in                   people with other families as well as
India where the number of people                   in schools and other public buildings,
has been variously estimated at                    but thousands of others have had to
between 70,000 and over 1 million,                 be housed in tents and hastily
but where the most probable figure is              constructed shelters. In Indonesia,
647,556.     The next two largest                  where the majority of displaced
displacements occurred in Sri Lanka                people have been accommodated in
where over half a million people                   tents and in homes, there has been a
were forced to flee, and Indonesia
where over 400,000 people are
estimated to have been displaced. In
the Maldives where 12,698 people
were displaced, this represented the
total evacuation of 13 out of the
country’s 200 inhabited islands. In
Somalia the displacement of people
was relatively smaller but equally
complex, with many parents
choosing to send children away to                                                  Ma, 2005 - Indonesia
12                             Male meeting report April 2005




marked resistance by displaced                       length of time displaced people are
people to accept being transferred to                expected to live in tent cities and
more permanent shelters they refer to                shelters will also play a role. In
as "barracks" and which they believe                 some areas local authorities and
are indicative of a decision by                      relief agencies may feel that major
authorities to make their stay                       investments in sanitation are not
permanent and negate their return to                 justified if people are going to be
communities of origin. In India,                     resettled soon even though no fixed
400,000     people     have     been                 dates have been set or can be set for
accommodated in 600 camps.                           this.

Overcrowding        and      physical                Psychosocial characteristics of
health                                               displacement
Everywhere       in     the     region               The social psychology of forced
overcrowding has become a major                      displacement is a complex one.
public health hazard that must be                    People are forced to leave under
addressed quickly if further problems                conditions of extreme duress and
are to be avoided. Overcrowding is                   when their lives and the lives of their
to some extent inevitable in all                     loved ones are in imminent and
disasters and in the days and weeks                  intense danger. Displacement in
                                                     natural disasters is also characterized
                                                     by such widespread injury and death
                                                     that even people who are not
                                                     immediately affected nevertheless
                                                     see, hear and feel distress all around
                                                     them.       The sense of being
                                                     overwhelmed by the power of natural
                                                     disasters and their capacity to
                                                     annihilate people can be profoundly
                                                     un-nerving. Chaos and loss of sense
                                                     of direction, especially among
                                                     children and elderly people who are
                      Carballo, 2005 - Maldives
                                                     not always as conceptually agile as
that followed the Tsunami it was not                 other people is also a common
always possible to provide the                       feature, and this too can be highly
number of tents and temporary                        disturbing.     Forced displacement
shelters       ideally       required.
Overcrowding is nevertheless now
producing a number of problems,
including physical promiscuity and
unacceptably high loads and
demands on water and sanitation.
The extent to which new health
problems related to overcrowding,
poor ventilation, physical proximity
of people and challenged sanitation
systems can be avoided will depend
in great part on the speed with which
overcrowding can be relieved and
                                                                           WHO, 2005 - Maldives
people can be given more space. The
                             Male meeting report April 2005                             13


means abandoning homes that have                   operations and came to the assistance
been    damaged      or   destroyed,               of people in need.
accepting to leave family heirlooms
and objects of sentimental value                   Host communities and physical
behind and cutting symbolic ties with              health
what may be years if not generations               The health relief effort in all the
of family memories and investments.                Tsunami-affected countries was
                                                   facilitated by the spontaneous
The sense of "loss of place"                       willingness of families, friends and
precipitated by this forced and abrupt             others to receive and accommodate
departure often leads people to also               displaced people. This took a huge
lose a sense of identity and self-                 load off local authorities and
esteem.      In disaster situations                international groups, but all too little
moreover, most people rarely know                  attention may have been given to the
where to flee, and even if their sense             needs of host families and to the fact
of survival is strong, the reality is              that, in their own unique way, they
that few people have a notion of if                too have suffered. Overcrowding in
and how they and their loved ones                  host families, for example, has been
will ever reach safety. Although in                as difficult for the host as for the
the case of the Tsunami the fact that              guests.     They have seen often-
only relatively narrow coastal areas               rudimentary sanitation facilities
were affected meant that people did                overwhelmed,        their      privacy
not have to move very far to reach                 compromised and their sleeping
"secure" areas, the conditions under               arrangements severely challenged.
                                                   In the Maldives where extended
                                                   families accommodated up to 30 new
                                                   people in houses that were already
                                                   small and overcrowded, the impact
                                                   has been far-reaching. Women have
                                                   reported waiting until midnight to
                                                   relieve themselves on the beach and
                                                   of going to different houses in search
                                                   of a toilet they could use. Although
                                                   there have been few reports
                                                   anywhere of disease outbreaks
                           www.wbnc.com            associated with this overcrowding,
which they had to get there were                   the load on host homes could quickly
extremely difficult. In Indonesia,                 begin to affect public health unless
Thailand and Sri Lanka, it meant                   preventative steps are taken.
fighting mountains of debris and in
the Maldives it meant trying to reach              Host communities and
other islands in crowded boats that                psychosocial issues
could offer little guarantee of safety             In the first weeks that followed the
on seas that were still seen as                    Tsunami host communities and
threatening.      The situation was                families in the Maldives were visibly
mitigated, however, by the rapidity                proud of their hospitality and their
with which national and international              contribution to the relief effort, and
governments and relief groups                      similar observations were reported in
mounted      search     and     rescue             Sri Lanka, Indonesia and Thailand.
                                                   With time, however, the willingness
14                            Male meeting report April 2005




of host families to continue                        voice concerns about being left out
accommodating displaced people has                  of the debate and of being taken for
begun to show signs of stress. In                   granted if indeed not already
some cases, there have been growing                 rejected. The psychosocial process
complaints about the imposition on                  they have been through and are still
space and scarce resources such as                  going through has left many of them
food and water. Expressions to the                  feeling highly vulnerable and if they
effect that displaced people are                    now begin to feel that they will not
thought to be receiving (rightly or                 be able to return home and to the
wrongly) inordinately more attention                only income-generating activities
than host families are becoming                     they know, they may become even
more common, and in all this it is                  more anxious, frustrated, and
important to keep in mind that most                 politically as well as psychosocially
host families in the region were and                restless. In all the areas that people
continue to be poor. Indeed they                    return to strengthening of health care
may be in the process of becoming                   services, including psychosocial
even poorer.       Nor should it be                 services, will be necessary.
forgotten that host families – like
most people in the region – who
were not immediately exposed to the
Tsunami also developed fears about
a potential reoccurrence of the
Tsunami and in many cases have
continued to suffer psychologically
as a result of the Tsunami.

Resettlement and health
Resettling displaced people is an
urgent priority in all the countries                                               Sherlock, 2005
concerned and will call for a unique
mix of political, social and logistical
acumen. In some of the countries the                Response to psychosocial
possibility of people returning soon                issues
(if ever) to their original homes may               Since the conflict in Bosnia,
be limited. Some areas have been so                 international agencies have given
devastated that reconstruction of                   increasing attention to issues of
homes and infrastructure will be                    psychosocial well-being in disasters.
difficult if not impossible. In most of             The response to the Tsunami was no
them levels of soil and ground water                exception     and     national    and
salinity have remained so high that it              international groups have given
is difficult to foresee any rapid return            priority to psychosocial issues. In
to the use of ground water or the                   some situations, however, there have
most basic cultivation of the soil.                 been concerns that the number of
This will inevitably exacerbate                     external agencies and groups
already      present     fears   among              working in this area has confused
displaced people about their future                 local people and local health and
and great care will have to be taken                social welfare authorities alike.
to involve them as much as possible
in decision-making on this issue.                   They brought different professional
Displaced people are beginning to                   standards, different models and ways
                             Male meeting report April 2005                            15


of working. In many cases they have                is emerging. In the Maldives the
not chosen to coordinate their                     Ministry of Health has estimated that
approaches among themselves or                     as many as 7,000 people, primarily
with local staff and in not doing this             women and children, may have been
they have raised serious questions of              "traumatized" by the Tsunami events
sustainability. There have also been               they experienced, and in Thailand
concerns that in the desire to help                health authorities report a significant
they may have failed to recognize                  increase in the number of
and build on the natural resilience of             prescription drugs and counseling as
people and communities.           The              well as other treatments for
competence of some groups working                  psychological     problems.          In
on psychosocial issues has also come               Indonesia, there has been a 15-20%
into question in some countries and                increase in out-patient load of people
everywhere there have been concerns                suffering     from     anxiety     and
that people arriving to work on                    depression.      Everywhere in the
psychosocial issues were not familiar              region there have been reports of
with the cultures involved, did not                children and adults complaining of
speak the languages of the people                  severe sleep disorders, nightmares,
they were hoping to serve, and were                intrusive thoughts and images of the
insensitive to the ways in which                   tidal wave, profound grief, loss of
people in different societies in the               appetite and social withdrawal.
Indian Ocean region respond to                     Many of these responses are to be
crisis.                                            expected and if transitory may not
                                                   necessarily present people with a
                                                   major threat to health. But if these
                                                   responses are not well managed and
                                                   become exacerbated for example by
                                                   further scares of Tsunami, loss of
                                                   hope and feelings of being unwanted,
                                                   could become a serious risk and lead
                                                   to highly dysfunctional conditions
                                                   for individuals, their families, and
                                                   the communities they live in. It is an
                                                   evolving situation that calls for
                                 ABC, 2005         sensitive vigilance and attention.

Psychosocial responses
Perhaps the most impressive
outcome in all the countries
concerned has been the natural
resilience of people and their
capacity to help each other as well as
themselves. It would nevertheless be
difficult to imagine a crisis of such
magnitude as the Tsunami not
precipitating psychosocial problems
and disorders of different types and
severity, and although the extent of
                                                                                         Carballo, 2005
problems cannot be estimated with
precision a picture of the magnitude
16                           Male meeting report April 2005




Pre-existing vulnerable groups                     physically evacuated children from
                                                   the Andaman Islands to places where
From a psychosocial point of view,
                                                   human security could be better
natural disasters affect everyone.
                                                   ensured.
Some people are nevertheless always
more vulnerable than others because
of who they are, where they are at
the time and their pre-existing health
condition. Natural disasters have the
capacity to exacerbate any previous
psychosocial problems that people
had as well as prompt new ones.
Some people could therefore suffer
more than others as a result of this.
This is especially so if they were
under treatment at the time and then
saw their access to that treatment and
care abruptly cut off. Little is known
about the nature of this dynamic in
the Tsunami-affected countries but
just like everywhere else it can be
expected to have been a present
danger.                                                                              ABC, 2005


                                                   The response to orphans in other
                                                   countries as well as in India will call
                                                   for equally creative responses that
                                                   will hopefully provide original
                                                   community and cultural continuity
                                                   for them and not prompt secondary
                                                   separation trauma. Similarly, for the
                                                   many adults who have been widowed
                                                   and those who lost children, the
                                                   future will remain bleak in the
                                Reuters, 2005      absence of innovative strategies
                                                   designed      to     facilitate     their
New vulnerable groups                              reintegration into society and
                                                   possibly into a new family and
In creating large numbers of orphans,              reproductive health cycle. In India
widows and widowers, physical                      this latter challenge has prompted
disabilities and elderly people who                efforts to provide women and men
suddenly lost family and their vital               who had been sterilized prior to the
sources of psychosocial support, the               Tsunami and who lost their children
Tsunami also created new types of                  in the disaster, with the possibility of
vulnerability and new vulnerable                   trying to reverse that sterilization.
groups. Many of them will need help
if they are to cope with the new
predicaments and challenges that
have been imposed on them. In a
unique expression of solidarity the
Indian Parliament voted to "adopt"
Tsunami orphans in India and
                             Male meeting report April 2005                             17


In Indonesia, the needs of people                  Nutrition
who lost limbs as a result of the                  Nutritional problems are always a
Tsunami has precipitated efforts by                challenge in situations of mass
volunteer    doctors    to    provide              displacement and especially so where
prostheses as quickly as possible in               nutritional status was already fragile
order to restore the social and                    prior to the disasters. In the case of
physical mobility of disabled people.              many of the populations affected by
In all these instances, however,                   the Tsunami, their poverty was
anecdotal reports suggest that far                 already linked to poor access to food
more counseling of the people                      and in the days immediately
concerned is called for, and that the              following the disaster the condition
                                                   of some people may have been made
                                                   aggravated by the shortage of food.
                                                   Nutritional problems have already
                                                   been reported from camps in Aceh
                                                   and there have also been reports of
                                                   nutritional anemia in the Maldives,
                                                   parts of Sri Lanka and India. All of
                                                   these may be indicative of problems
                                                   that were there before, but the fact
                                                   that they are now being highlighted
                                BBC, 2005          may help resolve them if emergency
                                                   interventions can be translated into
psychosocial complexity of the needs
                                                   more        sustainable      long-term
of people and the type of responses
                                                   strategies.
best suited to them call for more
attention than has been possible to
date. Much more attention will also
have to be focused on the elderly
who survived the Tsunami but now
find themselves without close
relatives and little source of social
security in cultures where security
has traditionally come from family.
Similarly in the case of the many
men who lost spouses and children,
and those who lost livelihoods,
innovative strategies are called for to                                           Carballo, 2005
ensure their re-integration into
income generating activities. In the               This said, however, in Indonesia and
past men have rarely been seen as a                Thailand, the provision of wheat
vulnerable group, but the Tsunami                  flour to people who have always
has possibly served to highlight the               been rice-eating people has not only
fact that no one is above the risk of              led to problems of unacceptability of
being damaged by disasters and that                food aid and inappropriate use, but
men have their own special needs                   has also been a reminder of how
that should not be ignored.                        quickly lessons learned elsewhere
                                                   can be forgotten. In all the countries
                                                   concerned there have also been
                                                   anecdotal reports of elderly people
18                           Male meeting report April 2005




not being able to masticate biscuits               could be said to be related to the
provided as part of emergency food                 Tsunami but this may well be a
rations.                                           function of under-reporting and the
                                                   fact that problems of pregnancy and
Reproductive health                                delivery are often taken for granted
                                                   in communities where maternal
In general relatively little attention
                                                   health has not been a priority.
appears to have been given to
                                                   However in the case of the Maldives
reproductive health. This is not
                                                   where reporting on pregnancy
surprising. Reproductive health has
                                                   outcomes continued to be systematic
long, albeit inappropriately, been a
                                                   in the wake of the Tsunami, there
forgotten step-child of humanitarian
                                                   were few if any indications of
relief.       UNFPA nevertheless
                                                   pregnancy interruption or other
estimates that at least 150,000 of
                                                   complications that could be linked to
Tsunami survivors were probably
                                                   the experience women went through.
pregnant at the time and this seems
                                                   On the other hand the fact that so
to be borne out by country-specific
                                                   many MCH care personnel were lost
reports. In India more than 4,000
                                                   in the Tsunami in Indonesia and
women are estimated to have been in
                                                   possibly elsewhere is indicative of
the last month of pregnancy and in
                                                   the limitations that must have been
the Maldives the number of pregnant
                                                   placed on women’s access to good
women on the affected islands is
                                                   antenatal, delivery and post natal
estimated to have been 1,500 when
                                                   care.    As many as 30% of all
the Tsunami struck. Estimates for
                                                   midwives in the Tsunami affected
Sri Lanka place the figure at 15,000
                                                   areas of Indonesia lost their lives and
pregnant women and a similar figure
                                                   in the Maldives there was sudden
is estimated for Indonesia.
                                                   departure of obstetricians working
                                                   there. Other more indirect impacts
                                                   include reports from Thailand that
                                                   the introduction of powdered milk in
                                                   some situations may have already
                                                   effected a significant deterioration in
                                                   breastfeeding and is a reminder of
                                                   the delicate balance between
                                                   humanitarian relief and the need to
                                                   support and promote practices such
                                                   as breastfeeding. The question of
                                                   gender violence has also been raised
                                                   in a number of fora because in many
                                                   man-made disasters (conflicts) in the
                                                   past sexual violence has been a
                                                   frequent and serious problem. The
                                                   meeting found few reports of this in
                                                   the Tsunami affected countries but
                                                   acknowledged that this may be an
                                                   example of under-reporting, and the
                                                   issue calls for possibly more
                              Carballo, 2005       vigilance and certainly sensitization
                                                   of communities than it is currently
To date there have been few reports                receiving. The high mortality of
of pregnancy complications that                    women, moreover, means the
                              Male meeting report April 2005                            19


demographic imbalance may place                     procured materials, personal hygiene
surviving women at even greater risk                kits and mother-baby kits and this is
of forced sex.                                      again a lesson for the future. The
                                                    kits included basic essentials for
Loss of commodities/supplies                        personal feminine hygiene but also
                                                    contained other things according to
The loss of supplies from hospitals
                                                    locally defined needs. In Indonesia
and pharmacies in some areas also
                                                    where many women had lost many of
meant a loss of contraceptive
                                                    their clothes, and were reluctant to be
supplies and hence an interruption in
                                                    seen without traditional head scarves,
family planning for people who were
                                                    the kits included material women
previously using contraception.
                                                    could use to cover their heads.
Provision of contraception in natural
                                                    Simple contributions such as these
and man-made disasters nevertheless
                                                    can make a significant difference to
remains a low priority for many
                                                    people in need and yet they are often
agencies and groups and this is often
                                                    overlooked.
made worse by the fact that people
do not (for a variety of reasons)
choose to raise this issue and request              Communicable diseases
more assistance.                                    The threat of communicable diseases
                                                    following natural disasters is always
Reproductive health kits                            present and in the case of the
                                                    Tsunami there were predictions that
In most of the countries affected by
                                                    serious epidemic outbreaks would
the Tsunami the loss of medical
                                                    occur as a result of the massive
equipment and the dramatically
                                                    destruction to infrastructure and
increased need and demand for
                                                    displacement of people. As of the
medical interventions was responded
                                                    end of April, however, no major
to in part by the introduction of pre-
                                                    disease outbreaks had been reported
packaged medical and reproductive
                                                    in the affected countries and what
health kits. The latter ones prepared
and provided by UNFPA found their
way into most of the displaced and
non-displaced persons situations in
all the countries concerned and
served to highlight the importance of
kits of this kind that can be easily
shipped and used by trained staff. In
the Maldives where they were sent to
all affected islands and to the islands
receiving displaced people, they                                                 www.who.int
permitted obstetric emergencies to be
                                                    spikes in diseases such as viral fever
handled even where the medical
                                                    and diarrhea have occurred appear to
facilities had lost all their equipment.
                                                    have been typical for the season.
What also became clear again in the
Tsunami was the very unique needs                   Minor outbreaks of Hepatitis A were
of women and how important it is to                 reported in displaced persons camps
be able to provide them with                        in Cheddipalayam, Sri Lanka, small
personal hygiene kits that help them                measles outbreaks in Alif Fenfush
maintain dignity as well as hygiene.                and Maamigili islands in the
In the countries concerned UNFPA                    Maldives, non-specific dermatologic
offices also made up, using locally                 infections and diarrhoeal diseases in
20                             Male meeting report April 2005




Hafun and Jeriban districts of                       diseases that might have been
Somalia, but these outbreaks appear                  provoked by unclean water. One of
to have been short-lived and                         the most important factors may be
contained.                                           that national health care systems
                                                     were strong and able to respond
Factors affecting low incidence                      quickly and this was clearly
of communicable diseases                             strengthened by the widespread
                                                     presence of national and international
It is not immediately clear why the
                                                     medical teams. Even in remote areas
incidence of communicable diseases
                                                     this meant that the timely
should have been so low but one of
                                                     identification,    treatment       and
the factors must surely be the speed
                                                     reporting of diseases and hence
with which both national authorities
                                                     prevention of spread was possible.
and international agencies were able
to respond with sound strategies for
providing clean water and other                      Communicable diseases in the
interventions. In India the air force                future
transported over 450 tons of water to                The fact that to date there have been
the Andaman Islands soon after the                   no major disease outbreaks is not to
disaster and throughout the Maldives                 say the problem has been entirely
massive supplies of bottled water                    averted.         In    situations    of
began to arrive on the affected                      overcrowding and where key
islands within the first days of the                 interventions (such as desalinization
disaster. International organizations,               plants) prove to have been transitory
NGOs and bilateral agencies                          products of international assistance
supplied desalinization plants of                    and not sustainable, diseases that
varying sizes, and while some of                     have thus far been successfully
these have gone on to present                        avoided could emerge.          Another
questions of maintenance, their                      potential threat is that although most
contribution to the water safety of the              if not all the camps for displaced
islands through much of January,                     people were designed as short-term
February, March and April has been                   solutions, some of them will become
enormous.        In other affected                   long-term if people are unable (as in
countries the timely drilling of bore                the Maldives) to return to their
holes and introduction of piped water                homes or are unwilling to be
into displaced persons camps and                     resettled elsewhere (as is the case in
communities       hosting    displaced               Indonesia and Sri Lanka). If and
people made an equally important                     where this occurs it may be
contribution to the prevention of                    impossible to ensure the type of
                                                     sanitation needed to avert public
                                                     health     problems       and     while
                                                     experience to date indicates that
                                                     predictions of epidemics did not
                                                     materialize, it is important that
                                                     disease surveillance systems be put
                                                     into place quickly and be as
                                                     community-based as possible.




                  Sherlock, 2005 - Indonesia
                             Male meeting report April 2005                           21


Perception of disease threat                       this now presents a major problem.
                                                   In Sri Lanka alone over 12,000 wells
Initial responses to the Tsunami were
                                                   were affected by high salinity and in
colored by the fear that the
                                                   some areas the shallow aquifers the
accumulation of dead bodies would
                                                   wells use as a source of water may
constitute a serious disease threat.
                                                   have been permanently damaged by
This misconception dominated many
                                                   the salt water. Carefully managed
of the actions taken in countries with
                                                   pumping and cleaning of wells may
large numbers of dead. Efforts to
                                                   help to re-establish some of them but
clarify this situation and explain that
                                                   overall the fresh-water to sea-water
bodies of people who die accidental
                                                   balance will take time to re-
deaths are unlikely to present any
                                                   equilibrate and it may require several
disease threat unless were not always
                                                   rainy seasons to work through the
successful. Numerous other reasons
                                                   problem and recover the amounts of
for timely disposal of bodies exist,
                                                   clean water that are needed. What is
however. Human bodies (and to a
                                                   clear is that the bottled water
far lesser extent animal remains) are
                                                   supplies that have been so effective
a source of emotional stress for
                                                   to date are probably unsustainable
survivors and are a constant reminder
                                                   from a cost and logistical point of
of the past as opposed to the fact that
                                                   view and in some instances highly
they have survived and can look to
                                                   sophisticated      reverse    osmosis
the future. The collection of human
                                                   systems may be impractical if cost-
remains is thus important from a
                                                   recovery is not possible and if
psychosocial perspective and must be
                                                   communities are unable to assume
done sensitively. Family members
                                                   responsibility for their maintenance.
usually want to able to identify
                                                   The Tsunami introduced many new
remains and go through the rituals
                                                   sanitation    problems,     especially
that surround death and burial in all
                                                   among displaced people. Some of
societies in order to give closure to
                                                   them had never had formal sanitary
incidents. The felt need in some
                                                   arrangements other than open ground
countries to remove and dispose of
                                                   and/or the sea, and now find
bodies quickly made it impossible
                                                   themselves in ‘camps’ where they
for many ritual practices to be
                                                   are having to be instructed on the
respected and has left some survivors
                                                   proper use of latrines and the
with a sense of guilt that will require
                                                   importance of this for public health.
counseling.
                                                   Water - sanitation coordination
Water and sanitation
                                                   Efforts to provide clean water and
Every emergency is a public health
emergency and although large
numbers of people did not die from
water-related diseases following the
Tsunami the need for clean drinking
water and water for washing remains
a high priority. In this regard the
Tsunami brought a range of new
problems including the high levels of
salinity in the ground water. For
people who still relied on wells and
had not been provided with                                                       www.who.int
alternative sources of clean water
22                           Male meeting report April 2005




good sanitation have highlighted the               greater sense of grief than was
importance of effective coordination               spontaneously forthcoming. In the
between government and operational                 Maldives where television played a
agencies. Where there has not been                 distinctively      important       and
good coordination it has been                      informative role, the television’s 24-
impossible to agree on common                      hour coverage against a background
standards or on the actions needed to              of funeral music was felt to have
meet those standards. The use of the               eventually become counterproductive
SPHERE standards has been                          for people watching it.
important in this regard but this has
not been without problems either and               Role of religion
in some countries and communities                  A consistent theme to emerge in the
expectations have been raised                      meeting was the important role that
beyond local or international                      religion appears to have played in
capacities (at the time) by the                    many of the Tsunami affected areas.
SPHERE standards.                                  In Indonesia, many observers have
                                                   commented       on      the   spiritual
Media                                              grounding      that      seemed      to
The role of the media in mobilizing                characterize     resiliency     among
the national and international                     survivors and the fact that local
response to the Tsunami was                        religious leaders were able to provide
highlighted in the meeting. News                   health information as well as solace
reporting played an early and vital                to people en masse. On the other
role in mobilizing concern and                     hand, there were also reports of
resources and in Sri Lanka was able                external relief groups arriving and
to provide the type of relief                      promoting their own religious
information that allowed both                      affiliations as part of their relief
government and external groups to                  efforts.      This contributed to
act in a timely fashion and together.              considerable      confusion     among
Where the media were not well                      beneficiaries in some countries and
informed, however, the impact was                  introduced serious questions about
at      times       counterproductive,             the type of role external religious
particularly     where     prospective             groups should play in humanitarian
donors were using media information                relief work.
in their assistance planning. One of
the examples of this were media                    Role of the military
reports that dead bodies posed a                   In all the countries affected by the
major communicable disease threat                  Tsunami, the technical and logistical
and donors (at all levels) promptly                capacity of the military stood out as
responded         by       dispatching             an important asset in the relief
precautionary supplies and shipments               operation and has continued to be an
of disinfectants in abundance. In                  important      ingredient      of     the
Thailand so much attention was                     reconstruction effort in many of the
given by the press to the need for                 countries.        In Indonesia, a
supplies that some communities                     combination      of     national     and
found themselves inundated with                    international military resources made
more clothes, medicines (often of                  it possible for difficult-to-reach areas
dubious shelf life and origin) than                of the country to be accessed by
they could handle. The media may                   search and rescue teams and be
also at times have created an even                 provided with food, water and
                             Male meeting report April 2005                            23


medical support. Similarly in the                  listed as dead for a year after the
Maldives, provision of supplies to                 Tsunami, and in some tourist-
affected islands and the construction              sending countries there has been a
of temporary shelters, schools and                 tendency to delay declaring Tsunami
other essential facilities quickly                 missing people as dead.          When
became the responsibility of the                   people pass from being officially
military and it is unlikely that any               termed “missing” to being classified
other sector could have performed                  as “dead” a variety of legal
the task within the same timeframe.                implications will follow for the rights
Involving the military, however, is                of survivors to compensation, to
not without its problems.          In              remarry and to inherit. In countries
countries such as Sri Lanka and                    governed by Sharia law, such as
Indonesia      that    have     been               Indonesia, where women cannot own
characterized by internal unrest and               property the resettlement of widows
where the military has been                        may well be adversely affected if it
                                                   remains        impossible      (unless
                                                   exceptions are made) to allocate
                                                   surviving      women      with    land.
                                                   Moreover, the degree of destruction
                                                   was so intense in some countries that
                                                   not only are the foundations of
                                                   houses (which might have served as
                                                   “proof”) gone but so are all the
                                                   certificates and deeds which both
                               www.who.int         people and local communities might
                                                   have been able to refer to in settling
identified with one side more than
                                                   claims. In the Maldives where many
the other, the capacity for it to be
                                                   young people lost educational
accepted and trusted by all would-be
                                                   certificates this too has been a cause
beneficiaries is limited.         The
                                                   of major stress and anxiety as well as
willingness and capacity of the
                                                   a matter of legal and administrative
military to play a dominant logistical
                                                   concern. In addition the fact that few
and technical role may also at times
                                                   people in the affected areas were
have obviated the potential for
                                                   insured either personally or for their
greater community participation and
                                                   property will have implications for
contributed to a sense of dependency
                                                   compensation and reconstruction
on the part of displaced people.
                                                   assistance.         From a health
                                                   perspective not only will this affect
Legal issues
                                                   financing of care and management of
In all the Tsunami affected                        disabilities, but will also have
(including countries where tourists                implications for the psychosocial
came from) vital statistics generally              well being of the people concerned.
distinguish between dead and
missing people. In countries such as               Donor response
Sri Lanka, Thailand and India the
                                                   Rarely    has   the    international
official distinction between dead and
                                                   community, national governments
missing is such that missing people
                                                   and others demonstrated such a
tend to be considered dead within a
                                                   massive and spontaneous response to
shorter delay than may be the case
                                                   a disaster as in the case of the
elsewhere. As indicated earlier, in
                                                   Tsunami. So ready and massive has
Indonesia missing people will not be
24                           Male meeting report April 2005




been the response that many field                  steps to inform all stakeholders about
agencies have referred to the notion               them. In other cases such as the
of funds looking for partners as                   Maldives where a health sector plan
opposed to the struggle for funds                  meeting had been held three weeks
they have experienced in the past.                 earlier, this had covered a possible
While this is a positive sign, the fact            aviation-airport disaster. There had
remains that much of the “Flash                    been little reason to anticipate a
Appeal” funding will now have to be                disaster such as the Tsunami in the
allocated and spent within such a                  Maldives. This is not to say that
short timeframe that it will challenge             responses in the region were tardy or
everyone and could lead to un-                     inefficient. On the contrary, some of
necessary      and       inappropriate             the responses probably deserve to be
spending. The opportunity to use                   analyzed as models of what can be
these funds for public health                      done in the future, but in almost all
development should thus not be                     cases there will be scope for much
overlooked, especially given the fact              more preparedness than has been the
that most of the countries are poor                case to date. The meeting also felt
and lacking in the development                     that many of the donors were also
resources they will need.          The             caught relatively unprepared and
meeting also highlighted the need for              some were unaware of the
donors to give more attention to the               multinational systems that could
proficiency of the teams they send                 have been used and which might
for there were many instances of                   have been more cost and human
teams that were clearly not as well                resource efficient.
prepared as they could/should have
been.                                              The bio-shield

Disaster     preparedness          and
planning
The Tsunami caught everyone by
surprise as most disasters do. It was
a tragic reminder of how much needs
to be done by countries to prepare for
natural disasters, be they floods,
earthquakes, typhoons or forest fires.
Much can be said of the many United                           Isarabhakdi, 2005 - Thailand
Nations agencies that responded so                 The Tsunami highlighted the fact
well to the disasters but which did                that in almost all the Tsunami
not necessarily have disaster                      affected areas shoreline vegetation,
response plans in place and well                   especially intense mangroves, were
rehearsed. Most were caught with                   not only resilient to the waves, but
staff on national holiday and with                 also seem to have exerted a highly
few contingency options available.                 protective effect on the immediate
At a country level there were also                 hinterland. Other trees also seem to
deficiencies. Despite the fact that                have withstood the waves, and this
earthquakes are not uncommon in the                experience should not be overlooked.
region some of the countries did not               Removal of natural vegetation from
have plans in place and some of                    around settlements in some areas of
those that had prepared plans in the               the world may expose communities
past had not taken the necessary                   to natural disasters they might
                             Male meeting report April 2005                             25


otherwise have been protected from.                      damage the psychosocial health
Indeed the Tsunami, as well as other                     and well being of people, this is
natural disaster experiences such as                     an area that should be given
floods and land slides, suggest that                     systematic attention including the
purposeful planting of trees and other                   training of primary health care
dense vegetation could be beneficial                     workers and selected people in
to the safety of communities in many                     communities to be able to
areas.                                                   identify, assist, and where
                                                         necessary refer people in need;
Conclusions and
recommendations                                    5. Because the Tsunami has
                                                      highlighted the vulnerability of
1. Because Tsunamis are rare events                   children who lost their parents
   and because many other natural                     special attention should be given
   disasters such as earthquakes,                     to ensuring their care preferably
   floods, and typhoons are far more                  within their own communities
   frequent, the follow-up to the                     and local cultures and in ways
   Tsunami should be to quickly                       that allow rapid reintegration into
   develop regional, sub-regional                     schooling;
   and national plans that take all
   natural disaster eventualities into             6. Because the reproductive health
   account and focus on common                        aspects of women and men’s
   public health features;                            lives are so often overlooked in
                                                      natural disasters more attention
2. Because most natural disasters,                    should be given to protecting and
   and certainly Tsunamis, cannot                     improving      maternal      care,
   be predicted with certainty, more                  breastfeeding, family planning,
   attention should be given to the                   information on adolescent sexual
   routine education of all the public                health, addressing the possible
   in disaster prone areas as to what                 need for some individuals and
   to do if natural disasters occur,                  couples to re-start reproductive
   and the development and training                   lives, and the strategic pre-
   of national and regional teams on                  positioning of RH kits;
   public health and disaster
   preparedness and prevention;                    7. Because natural disasters of large
                                                      magnitude are always complex
3. Because the Tsunami has                            and touch on all sectors of
   highlighted       the     special                  society, preventing and preparing
   vulnerability of groups such as                    for disasters must involve all
   women and children, much more                      sectors and recognize and use the
   attention should be given to                       added value of sectors such as the
   preparing them for any new                         military, religion and the media;
   incidents and to encouraging
   communities to discuss the                      8. Because the implementation and
   reasons why they were so much                      coordination of public health
   more at risk than others;                          responses to disasters such as the
                                                      Tsunami often falls to local and
4. Because one of the most                            regional authorities, all disaster
   dominant features of natural                       preparedness     plans     should
   disasters is their capacity to                     include more specific reference
                                                      and allocation of responsibilities
26                             Male meeting report April 2005




     to those authorities and provide                      duplication and waste, all NGOs
     them with the training and the                        (local and international), bi-
     administrative     support  they                      laterals, UN agencies, and
     require including:                                    government agencies should
                                                           accept to work under the
     8.1 appointing      senior     level                  direction of trained national and
         government officers as ex                         local coordinators;
         officio Relief Coordinators
         for all national, state and                 12. Because the risk of confusion is
         provincial level operations                     always high with respect to the
     8.2 appointing      senior     level                logistics of public health (and
         administrative officers at the                  other) goods in the response to
         district level as ex officio                    disasters such as the Tsunami,
         District Relief Coordinators                    more efficient means of tracking
     8.3 ensuring      that     everyone                 items sent to and received by,
         understands       their    role,                beneficiaries     should      be
         responsibilities             and                developed, and donors should
         authority;                                      ensure that they participate with
                                                         national teams in tracking and
9. Because the Tsunami experience                        providing detailed lists of the
   has so much to teach the                              contents of shipments;
   international community and
   national authorities about disaster               13. Because there were once again
   preparedness and the public                           instances of inappropriate drugs
   health response to disasters, an                      and other materials being sent to
   evaluation of lessons learned, for                    countries, much more care should
   example in areas such as                              be exercised by donors and the
   communicable disease control,                         public with respect to quality and
   reproductive health, psychosocial                     relevance of contributions;
   issues, and systematic monitoring
   of the public health domains over                 14. Because of the need to be able to
   the coming months should be                           respond quickly with public
   encouraged everywhere in the                          health interventions in natural
   region;                                               disasters, customs, excise and
                                                         travel    requirements    should
10. Because the Tsunami has taught                       always be simplified to facilitate
    us that public health emergency                      movement of equipment, supplies
    preparedness plans are only as                       and personnel;
    useful as the number of
    stakeholders that know about                     15. Because local cultural and
    them and can use them, ensuring                      political factors as well as
    the widespread distribution of                       community        capacities  will
    plans and involving all partners                     always affect the public health
    in regularly reviewing and                           response to natural disasters,
    rehearsing those plans should be                     external stakeholders should try
    actively promoted;                                   to     familiarize   their  staff
                                                         accordingly and try not to by-
11. Because coordination is so                           pass government channels except
    essential  to   the    effective                     when specifically invited to do
    implementation of public health                      so;
    measures and avoidance of
                            Male meeting report April 2005                            27


16. Because so many public health                 19. Because the poor are so often the
    agencies, bi-lateral donors and                   primary victims of the public
    others are involved in responding                 health impact of natural disasters
    to natural disasters steps should                 steps should be taken to ensure
    be taken to ensure compatibility                  that public health (and other
    of competence and the standards                   sector) planning for and in
    used by them, and the need to                     natural disasters is preferentially
    strengthen rather than negate                     directed to them, and specifically
    local capacities and resilience;                  to reducing the additional risks
                                                      they are exposed to as a result of
17. Because the usual response in                     the lack of insurance coverage,
    natural disasters is to give                      residential zoning and inadequate
    priority to the health needs of                   house construction;
    displaced people, care should be
    taken to balance this by also                 20. Because individual houses may
    addressing the needs of host                      never be able to offer the security
    families and communities that                     required in disasters, local
    have their own special needs;                     authorities should be encouraged
                                                      to promote use of multipurpose
18. Because the process of recovery                   public     buildings     including
    and rehabilitation is rarely                      mosques, churches and schools
    complete until the affected                       as “safe areas” and equip them
    populations have been able to                     accordingly;
    return to gainful occupation and
    normal life, steps should always              21. Because of the amount of
    be taken to allocate a portion of                 funding allocated to the Tsunami
    relief resources to the longer-                   response and because the timing
    term reconstruction and recovery                  for use of relief funds may be too
    process including providing                       short, extensions should be made
    small grants to people;                           in the case of many countries and
                                                      some should be redefined so that
                                                      it can be used for development
                                                      purposes.
28                          Male meeting report April 2005




Appendix 1 – India Country Report

                       Prof. Lalit M. NATH, MD, DrPH
                    Voluntary Health Association of India

Area Affected
The coasts of India were struck by the Indian Ocean Tsunami at approximately
9:00 am local time on 26 December 2004. The Tsunami caused extensive damage
on the south and south-east coasts of India in the states of Tamil Nadu, Andhra
Pradesh, Kerala and the Union Territories of the Andaman and Nicobar Islands
and Pondicherry. It affected nearly 2,260 kilometres of coastline and the entire
land area of the Andaman and Nicobar Islands. Tidal waves as high as 10 metres
penetrated between 300 metres and three kilometres inland.

The Andaman and Nicobar Islands in the Bay of Bengal were particularly affected
by the underwater earthquake that caused the Tsunami. A total of 215 aftershocks
were reported in the weeks following the Tsunami. Out of the 37 inhabited islands
in the Andaman and Nicobar group, 15 were affected by the Tsunami and
flooding.

Figure 1 shows the affected areas. The worst hit areas were the Andaman and
Nicobar Islands, which reported the greatest number of missing persons resulting
from the Tsunami, and the southern state of Tamil Nadu, which reported over
7,983 deaths, with over 6,000 from just one district.
                              Male meeting report April 2005                     29

            Figure 1: Areas of India affected by the 26 December 2004 Tsunami




Almost all of mainland India has an extensive network of good roads and the
Tsunami-affected coastal areas were no exception. In general, all-weather roads
connect even the smallest villages. Additionally, both public sector and private
buses regularly service the entire affected mainland area. The transport system in
the Andaman and Nicobar Islands is not overly dependant on roads. Inter-island
communication is almost entirely based either on a very limited air-ferry system
or a regular marine transport network.

On the mainland, the major occupation of the majority of people affected by the
Tsunami was fishing and related activities such as cleaning, packaging and
transport of fishery products. Some were also involved in aquaculture and
shrimp/prawn farming. Almost all villages also had arable land used to grow food,
usually for local consumption.

In the southern part of India, virtually every sizeable settlement has public sector
schooling facilities. Public sector health infrastructure also exists throughout the
country. A primary health centre is provided for every 30,000 of population and
sub-centres are provided for every 5,000 persons. In the Andaman and Nicobar
Islands, the system was modified to reflect an island population including sparsely
distributed and isolated groups.
30                                     Male meeting report April 2005




Population Affected
A total of 2,731,874 persons were affected by the disaster9. This includes the
entire population of the 15 affected islands of the Andaman and Nicobar group.
The exact urban-rural population is not available, but those affected on the
mainland were mainly from coastal settlements.

In the Andaman and Nicobar Islands, the only town of any size is Port Blair. The
rest of the territory is sparsely populated and still houses many reclusive tribal
groups who are not in regular contact with any outside agency. All together,
perhaps half of the 295,959 inhabitants of these islands live in Port Blair or other
small townships. The rest are very widely dispersed.

Impact
Physical and Infrastructure Damage

157,393 dwelling units in 897 villages were damaged by the Tsunami. A total of
638,297 people were evacuated. Around 14,827 hectares of cropped areas were
damaged. Approximately 10,260 head of cattle were lost and 74,025 boats
destroyed. Though there was some damage to the road network on the affected
coasts, most of the network remained intact and most parts of the coast could be
easily reached. Marine transport between individual Andaman and Nicobar islands
was not greatly affected.

Local telecommunication links were generally disrupted in the Tsunami hit areas.
However, in most situations links were soon restored in most affected towns and
large villages.

On the mainland there was no interruption to routine air transport or shipping.
However, the Andaman and Nicobar Islands suffered a severe disruption of
services. The airport at Port Blair was damaged but soon repaired and functional.
The airport and the Indian Air Force base on the Nicobar Islands were severely
damaged, but have since been restored.

Harbours in the Andaman and Nicobar Islands suffered severe damage, with
almost all jetties and wharfs affected. Telephone lines and communication
equipment were completely washed away. The harbours at Port Blair, Car
Nicobar, Nacowrje (Kamorta) and Nacowrje (Champin) remained functional. Of
the 35 existing lighthouses, only two remained operational.

According to the assessment carried out by government agencies, damage to the
health infrastructure was limited, both on the mainland and the islands.

Rehabilitation and reconstruction in the Tsunami-affected states and territories in
India will cost about US$1.2 billion, as estimated by a damage-and-needs
assessment report prepared jointly by the World Bank, Asian Development Bank
and the United Nations (UN). The assessment report estimates the overall damage

9 Special SITREP No.32-5/2004-NDM-I, Government of India, Ministry of Home Affairs, 18 January 2005
                                 Male meeting report April 2005                                                   31


to assets to be about US$575 million and puts productivity losses at about US$450
million. The reconstruction estimate is higher than these damages, as it takes into
account replacement and necessary upgrade costs. Tamil Nadu is the worst
affected state with reconstruction needs estimated at US$868 million, followed by
Kerala (US$158 million), Pondicherry (US$114 million) and Andhra Pradesh
(US$73 million). The report assessed damages and needs by state and by sector
and concluded that the largest proportion of damage was concentrated in housing,
fisheries and to some extent in infrastructure and agriculture. Reconstruction
needs are estimated at US$490 million for housing and US$285 million for
fisheries.

Mortality

India has officially reported 10,749 deaths from the Tsunami, but this figure may
well be a considerable understatement as 5,640 persons listed as missing can now
be presumed to have died. Taken together, the Tsunami toll in human lives is
probably over 16,000.

                       Table 1: Mortality statistics for affected areas
            States/Territories                        Death toll                     Persons missing

            Tamil Nadu                        7,983                                   0
            Andhra Pradesh                     105                                    11
            Kerala                            171                                    NA
            Pondicherry                        591                                    75
            Andaman     and           Nicobar 1,899                                  5,554
            Islands
            Total                                     10,749                         5,640
                    Source: SITREP 35, Ministry of Home Affairs, National Disaster Management (NDM) division


     Table 2: Demographic details of Tsunami-affected districts in the state of Tamil Nadu




                                                                                        Source: Revenue Department
                          (Similar information is available for the rest of the affected states and Union Territories)
 32                                              Male meeting report April 2005




 Available information has clearly established that amongst those killed by the
 Tsunami, women outnumber men about three to one. In Cuddalore, for example,
 almost three times as many women were killed as men, with 391 female deaths
 compared to 146 men. In Pachaankuppam village, the only people to die were
 women.10 A report by Oxfam notes: "in some villages it now appears that up to
 80% of those killed were women. This disproportionate impact will lead to
 problems for years to come unless everyone working on the aid effort addresses
 the issue now. We are already hearing about rapes, harassment and forced early
 marriages".

 One report concluded that women suffered disproportionately because they had a
 more difficult time outrunning the surging waters or were at home while the men
 were fishing out at sea or working in the fields.

 Morbidity

 A total of 6,913 people were reported injured in the areas of India affected by the
 Tsunami. Comprehensive data is unavailable, but Table 3 provides details of the
 morbidity experienced in Cuddalore, one of the worst hit districts of Tamil Nadu.

                         Table 3: Morbidity data collected for 15 days from Cuddalore
    Date            Injuries   Fever     ADD          ARI        Skin       Others                            Total         Measles
(dd/mm/yy)
  29/12/04                60            721              0          1,561               0         2,324         4,666             0
  30/12/04               105            890              0          3,321               0         4,560         8,876             0
  31/12/04                 0            460             33          1,304               0         2,430         4,227             1
  01/01/05                 0            439             11            888               0         2,361         3,699             2
  02/01/05               191            694              7            997              34         1,353         3,276             6
  03/01/05               250          1,160             53          2,079             249         6,923        10,714             2
  04/01/05                 8            215              9            992               7         3,338         4,569            13
  05/01/05               144          1,394             26          2,859               6         4,821         9,250             1
  06/01/05               112            398             22          1,140              37         1,647         3,356             3
  07/01/05                64            423             28            790               0           952         2,257             0
  08/01/05                53            367             16          1,110              10         1,774         3,330             6
  09/01/05                55             67              0            461               9           566         1,158             0
  10/01/05                41            167             18            527               4           602         1,359             0
  11/01/05                52            138             15            508               0           605         1,318             3
   Total               1,135          7,533            238         18,537             356        34,256        62,055            37
                                                      Key: Acute Diarrheal Diseases (ADD), Acute Respiratory Infections (ARI).


 Epidemics and Infectious Disease: There was surprisingly little morbidity from
 disease outbreaks in the aftermath of the Tsunami. The breakdown of the water
 supply and sanitation systems raised fears of outbreaks of diarrhoeal disease.
 Other factors, such as over-crowding, had the potential to contribute to outbreaks
 of communicable diseases. However, no outbreaks were reported.

 The Ministry of Health closely monitored the sporadic incidents of diarrhoeal
 disease and few reported cases of measles. 75 medical camps/teams were
 functional in Tamil Nadu. 101 stationery medical teams, 72 mobile medical teams
 and 568 para-medical teams were deployed to provide medical aid to the victims


 10 Oxfam. (http://www.oxfam.org.uk/what_we_do/issues/conflict_disasters/bn_Tsunami_women.htm)
                                    Male meeting report April 2005              33


in Andhra Pradesh. In Kerala, the state government deployed 224 doctors in the
affected areas and set up 40 medical camps.

A medical team led by the Director General of Health Services went to Port Blair
to coordinate health efforts in the Andaman and Nicobar Islands. In addition to
staff of the armed forces, 80 doctors and 20 nurses from central institutions were
deployed to various islands. A 120-bed hospital operated on the INS Magar.
Emergency medicines and disinfections were delivered as early as 3 January 2005.
In total, 148 specialised medical teams were deployed in the islands.11

Reproductive Health: There is little information available about the numbers of
pregnant women affected by the Tsunami. However, an estimate can be made
based on the crude birth rate for the affected areas. The rate in Tamil Nadu is
around 18.5 per thousand population. As the total population of the affected parts
of the state was 896,163, one can expect 16,579 births in a year or 8,289 women
to have been pregnant at a period of gestation varying between three and nine
months. Of these about 1,381 women would have been in the final month of
pregnancy. In Tamil Nadu, over 94% of deliveries are institutional and it can be
assumed that interventions would have been sought for delivery wherever
available.

There is no data about pregnancy wastage, although there are anecdotal reports of
women having given birth soon after the Tsunami.

Another problem has arisen where couples that favoured sterilisation as a method
of family size limitation have lost their children. Government officials in Madras
have announced that families who lost all of their children to the Tsunami would
be offered free sterilisation reversal procedures at government hospitals. The
Community Health Education Society, a Madras-based non-governmental
organisation (NGO) providing counselling to Tsunami victims in Tamil Nadu, has
said that more than 600 women and about 100 men who had undergone
tubectomies or vasectomies were desperate to reverse their sterilisation.

Psychosocial Health: Survivors from the areas affected by the Tsunami are very
likely to have severe psychosocial problems, particularly those who lost loved
ones. Perhaps most at risk are child survivors who have witnessed the fury of the
Tsunami and women who have lost children and family. Reports are available of
such disorders in all the usual manifestations, including severe depression, post-
traumatic stress disorder, suicide and violence/aggression.

Inevitably, many children lost one or both of their parents. Initial estimates show
that 1,744 children under the age of 18 were orphaned and 1,450 lost one parent.
Of the children orphaned, 644 are five years of age or younger and 800 of those in
the same age group have lost one parent. In Nagapattinam, the worst affected
district, 200 children are reported to have been orphaned, while many more have
lost one parent. The government, backed by some NGOs, has decided not to
encourage the adoption of such orphans outside India. A strong feeling has
emerged that both the children and the community would prefer for the orphans to
be cared for in their own community.

11
     WHO report dated 4th January
34                                Male meeting report April 2005




In addition, reports indicate that 11,750 children were separated from their
families in the affected areas, with nearly 15,000 youngsters, including 6,133
infants, missing.12

As one report stated: “children are among the most affected Tsunami survivors,
both emotionally and physically. They are often found sitting at the seashore,
gazing blankly at each other, not knowing what to do”.13

There is a need to provide counselling and social support to victims, especially
those who are bereaved. The World Health Organisation (WHO) is in discussion
with the National Institute of Mental Health and Neurosciences (the WHO
collaborating centre for mental health), the Indian Psychiatry Society and the
Vidyasagar Institute of Medical Sciences, New Delhi to help the agencies in the
affected districts as soon as possible.

Environmental Health: With the exception of the Nicobar Islands, the drinking
water supply in most affected areas was reported normal. Adequate quantities of
bleaching powder/halogen tablets were made available to the affected areas on the
mainland. In Port Blair, 80% of the piped water supply was restored by early
January. Three water points were established with diesel generating sets in Car
Nicobar.

Displacement
While the total number of people displaced is not precisely known, authorities
report relocating 647,556 people to safer places, including 112,517 who were
housed in the 256 camps that were set up. Other people moved in with friends and
relations in nearby towns.

There is little evidence of large-scale permanent migration. Most displaced
persons either sought shelter in one of the 256 emergency camps, moved to higher
ground or moved further inland. There are some anecdotal accounts of families
who had moved to the Andaman and Nicobar Islands for work returning to the
mainland.

Following the disaster, shelter was provided by local authorities, NGOs and other
organisations, often in schoolhouses and other public buildings. Within a few
days, tents became available and were widely used. The Andaman and Nicobar
Islands, which sustained extensive damage to isolated settlements and villages,
received an airlift of 15,612 tents. In many places, temporary structures were put
up with galvanised iron (GI) sheeting as roofs. By the middle of January, 46,375
GI sheets had been dispatched to affected states and a further 294,000 were on
order to be shipped to the Andaman and Nicobar Islands for the construction of
temporary shelters.

Within a few weeks of the Tsunami, most civic services were restored, including
transport and communication. Schools were arranged for displaced and affected
12
     The Hindu, 12th January 2005
13
     ACT Situation Report, ASRE51/India 02/05
                                Male meeting report April 2005                           35


children, with some children from Car Nicobar being evacuated to schools in Port
Blair, Chennai or even Kolkata.

        Figure 2: WRO India map of health rehabilitation initiatives in southern India




Responses
Immediately after news of the Tsunami came in, the Government of India
mobilised central resources, including the armed forces. The respective state
governments concentrated on the rescue of those trapped or isolated by the
Tsunami. The initial focus was immediate relief, water, food and shelter. Local,
national and international NGOs, especially those with offices in the affected
states, worked alongside government teams to ameliorate the effects of the
disaster. WHO (India) immediately established a local coordination office in
Chennai and other UN agencies contributed their respective expertise. The
Director General of Health Services convened a meeting of public health experts
to plan immediate and mid-term interventions.

The Government of India refused financial help from overseas, stating that India
had adequate resources to cope with the disaster. Help was requested from the
World Bank and Asian Development Bank to assess the extent of loss and
damage, as well as the anticipated rebuilding costs.

In the Andaman and Nicobar Islands, the government took responsibility for
rescue and rehabilitation work. The Voluntary Health Association of India, the
largest network of public health NGOs in India, was requested by the government
to take responsibility for the Hut Bay area. Teams were sent to the area in less
than 24 hours.
36                              Male meeting report April 2005




The WHO (India) Office and the Government of India collaborated actively in
augmenting the human resources available to offer psychosocial support. With the
involvement of various partner organisations the following actions were initiated:

     •   WHO led a UN Disaster Management Team to Chennai to assess the
         situation.
     •   WHO, together with UNICEF and UNDP, developed a framework for
         providing psychosocial support for affected populations.
     •   Contracts were initiated with NIMHANS in Bangalore, VIMHANS in New
         Delhi, SCARF in Chennai, the Medical College in Alleppy, JIPMER in
         Pondicherry and SMHA in Kerala.
     •   A state-level consultation was held on 24 January 2005 and an action plan
         finalised for Tamil Nadu.
     •   The Tamil Nadu government set up a cell in the Department of Social
         Welfare for coordinating psychosocial support.
     •   766 persons were trained in Tamil Nadu; 100 teachers were trained in
         Pondicherry; psychosocial interventions were provided in relief camps in
         Kerala; and 57 community-level workers were trained in Nagapattinam.
     •   A training manual for helping children was developed by VIMHANS.
     •   At a meeting of WHO, UNICEF and VIMHANS representatives held in
         Chennai from 22 to 24 February 2005, a training manual to be used for
         providing psychosocial support was reviewed and finalised. A list of master
         trainers was also prepared.
     •   Technical assistance was provided to Kerala to develop a sustainable
         strategy using existing infrastructure in the Health Department. Similar
         discussions were also initiated with Andhra Pradesh.
     •   Psychologists were made available to assist initiatives in the affected states.
     •   The training of NGO volunteers in providing psychosocial support in
         affected areas of Kerala, Andhra Pradesh and Pondicherry was expanded
         through medical colleges.

Priority Issues Identified
The immediate focus in response to the disaster was on rescue and providing food,
water and shelter. Subsequently, the focus shifted to include medical care, family
reunification and better relief camps. As many people had lost their homes and
possessions, clothing also had to be provided.

Most of those affected were either families of fishermen or involved in local fish
processing. With over 74,000 boats destroyed and in view of the severe
apprehension felt by many victims about returning to the sea, psychosocial
rehabilitation ultimately became a priority in order for victims to resume their
livelihoods.
                               Male meeting report April 2005                         37


Conclusions
The experiences of the Tsunami, the earlier Gujarat earthquake and the Orissa
cyclone have contributed many useful lessons for the management of similar
future episodes in India.

The main problem was not one of securing aid, but of coordinating and managing
it effectively. Inappropriate aid, such as cooked food that could not be distributed
in time and food not liked by the local population, led to a waste of time and
resources. Donated clothing was often not suitable for local conditions and not
always culturally appropriate. Ultimately, much of the contributed clothing was
broken down for conversion to rugs.

In addition, the large numbers of individuals or organisations providing aid led to
confusion. In areas where aid efforts were well coordinated, such as the worst hit
district of Nagapattinam, where a single person in a position of authority was
responsible, aid reached all those in need and resources were well used.
Accordingly, the local senior administrator, Deputy Commissioner, Collector or
District Magistrate should be given explicit responsibility for coordinating all
relief efforts in the event of a major crisis such as an earthquake, cyclone,
hurricane or Tsunami. Training of officers in coastal districts should also be
routinely organised.

The role of local community-based organisations and of existing NGOs should be
encouraged. These groups have a long-term presence in the community and play a
vital role in ensuring the eventual restoration of the area. Larger organisations,
whether country based or international, tend to phase out their assistance after the
initial phase.

Visits by VIPS have mixed results. Though they may boost the morale of both aid
providers and victims, they distract local authorities from more directly aid-linked
activities.

Interventions for responding to an acute emergency, such as the Tsunami, must
necessarily be planned as a phased effort. The initial need is rescue and first aid
help to the injured. Soon after, provisions must be made for water, food and
shelter. After that, rebuilding starts and water, electricity and telecommunication
links are restored. Finally, efforts must be made to make communities self-
supporting and to help people return to their previous occupations. Resources
must be made available to ensure that effective interventions continue as long as is
required.

Good public health interventions are necessary to minimise the incidence of
infectious disease, but there must also be measures for the early detection of and
immediate intervention in outbreaks. The district health officer must put affected
areas under a system of sensitive disease surveillance with a prompt response
component. Each district must designate a rapid response team, with an ever-
ready emergency kit. The rapid response team could be composed of existing staff
at the district health office, but it is desirable that there be at least one person with
formal training in public health/epidemiology.
38                           Male meeting report April 2005




To provide shelter in the event of a Tsunami, or the more likely storm surges,
cyclones or hurricanes, specially reinforced structures should be mandated for
buildings such as schools, community meeting halls, etc. All new buildings should
be constructed at a distance from the shoreline, preferably on higher ground.
Another option is to put buildings on stilts in risk prone areas. Similarly, the great
protective benefit of dense vegetation such as mangroves and casuarina has been
adequately demonstrated by the Tsunami. Further denudation of mangroves must
stop and efforts be made to re-establish protective vegetation wherever possible to
create an effective “bio-shield”.

Public awareness programmes should be initiated in Tsunami-prone areas,
including appropriate action to take on land or at sea. The government should also
encourage insurance programmes for life, boats, habitations etc. in risk prone
areas.
                                Male meeting report April 2005                                      39


Appendix 2 – Republic of Indonesia Country Report

                             Melania Hidayat, MD, MPH
             National Programme Officer on Reproductive Health
                                   Philip Stokoe, MD
                           Director of Operations in Aceh
                         UNFPA Indonesia Country Office


Area Affected
The massive earthquake that occurred off the west coast of Sumatra at 7:58 am on
26 December 2004 triggered the subsequent Tsunami flood wave that devastated
the Aceh region. Seawater swept up to five kilometres inland causing massive loss
of life and damaging homes and buildings, roads and bridges,
telecommunications, water sources and electricity supplies, crops, irrigation and
fishery infrastructures, schools, health facilities and medical supplies.

Population Affected
The Tsunami devastated and shocked the communities living in Aceh province,
where the population was estimated at around 4.35 million pre-Tsunami.
                         Table 1: Distribution of population and IDPs
No    District                          Population pre-Tsunami              IDPs
1.    Kodya Banda Aceh                                         269,091                        120,000
2.    Aceh Selatan                                             200,000                          5,448
3.    Aceh Besar                                               306,718                        116,984
4.    Aceh Barat                                               227,278                         47,921
5.    Aceh Utara                                               395,800                         97,942
6.    Pidie                                                    517,452                         49,421
7.    Bireun                                                   350,964                         35,648
8.    Lhok Seumawe                                             156,478                         17,000
9.    Aceh Jaya                                                 93,547                         31,465
10.   Nagan Raya                                               152,748                         11,281
11.   Aceh Barat Daya                                          153,411                           N/A
12.   Aceh Timur                                               253,151                         22,000
13.   Langsa                                                   141,138                           N/A
14.   Aceh Tenggara                                            168,034                           N/A
15.   Aceh Tengah                                              158,641                          3,454
16.   Simeuleu                                                  76,629                         22,849
17.   Gayo Iues                                                 83,695                           N/A
18.   Aceh Singkil                                             174,007                           N/A
19.   Aceh Tamiang                                             238,718                          2,800
20.   Kodya Sabang                                              27,447                          2,400
21.   Bener Meriah                                             120,000                            948
      Total                                                  4,264,947                        479,561
                                                                 Source: Bakornas report 11 January 2005
40                          Male meeting report April 2005




Impact
Physical and Infrastructure Damage

Services in the provincial hospital RS Zainul Abidin, which was the main referral
hospital for comprehensive emergency obstetric care, collapsed in the first weeks
of the disaster. Seawater and mud flooded the hospital building and destroyed
equipment, drugs and furniture. A small part of the hospital later reopened,
providing emergency room services, adult and child care, but not emergency
obstetric care.

The military hospital and the private Fakinah hospital in Banda Aceh remained
functional after the disaster. Both hospitals focused on the provision of emergency
medical services. Maternity wards were converted to absorb the wounded and
injured. Following the Tsunami only Fakinah hospital maintained the capacity to
conduct a caesarean section.

The referral system for emergency obstetric care collapsed for both the general
population of Aceh and the internally displaced population (IDPs).

According to data collected up to 11 January 2005, 41 puskemas – health facilities
capable of providing basic emergency obstetric care – were damaged out of 240 in
Aceh Province. Three puskemas out of six were totally damaged in Banda Aceh
city.

Official figures from the Ministry of Health estimated the number of health
provider personnel who suffered from the disaster to be 634, with 251 dead and
357 missing. This excludes those working in the private sector.

According to the Indonesian midwifery association, a large number of midwives
were lost. In addition, those that survived lost almost all their equipment and
supplies, limiting what they could offer in terms of services.

Mortality and Morbidity

On 26 March 2005, Bakornas, the national Natural Disaster Management
Coordinating Board, ceased issuing updates on the numbers of reported dead and
missing as a result of the Tsunami. As at 30 March 2005, the total number of dead
and buried stood at 126,602 in Aceh and 130 in North Sumatra (Table 2).

Based on information provided by the satlak (the coordinating body at the district
level), Bakornas reported on 30 March 2005 that the number of displaced people
stood at 514,150 in Aceh and 19,620 in North Sumatra. Duplicate registration of
IDPs is likely, given the high mobility of the population (Table 2).

Estimates of population loss have reached as much as 280,000 people in Aceh
Province. Around 130,000 people remain missing, presumed dead. Some
communities perished entirely, other to various degrees, wiping out entire families
and creating many single parent households and unprotected orphans. Greater
numbers of women and children died than men and the demographic implications
                                 Male meeting report April 2005                                         41


of this have yet to be fully assessed. Traditional family and community structures
were destroyed, and traditional, religious and women’s leaders lost.

                       Table 2: Numbers of dead, missing and displaced
     Date          Dead and buried                 Missing                                  Displaced
                  Aceh       N. Sumatra       Aceh       N. Sumatra                  Aceh          N. Sumatra
31-Jan-05           108,110             130         127,749                 24         426,849                 N/A
28-Feb-05           124,829             130         111,578                 24         400,376             19,620
31-Mar-05           126,602             130          93,638                 24         514,150             19,620
                                                        Source: UNOCHA situation report no 38, 13 April 2005


Based on an accurate survey of 1,075 people in one camp, it is evident that more
women and children were lost in the Tsunami than men. Compared to 400 men
between the ages of 18 – 55, there were only 274 women in the same age group.
However, further demographic assessment needs to be conducted to review the
extent of changes to the normal demographic pyramid.

Reproductive Health

            Table 3: Estimated numbers of pregnant women at the time of the Tsunami
                                                           Estimation of maternal indicators for IDPs
                                                     # women at # pregnant        # deliveries # deliveries
No           District        Population     IDPs    reproductive      women         per year      per month
                                                        age

1     Kodya Banda Aceh           269,091       12,000               3,336            284                247           21
2     Aceh Selatan               200,000        5,448               1,515            129                112            9
3     Aceh Besar                 306,718      116,984              32,522          2,769              2,408          201
4     Aceh Utara                 395,800       97,942              27,228          2,318              2,016          168
5     Aceh Barat                 227,278       47,921              13,322          1,134                986           82
6     Pidie                      517,452       49,421              13,739          1,170              1,017           85
7     Bireun                     350,964       35,648               9,910            844                734           61
8     Lhok Seumawe               156,478       17,000               4,726            402                350           29
9     Aceh Jaya                   93,547       31,465               8,747            745                648           54
10    Nagan Raya                 152,748       11,281               3,136            267                232           19
11    Aceh Barat Daya            153,411                                -              -                  -            -
12    Aceh Timur                 253,151        22,000              6,116            521                453           38
13    Langsa                     141,138                                -              -                  -            -
14    Aceh Tenggara              168,034                                -              -                  -            -
15    Aceh Tengah                158,641         3,454                960             82                 71            6
16    Simeuleu                    76,629        22,849              6,352            541                470           39
17    Gayo lues                   83,695                                -              -                  -            -
18    Aceh Singkil               174,007                                -              -                  -            -
19    Aceh Tamiang               238,718        2,800                 778             66                 58            5
20    Kodya Sabang                27,447        2,400                 667             57                 49            4
21    Bener Meriah               120,000          948                 264             22                 20            2
      Total                    4,264,947      479,561             133,318         11,350              9,869          822
42                                Male meeting report April 2005




Displacement
According to figures from the Indonesian government, as of 11 January 2005
there were 645,251 IDPs, with 479,561 scattered over 16 districts and
municipalities in Aceh Province, 165,083 in North Sumatra Province and around
607 in DKI Jakarta Province.

Numbers changed rapidly in the weeks and months following the Tsunami as
some IDPs moved out of temporary shelters to live with neighbours and relatives
or to return to their villages. Some areas remained unreachable for several weeks,
so the numbers of IDPs in these areas was not known.

The sex and age of residents in some camps were recorded, but no further
information was available. Similarly, there is no accurate information or figures
for IDPs living with relatives and host communities, who never registered at the
temporary shelters. These IDPs will still need assistance in the future as the
impact of the Tsunami on livelihoods, income and agricultural crops becomes
more evident and given the added burden for survivors of taking care of extended
families with limited resources and income.

As of 11 January 2005, there were more than 350 spontaneous IDP settlements in
Banda Aceh, Aceh Besar and Pidie districts, with numbers ranging from 40 to
10,000 people. The IDP populations were residing in mosques, schools and public
buildings and also in tents or under plastic sheets.

A report from the non-governmental organisation (NGO) Helen Keller
International (HKI) noted that the median population of the camps was 275 and
the median size 2000 m2. This translates into 3.4 m2 per person. A closer look at
the crowding levels by shelter type shows that tents were the most crowded, with
more than 87% not providing the minimum required floor area per person of 3.5
m2. Despite that, the conditions of 82.4% of the large tents (32-105 m2) were
described as good or fair. This was not the case for the small tents (6-32 m2) or
those made of plastic.

                           Table 4: Camp demographics and crowding
                       Indicator                        Median (Min – Max)
              Population size                                      275  (7 – 1,675)
              Area (m2)                                          1,000 (15 – 8,000)
              Available space (m2/person)                           3.4 (0.5 – 125)
              Underfives (number)                                    11   (0 – 150)
              Underfives (% of total)                                 7    (0 – 25)
                                                         Source: HKI Tsunami relief report, 13-30 January 2005


                                Table 5: Crowding by shelter type
                 Shelter type                     m2/person                      < 3.5m2/person
                                             Median (min-max)                         (%)
     Large tent (>32 m2)                             1.8 (0.5 – 6.2)                          88.2
     Small tent (<32 m2)                             1.7 (0.2 – 2.1)                          100
     Tent of plastic sheet                             2.0 (0.2 – 4)                          93.3
     Building (mosque, school, etc)                2.6 (0.6 – 28.6)                           61.5
                                                         Source: HKI Tsunami relief report, 13-30 January 2005
                            Male meeting report April 2005                     43


Responses
The emergency response from international donors, governments (including the
military), United Nations (UN) agencies and international and national NGOs was
overwhelming and considered to be unprecedented. A Flash Appeal to support
Tsunami-affected countries was issued by the UN on 6 January 2005 in Jakarta,
for the amount of US$977 million. However, such a response requires extensive
coordination, supported by good logistics and communication, in order not to
duplicate efforts and to be most effective.

The following gives details of established and proposed medical aid as of 22 April
2005:

1. Indonesian military: Kesdam Military Hospital. Capacity: 120 beds with two
   operating theatres and three intensive care units.
2. Australian medical team: Fakinah Hospital, Banda Aceh (private hospital).
   Capacity: 27 members with 60 beds and two operating theatres dedicated
   mostly to surgery (plastic, general and orthopaedic)
3. Zainul Abidin public hospital: Australian, New Zealand and German military
   support teams. Capacity: 40 adult beds and 15 paediatric beds, with two beds
   for intensive care.
4. ICRC: field hospital to be located in the soccer stadium in Banda Aceh.
   Capacity: 37 members with 100 beds.
5. Danish Medical team: to be located at the University medical campus in
   Banda Aceh. Capacity: two orthopaedic surgeons and support staff with up to
   100 beds.
6. Estonian medical team: Fakinah Hospital, Banda Aceh. Capacity: 15 members
   working in the emergency department.
7. Singapore military hospital: Senjata IDP camp. Capacity: 30 members
   providing day surgery (orthopaedic and plastic), primary health care and some
   laboratory capacity.
8. Chinese medical team: Banda Aceh airport. Capacity: 35 members providing
   general and emergency surgery and with outreach teams for remote areas.
9. Russian medical team: to be located in Senjata IDP camp. Capacity: 150
   members including 37 doctors and 30 nurses; a military field hospital with no
   surgical capacity.

Conclusions
The experience of responding to the impact of the Tsunami in Indonesia
highlighted several issues that need attention in planning for future emergency
preparedness. Effective coordination is vital. In Indonesia, more than 70 medical
and public health NGOs actively provided care and assistance to the population.
The provision of aid must comply with established SPHERE standards and must
take into consideration cultural issues. Women’s needs in particular were not
properly addressed in the response to the Tsunami. Reproductive health remains a
critical issue.
44                                 Male meeting report April 2005




Appendix 3 – Republic of Maldives Country Report

                        Ahmed Afaal, BappSc(HIM), MA(HSM)
                                 Deputy Chief Coordinator
            Health Relief Unit, Ministry of Health, Republic of Maldives

Area Affected
At approximately 9:00 am local time on 26 December 2004, the group of islands
comprising the country of the Maldives was struck by the Tsunami generated by
the massive underwater earthquake off the coast of Sumatra (Figure 1). The
Maldives is an archipelago of islands in the Indian Ocean that spread over a
distance of 900 kilometres, located between northern latitude 4 to slightly south of
the equator. The land area, which covers about 26 geographic atolls, is grouped
into 20 administrative atolls. The population of the Maldives is about 300,000.

The country faces two main geographic challenges: (a) the presence of a highly
dispersed landmass of very small size, resulting in a highly dispersed population,
and (b) the low altitude of the islands, which have an average elevation of 1.5
metres above sea level. The low altitude means that global warming has always
been perceived as the main long-term risk to the islands.

The country has 1,190 islands, of which 198 were inhabited prior to the Tsunami.
Of these islands, only 28 have a land area greater than one sq km. One-third of the
inhabited islands have a population of less than 500 and 70% of the inhabited
islands have a population of less than 1,000. This extremely low population
density makes the Maldives unique, even among small island archipelagic states.
It raises the cost of delivering social services and of public administration, as there
is hardly any scope to generate economies of scale. It also poses unique challenges
to development, relief and recovery efforts.

The urban population is concentrated in the greater Malé area, home to almost
one-quarter of the population. Continuing immigration from other parts of the
archipelago is placing increasing strain on social and public services in Malé.

     Figure 1: Impact of the Tsunami on the Maldives. Red indicates areas of highest impact and
                              yellow indicates areas of lowest impact.


      N
                             Male meeting report April 2005                       45


The main industries in the country are tourism and fishing. Over a 100 islands are
self-contained resorts. The physical infrastructure in these resorts conforms to
international guidelines. The most developed roads are in the greater Malé area
and in the southern landmasses of the country.

All children in the Maldives have access to the first seven years of formal
schooling. Students are scattered over all the inhabited islands and a school is
available on all these islands. In 2004, there were 225 schools in the country.

Impact
Physical and Infrastructure Damage

As the Maldives has not previously experienced any major disasters, many
facilities were constructed near the seafront, making them vulnerable to the
Tsunami. In the rural islands, the housing infrastructure was very weak and did
not withstand the pressure of the Tsunami. Malé, being highly protected, did not
sustain major damage to its roads and most southern landmasses were also spared
major damage. However, some of the causeways connecting islands were severely
affected. Most public buildings, such as schools, health facilities and mosques,
proved to be of good quality and largely withstood the impact of the Tsunami.

Of the approximately 225 schools in the country, about 37% were damaged to
varying degrees and nine were totally destroyed. In the health sector, one regional
hospital, two atoll hospitals, 19 health centres and 21 health posts were affected to
varying degrees. A large part of the loss was damage to equipment, consumables
and other hospital materials. The cost of capital loss to the health sector is
estimated at US$12 million.

Sanitation infrastructure in the majority of the country was not of a high standard
prior to the Tsunami. The loss to this sector is estimated at about US$6 million. In
the water supply area damage and loss is estimated at about US$5 million.

Mortality

The total reported direct mortality from the Tsunami is 81, including 75 locals and
six foreigners. Table 1 provides a detailed demographic analysis of the fatalities.
Two characteristics are of note. First, the highest number of fatalities occurred in
two age groups: those under the age of ten and those over 60. Second, in all age
groups there were a greater number of female fatalities than male.

In addition to the deaths, some 27 people are reported missing. The trends in the
distribution of the missing people are similar to those of the dead and are detailed
in Figure 2. A total of 27 children under the age of 18 were orphaned as a direct
result of the Tsunami. Data from the National Disaster Management Centre
(NDMC) gives the age and sex of these orphans (Figure 3). No data on the elderly
or widows was available at the time of compiling this report.
             46                                        Male meeting report April 2005



                                       Table 1: Age distribution of dead and missing people
                                                                                                                                     Above
                  Category           Under 10      10 to 19       20 to 29      30 to 39         40 to 49          50 to 59
                                                                                                                                      60
                             F                18             5              2            0                 5                 0           12
              Dead           M                14             2              3            2                 1                 3             8
                             F                 8             2              3            0                 2                 0             1
              Missing        M                 8             1              0            0                 0                 0             2
                             F                26             7              5            0                 7                 0           13
              Total
                             M                22             3              3            2                 1                 3           10


              Figure 2: Distribution of dead and missing                                Figure 3: Demographic Characteristics of
                             by age group                                                              Orphans
                                                                                  18                                      16
                                                                                  16
         6                                                                        14
                                      Dead         Missing          Total                                                            11
         5                                                                      n 12
                                                                                                                                               Male
                                                                                u 10
         4                                                                      m 8                                 7
                                                                                                                                               Female
Number




                                                                                b                                        5
         3                                                                         6         4                 4
                                                                                e                                                3
                                                                                r 4                2   2
         2                                                                         2    0
                                                                                    0
         1
                                                                                         <5        5 to 9 10 to 14 15 to 17           Total
         0   Under 10-19     20-29    30-39    40-49    50-59     60+                                      age group
              10
                                       Age



             There is anecdotal evidence that some people died after long periods of
             hospitalisation, in some cases more than two months, due to injuries sustained
             during the Tsunami. Most of these people were over the age of 60. There was no
             mortality from disease outbreak, since no outbreaks occurred.

             Morbidity

             It is reported that some 1,313 people sustained various injuries due to the
             Tsunami. However, statistics available from the medical relief data report some
             688 cases of injuries. Almost all injuries would have been reported in the very
             early phase of the relief operations. Table 2 gives details of the type of injury and
             the sex of the injured. An additional ten cases of near drowning were reported.

                                             Table 2: Reported injuries by sex
                                   Type of injury                Male         Female                               Total
                        Cuts and bruises                              141          72                                  213
                        Fractures                                      22          17                                    39
                        Head Injury                                     4            4                                    8
                        Minor Injuries                                188         152                                  340
                        Other musculoskeletal injuries                 55          33                                    88
                        Total                                         410         278                                  688

             Epidemics and Infectious Disease: Immediately after the Tsunami, surveillance
             for disease outbreaks was strengthened and daily reports were supplied to the
             NDMC. Despite predictions to the contrary, there was no major disease outbreak.
             Compared to the previous year, there was an increase in the incidence of diarrhoea
                                 Male meeting report April 2005                                            47


above the outbreak threshold shortly after the Tsunami. However, the incidence
quickly stabilised to within a normal range (Figure 4). Similar trends were seen in
other diseases, such as viral fever and acute respiratory infections (ARI) (Figures
5 and 6). None of these diseases reached epidemic proportions.

                     Figure 4: Comparison of Diarrhoea Incidence - 2003/04 to 2004/05

               140



               120                                       Threshold

               100
 No of cases




                80                Tsunami

                60



                40



                20



                0


                                                             Date


                                               2004-05      2003-04       Threshold level


                                                          Source: Department of Public Health surveillance data



                     Figure 5: Comparison of Viral Fever Incidence - 2003/04 to 2004/05

               500             Tsunami
                                                                                       Threshold
               450


               400


               350


               300
 No of cases




               250


               200


               150


               100


                50

                0


                                                             Date


                                               2004-05      2003-04       Threshold level

                                                          Source: Department of Public Health surveillance data
48                           Male meeting report April 2005




                     Figure 6: Comparison of ARI Incidence - 2003/04 to 2004/05
                                                                                                  Threshold
               450


               400           Tsunami
               350


               300
 No of cases




               250


               200


               150


               100


                50


                0


                                                        Date


                                           2004-05      2003-04      Threshold level

                                                     Source: Department of Public Health surveillance data


A month after the Tsunami, there were concerns of possible outbreaks of mumps
following the diagnosis of nine children between the ages of six and 13 at the
Hulhumale temporary accommodation facilities for internally displaced people.
These cases were distributed between four of the 15 families living in the facility.
However, proper precautionary measures prevented the disease from spreading.
Sporadic cases of mumps continued to be reported from a number of islands,
especially those hosting displaced people.

A few weeks after the Tsunami, a large number of crow deaths were reported in
the country. Swift action was taken to investigate the cause and also the possible
threats to humans. Investigations showed that the virus was not a usual pathogen
of humans.

Reproductive Health: It is estimated that there were approximately 4,000 pregnant
women in the Maldives at the time of the Tsunami. There is no record that any
pregnant woman died as a direct result of the Tsunami. However, reproductive
health conditions resulting from the effects of the Tsunami may arise in the future.
It is also important to note that, given the culture and tradition, many reproductive
health conditions, especially reproductive tract infections, may not have been
reported due to the reluctance of individuals to seek care.

Psychosocial Health: Psychosocial interventions are one of the least developed
areas in the social sector. The impact of the Tsunami on the psychosocial status of
the people created a major demand for these services that the Maldives does not
have the capacity to meet. Despite this, the relevant government, non-
governmental and voluntary organisations initiated psychosocial assessments and
interventions. International aid has also been overwhelming in this respect.
                             Male meeting report April 2005                        49


Emergency and intermediate outreach teams reached some 2,000 – 3,000
internally displaced people and conducted counselling and psychological first aid.
Furthermore, emotional support brigades were established within communities
and psychological first aid training given to these groups.

A number of social issues, especially those related to congested living conditions,
were reported. Anecdotal evidence suggests an increased incidence of gender-
based violence and of theft.

Displacement
According to a Joint Assessment Report by United Nations agencies, about 12,482
people were initially displaced by the Tsunami, of which 6,681 were internally
displaced in their original islands of residence and 5,801 were temporarily
displaced on other islands. A large percentage of those displaced were housed in
temporary accommodation facilities. Within four months of the Tsunami the
number of internally displaced had been reduced to 5,542.

Responses
The health sector was quick to respond to the disaster. Within three hours of the
Tsunami the sector mobilised a task force with clear responsibilities to initiate
relief work. The major weakness in responding to the disaster was the lack of a
proper response plan. Despite this, medical relief operations started in an
organised manner. Relief items, especially medicines, were dispatched with the
help of locals returning to their islands from the capital. This proved to be the only
effective way to reach populations quickly. Despite the lack of communication,
the health system continued to function effectively.

The national coast guard played a crucial role in evacuating the injured to
hospitals in the capital and elsewhere. Within about 72 hours, the majority of the
injured had been attended to and an intermediate relief phase started. Surveillance
was strengthened and a parallel surveillance mechanism was established to ensure
that any possible outbreaks of disease were quickly recognised and attended to.

The health sector response was delivered in three stages. The emergency response
stage looked at establishing a health task force, attending to the injured, initiation
and dispatch of medical supplies, initiation of a parallel surveillance system,
initiation of psychological support, establishing contact with health facilities and
initiation of damage reporting.

The intermediate stage looked at assessing the situation and strengthening the
interventions of the emergency phase. The delayed response stage looked at
reconstruction and rehabilitation of health, water and sanitation facilities and at
implementing a steady transition to a normal situation.

It is important to note the independent work of the community in responding to
the Tsunami. Many boat owners coordinated with the government relief
operations, especially in the provision of water to the communities.

A large number of international relief assistance was also provided. However,
given the circumstances, there was a delay in international relief teams reaching
50                            Male meeting report April 2005




the country. By the time some of these teams arrived in the Maldives, the injured
had been attended to. Some medical teams had to be posted in hospitals for
routine elective surgeries and consultations in low impact areas. A large number
of medicines were also donated. These were quickly distributed to health facilities
throughout the country. However, some medicines donated had expired and others
had instructions in languages other than English and could not be used.
Furthermore, extremely large numbers of specific relief items proved to be more
of a burden than a help. However, most agencies coordinated with local relief
operations to identify the needs on the ground before relief items were dispatched.

Overall, the response to the disaster was overwhelming and was managed
reasonably well given the capacity of the country to address such a situation.
Considerable challenges remain in managing ongoing donor assistance and
coordinating this assistance properly.

Priority Issues Identified
Priority needs and issues can be divided into the immediate requirements and into
the much broader, longer-term requirements. The immediate priorities included:

     •   Reconstruction and rehabilitation of housing, schools and health facilities
     •   Continued psychosocial support
     •   Continued disease surveillance of the displaced population
     •   Ensuring access to adequate amounts of safe drinking water and food in the
         displaced populations
     •   Managing donor assistance and coordination

The broader and medium to longer-term themes include:

     •   Development of a comprehensive disaster reduction and management
         strategy
     •   Capacity building for interventions, especially psychosocial support
     •   Empowering communities to react to disaster situations through early
         warning systems, drills and other actions

Following the Tsunami, the population and development consolidation
programme initiated by the government in the 1990s has been stressed. Voluntary
relocation to safer islands with potential for development has increased. New
services and facilities will need to be developed to assist the integration of the
settlers, but it must be ensured that these are not of a higher standard to those in
place for the existing residents.

Conclusions
The South-Asian Tsunami devastated the islands of the Maldives as a whole.
Although the number who died or who were injured was relatively small in
proportion to the total population, the whole country was affected by the disaster.
Yet despite the lack of a proper disaster management plan, quick action was taken
to relieve the population from the effects of the Tsunami.
                            Male meeting report April 2005                      51


Overwhelming donor assistance was provided to the country, most of which was
received in good time and was useful. However, the country has a very limited
capacity to absorb the costs of rebuilding and the implementation of the short and
long-term relief operations. As a result, the Tsunami reconstruction and
rehabilitation efforts are not proceeding quickly, although well-planned strategic
action is being undertaken to relieve the population from the stress and tension of
the disaster. The health situation of the dispersed population needs to be
continuously monitored and special emphasis is required in the area of
psychosocial support. Capacity building and empowering the population to react
to disaster situations will be a challenge. The water and sanitation situation, as
well as environmental damage, need further assessment and swift action.

The immediate relief operations following the Tsunami on 26 December 2004
were quite successful in the Maldives. However, long-term action with regard to
reconstruction and rehabilitation, leading to restoration of normal livelihoods,
remains a major challenge.
52                          Male meeting report April 2005




Appendix 4 – Somalia Country Report

                                Joyce Jett Ali MA
             Director, Advance Development International (ADI)
                      Member of the Board, Horn Relief

Area Affected
The Tsunami caused by the earthquake off the northern tip of Sumatra on 26
December 2004 hit the north-east coastline of Somalia about seven hours after it
was triggered, at around 11:00 am local time. While the Tsunami struck a number
of countries on the east coast of Africa, Somalia was the worst affected.

The stretch of coastline affected covers approximately 650 kilometres between
Hafun (Bari region) and Gara’ad (Mudug region) in Puntland. The worst hit towns
and villages include Hafun, Bender Beyla, Kulub, Garacad and Dharin Raqas.
Hafun was the most devastated, with the majority of its infrastructure destroyed.




                                                   Source: WHO South Asia Tsunami Situation Report 21


Population Affected
The total coastal population in the area between Hafun and Gara’ad is estimated to
be 44,000, roughly 7,300 households. The people of this region are mainly from
the Majarteen sub-clan of the Darood. Communities occupying the coastal areas
stretching from the Hafun peninsula to Gara’ad have strong social and economic
links with pastoral communities in the area.
                            Male meeting report April 2005                      53



The movement of pastoralists from the hinterland towards the coast, especially to
profit from fishing opportunities, had increased during the previous years as
inland pastoral livelihood zones suffered due to a series of natural disasters that
killed off much of their livestock. Some also came from urban centres, such as
Garowe, Bossaso, Qardho and Galkayo, as well as areas in the south. These
groups mostly came for the eight to nine months fishing season from late
September to April/May and are therefore categorised as seasonal migrants. Some
have settled along the coastline and are categorised as recent migrants. This has
led to a number of new semi-permanent and permanent coastal settlements
developing. The population of the Puntland coastline can therefore be divided into
three categories: residents, recent migrants and seasonal migrants.

The fishing industry was by far the most important in terms of household income
for the coastal population. The resident communities mainly depended on
commercial fishing of lobster, shark and kingfish for export. With the exception of
the main towns, the settlements primarily existed for fishing. There was limited
livestock husbandry and minimal small-scale shallow-well and spring-fed farming
of vegetables and rain-fed cowpeas.

A rapid assessment of Bender Beyla district, Bari Region by Horn Relief, a
Somali non-governmental organisation (NGO), established that 10 villages in this
area with a total number of households estimated at 2,340 were affected. Another
initial assessment of the region by Reliefweb asserted that as many as 18,000
households had been adversely affected. The lack of proper baseline data and high
levels of seasonal migration make accurate assessments of population figures for
these communities difficult. These estimates are based on community input and
observation.

Impact
Very little baseline information existed for the area hit by the Tsunami. The
Tsunami Interagency Assessment Mission (TIAM) estimated that following the
Tsunami 2,304 people faced a humanitarian emergency and 16,920 people a
livelihood crisis. The Tsunami and the destruction left in its wake pushed a
proportion of Somalia’s middle class into poverty. Prior to the Tsunami, the poor
made up 30-40% of the population. Post-Tsunami, this group grew to 45-55%.

The TIAM assessment gives no breakdown of the demography of survivors.
However, it is evident that the Tsunami increased the vulnerability of already
vulnerable groups, such as orphans, widows, the elderly and the disabled.
Organisations such as the Woman’s Edge Coalition are highlighting the effect of
the disaster on women, including new ‘Tsunami widows’ who have become fully
responsible for their families following the death of their spouses. Some groups
are recommending special training for women to give them the skills necessary to
rebuild family businesses or learn a new trade.

Physical and Infrastructure Damage

An estimated 600 fishing boats were lost or destroyed by the Tsunami and an
estimated 75% of fishing equipment lost or damaged beyond repair. The increased
54                           Male meeting report April 2005




dependence in recent years of coastal communities on fishing as a source of
income means that the Tsunami will have an even greater impact on their ability
to provide for their families than it would have done in previous years.

The existing road infrastructure in the region was poor and was further damaged
by the Tsunami. The access road to the Hafun peninsula, which had previously
been open during low tide, was cut off due to damage. As a result, food and non-
food prices initially increased in the region and humanitarian organisations found
some coastal communities difficult to reach.

The Tsunami contaminated the shallow water wells along the entire coastal strip.
Clean drinking water had to be trucked in from inland sources. Consequently, the
price of clean drinking water increased between Hafun and Gara’ad.

The lack of basic and referral health services in the area and the poor quality of
those that do exist remains a matter of serious concern. With the exception of
polio and tetanus vaccination campaigns, vital services were not being provided.
36 villages in the region hit by the Tsunami had no functioning health facility. The
nearest referral hospitals at Bossaso, Garowe and Galkaya are 400-600 kilometres
away and transport is expensive and unreliable. Access to health care remains a
major obstacle to receiving treatment. However, the Tsunami was not responsible
for the destruction of Somalia’s health facilities. The health infrastructure had
been overwhelmingly destroyed during years of war and poverty. The continuing
political instability in Somalia contributes to infrastructure problems.
The schools in Kulub (Jeriban district) and Hafun (Hafun district) were totally
destroyed by the Tsunami. The school in Hafun was replaced with a temporary
school put in place by UNICEF. The other existing schools in Bender Beyla, Eyl,
Gara’ad and Dhinowda continued to function. However, the payment of teachers
has been affected as families are no longer able to pay the school fees and there is
a serious risk that the still functioning education infrastructure will collapse.

Mortality

The UN Office for the Coordination of Humanitarian Affairs (UNOCHA)
reported that 298 people were killed as a result of the Tsunami in Somalia.

Morbidity

Epidemics and Infectious Disease: With the exception of an increase in cases of
diarrhoea, which lasted two weeks in Hafun and persisted in some villages of the
Jeriban district, the TIAM assessment completed on 8 February 2005 reported no
cases of meningitis, cholera or malaria, no cases of malnutrition and no immediate
major health problems in the villages visited. There were some unconfirmed
reports of deaths due to diarrhoea amongst the community in Gara’ad. The World
Health Organisation (WHO) documented an increase in malnutrition in Tsunami-
affected areas of Somalia. However, they confirmed that there were no major
disease outbreaks as a result of the Tsunami.

The poor quality of available water, lack of sanitation and poor hygiene practices
represent a big public health hazard. The presence of vectors such as flies, mites,
mosquitoes, lice, scabies and rats are an added risk factor. As a result, the main
                             Male meeting report April 2005                        55


issues addressed in terms of recovery following the Tsunami were related to
maintaining access to safe water and improving hygiene and sanitation while
ensuring provision of oral rehydration solutions and health education.

The main diseases and illnesses reported by health workers or local communities
remained similar to the pre-Tsunami situation, ie. diarrhoea, acute respiratory
infections, skin diseases such as scabies and fungal infections, conjunctivitis,
arthritis and anaemia.

Reproductive Health: The TIAM assessment reported that there were only three
functioning MCH/OPD services in Hafun, Bender Beyla and Gara’ad and one not
functioning in Beday, Eyl. Nurses, community health workers, traditional birth
attendants and traditional healers staffed these erratically.

There are no figures that indicate how many pregnant women were put at risk in
Somalia as a result of the Tsunami. The UN Population Fund (UNFPA) estimates
that 15 percent of pregnant women in the countries affected by the Tsunami would
have been likely to suffer pregnancy complications even before the disaster and
that this rate would necessarily increase following the Tsunami due to its impact
on health facilities.

According to UNICEF, Somalia has the sixth highest child mortality rate in the
world. Given the already critical reproductive health situation in Somalia, it is
unlikely that the Tsunami had a serious impact on it.

Psychosocial Health: It is reported that following the Tsunami, depression, trauma
and increased rates of violence and suicide are widespread throughout the affected
area. However, with few formal assessments undertaken or diagnostic specialists
in the area, the depth of these issues are particularly difficult to characterise. The
lasting psychosocial effects of the Tsunami may only become clear in the months
and years ahead.

Although the death toll in Somalia was relatively small compared to other
Tsunami-affected countries, numerous households were devastated, especially
where families lost vital, uninsured, fishing equipment necessary for their
livelihood, or for those dependent on the fishing sector in the region. For many
whose equipment remained intact, anxiety about returning to the sea is forcing
families to seek other sources of food and income, although options are limited
and there is little productive agricultural land in the region.

The impact of the Tsunami has exacerbated an already precarious situation, even
for those not directly affected by it. Damage to the coastal region has forced up
the prices of food and other necessities. Fewer families are now able to meet the
costs of school fees for their children to the extent that some schools are
threatening to close. As a result, families otherwise unaffected by the Tsunami are
being split up as parents send their children away to stay with relatives or contacts
in other districts so they can go to school.

Environmental Health: While the wave that struck Somalia did not cause as much
damage or mortality as in many countries of South and South-east Asia, it
nonetheless had a significant negative impact on the coastal region. One of the
56                           Male meeting report April 2005




primary concerns surrounds the material carried ashore by the Tsunami. For the
past 15 years, some European companies have used the waters off the coast of
Somalia as a dumping ground for toxic wastes and hazardous materials. With the
Tsunami the waste containers were moved around, broken open and even carried
as far as 10 kilometres inland. The hazardous waste released is reportedly
affecting the local people, causing health problems and contaminating
groundwater in some areas. Materials that may have been carried inland include
uranium, radioactive waste, leads and heavy metals such as cadmium and
mercury, as well as hospital and chemical wastes.

Displacement
According to UNOCHA, 5,000 people were displaced by the Tsunami and up to
54,000 people affected. Following a humanitarian mission, one UN Emergency
Relief Coordinator reported that one out of ten Somalis were living as displaced
people or refugees, though not necessarily as a result of the Tsunami. Natural
disasters and civil and economic insecurity had previously resulted in considerable
internal displacement in the region.

The areas most affected by the Tsunami were Hafun, Bender Beyla, Dharin Raqas
and Kulub, with a total of 11,520 people. Substantial damage to housing and
infrastructure occurred in these towns. Hafun stands out as being the most
devastated, with the majority of its infrastructure destroyed. A total of 600 houses
were destroyed in addition to shops, mosques and offices. In Bender Beyla, 122
houses were partially damaged. In Eyl, 48 ‘hut-type’ dwellings were destroyed
and 200 houses were reported as damaged in Kulub. It has been reported that
more than 2,000 houses were destroyed and 40 villages affected by the tsumani in
north-east Somalia.

Many displaced people from Hafun set up shelter 300 to 400 metres from shore
using branches and plastic sheets provided by UNHCR, along with non-food items
such as blankets, sleeping mats and kitchen sets. UNHCR planned to rehabilitate
1,000 houses and rebuild another 500.

Responses
The following agencies were active in responding to the impact of the Tsunami in
Somalia:

UN agencies: World Food Programme (WFP), UNICEF, UNHCR, WHO, OCHA,
UN-HABITAT, FAO

Government agencies: The European Commission Humanitarian Aid Department
(ECHO), South African government, Somali Aid Coordinating Body (based in
Nairobi), Humanitarian Affairs and Disaster Management Agency (HADMA)

International NGOs: Médecins Sans Frontières – Holland, Diakonia, VSF-Suisse,
CARE, IFRC/SRCS, Save the Children, American Jewish World Service

Local NGOs: Horn Relief, BMA, the Galkayo Education Centre for Peace and
Development (GECPD), TAAKULO, The Somali Reconstruction and
                            Male meeting report April 2005                      57


Develoment Organisation (SOREDO), SWV, Rahmo Rehabilitation Organisation,
United Somali Professional Organisation (UNISOPO), MRO

Operational agencies, including WFP, CARE and UNICEF responded
immediately. The agencies evaluated the situation and identified needs including
food, shelter, household items, water and emergency medical kits. The first relief
reached Hafun, the most affected town, on 28 December 2004, two days after the
disaster. There were logistical constraints and challenges to reach some of the
affected coastal villages.

WFP started distribution of emergency food relief in Hafun on 30 December
2004, followed by other affected towns and villages on the coastline. 432 metric
tonnes of assorted cereals, pulses and vegetable oil were distributed to 30,500
beneficiaries in 38 different locations.

CARE worked with local partners to distribute foodstuffs including sugar, wheat
flour, milk powder, cooking oil and dates. They also distributed utensils, fuel for
water tankers and materials for constructing latrines. SOREDO distributed this
food in Hafun to 2,500 beneficiaries. TAAKULO distributed food in Bender
Beyla district. SWV distributed food to 900 beneficiaries in Eyl District and
Rahmo distributed food and non-food aid items to 1,237 beneficiaries.
UNICEF assisted 12,000 people in the villages of Hafun, Gara’ad, Bender Beyla
and Eyl. They distributed clean water, shelter materials, cooking sets and
mosquito nets, supported the restarting of schools and, in collaboration with
WHO, provided emergency medical care.

The South African government sent a consignment containing 20 tons of food to
cover the needs of 500 families, 500,000 water purification tablets, 400 tents,
rubber flooring for the tents, 1,000 blankets and four tons of medicine.

The Galkayo Education Centre for Peace and Development distributed necessities
including fuel, flour, rice, sugar, clothes, blankets and plastic tarpaulins to 610
families in four towns in the Jeriban District. They also provided 786 families
with women’s clothes. In addition, they organised two women’s committees so
that women could express their needs to those making decisions about refugee
camp management and resource distribution.

Health partners UNICEF, SRCS, MSF-Holland and WHO met the main
emergency needs created by the Tsunami. Minor wounds were dealt with, basic
essential drugs and materials provided, including two basic emergency kits from
WHO, each sufficient to cover the needs of 10,000 people for three months,
vaccinations, cholera kits, ORS, chlorine for water disinfection and impregnated
mosquito bed nets.

The Joint UNEP/OCHA Environment Unit has taken on the task of assessing the
damage caused by the presence of toxic wastes swept inland by the Tsunami from
containers dumped off the coast.

In January, a group of relief agencies requested US$10 million in a Flash Appeal
to provide humanitarian relief to the affected population of Somalia.
58                           Male meeting report April 2005




Priority Issues Identified
Drinking water, food, medicine and shelter were cited as the highest priorities by
relief agencies working in the affected areas of Somalia. Restoration of
livelihoods and the fishing industry is also critical. Unfortunately, the structural
shortcomings of the region, including the absence or low presence of government
and other implementing bodies and the isolation of coastal communities due to
lack of roads, hindered the assessment of activities and the process of providing
disaster relief to the victims of the Tsunami.

Conclusions
Despite its negative impact, the Tsunami is an opportunity to bring international
attention to a population that has long been neglected and for addressing its public
health needs. It also represents an opportunity for increased coordination and
cooperation between different organisations and agencies operating in the region.
The response to the Tsunami needs to be followed up with additional development
work in the area and the creation of stronger public health systems. It is also an
opportunity to establish disaster preparedness systems at the regional and local
levels in an area that was otherwise totally neglected.

However, it is important that the needs of other vulnerable communities in
Somalia, including those affected by other natural disasters and the civil war, are
not ignored.
                             Male meeting report April 2005                       59


Appendix 5 – Democratic Socialist Republic of Sri Lanka
Country Report

  M.A.L.R. PERERA, MB: BS, M Med.Sc and MD (Community Medicine)
          Health Systems Management Specialist & Senior Associate
                  Health Policy Research Associates (Pvt) Ltd.




Area Affected
Between 9:30 and 10:00 am local time on 26 December 2004, the coast of Sri
Lanka was hit by the Tsunami caused by the underwater earthquake originating in
Sumatra. All the coastal districts from Jaffna in the north, along the east coast and
up to Puttlam on the north-western coast were affected, representing five out of
Sri Lanka’s nine provinces. In the Northern Province, the districts of Jaffna,
Killinochchi and Mullaitivu were affected; in the Eastern Province, Trincomalee,
Batticaloa and Ampara; in the Southern Province, Hambantota, Matara and Galle;
in the Western Province, Kalutara, Colombo and Gampaha; and in the North-
Western Province, Puttlam (Table 1). The total estimated mid-year population of
these districts in 2003 was 1.331 million.
60                                   Male meeting report April 2005



                                     Table 1: Land area by district
                                                                                      Land           % of
     Administrative Area                                                              Area as        Total
     (Province/District)                                                              of 1988        Land
                                                                                      (sq km)        Area
     Sri Lanka                                                                           62,705          100
     Western Province                                                                     3,593         5.73
        Colombo                                                                              676        1.08
        Gampaha                                                                           1,341         2.14
        Kalutara                                                                          1,576         2.51
     Southern Province                                                                    5,383         8.58
        Galle                                                                             1,617         2.58
        Matara                                                                            1,270         2.03
        Hambantota                                                                        2,496         3.98
     Northern Province                                                                    8,290        13.22
        Jaffna                                                                               929        1.48
        Kilinochchi                                                                       1,205         1.92
        Mullaitivu                                                                        2,415         3.85
     Eastern Province                                                                     9,361        14.93
        Batticaloa                                                                        2,610         4.16
        Ampara                                                                            4,222         6.73
        Trincomalee                                                                       2,529         4.03
     North-Western Province                                                               7,506        11.97
        Puttalam                                                                          2,882         4.60
                          Source: 1 Survey General's Department. 2 Based on Census of Population and Housing, 2001


The main economic activities in the affected areas were fishing, agriculture,
tourism, coir, handicrafts and other small to medium scale industries. A good
network of roads existed in all areas. According to the Ministry of Highways, the
density of the road network in 2003 was nearly 1.53 kilometres per sq km. The
affected areas were also home to 3,547 schools that served over 1.5 million
students. The Tsunami-hit areas also had an abundance of health care facilities
(Table 2).

                   Table 2: Distribution of health care institutions in affected areas
                                                                   CD &
     Category      TH    GH      BH      DH       PU      RH                   CD Other                 Total
                                                                    MH
     Number        17     12      29      69      55      49         67        180     7                 485
                                                                 Source: Director of Information, Ministry of Health


Key: teaching hospitals (TH); general hospitals (GH); base hospitals (BH); district hospitals (DH);
peripheral units (PU); rural hospitals (RH); central dispensaries and maternity homes (CD and
MH); central dispensaries (CD)
                                                             Male meeting report April 2005                                                                       61


             Population Affected
                                                Table 3: Population and density, by district
                                     Estimated mid-       Percentage        Density as of                                                                     Population in
                                                                                                                            Average annual
  Administrative Area                year population     Distribution of   2002 (persons                                                                        2003 (in
                                                                                                                             growth rate
  (Province/District)                   as of 2002 2    population as of     per Sq.Km)                                                                        thousands)
                                                                                                                              1981-2001
                                      (in thousands)          2002
Sri Lanka                                           18,955                          100                           302                                1.1                  19,253
Western Province                                     5,442                              29                    1,515                                                        5,471
  Colombo                                            2,263                              12                    3,348                                  1.3                   2,305
  Gampaha                                            2,105                              11                    1,570                                  1.9                   2,089
  Kalutara                                           1,074                               6                        681                                1.2                   1,077
Southern Province                                    2,299                              12                        427                                                      2,324
  Galle                                              1,000                               5                        619                                1.0                   1,011
  Matara                                              767                                4                        604                                0.8                      780
  Hambantota                                          531                                3                        213                                1.1                      533
Northern Province                                    1,042                               5                        126                                                      1,106
  Jaffna                                              481                                3                        518                                -2.0                     589
  Kilinochchi                                         129                                1                        107                                1.6                      140
  Mullaitivu                                          124                                1                        51                                 2.2                      141
Eastern Province                                     1,442                               8                        154                                                      1,518
  Batticaloa                                          496                                3                        190                                1.9                      536
  Ampara                                              601                                3                        142                                2.0                      605
  Trincomalee                                         345                                2                        136                                1.4                      377
North-Western Province                               2,183                              12                        291                                                      2,197
  Puttalam                                            718                                                                                            1.8                      722
                                              Source: 1 Survey General's Department. 2 Based on Census of Population and Housing, 2001


                 Table 4: Estimated percentage of urban population in some Tsunami-affected districts, 2004
                                                                                                                          Trincomalee
                                                                       Hambantota




                                                                                                                                                             Mullaitivu
                                                                                                                                        Batticaloa
                                          Gampaha
                          Kalutara
  District



               Ampara




                                                          Puttlam




                                                                                             Matara




                                                                                                                                                                           Jaffna
                                                                                                          Galla




 %
              20         22               30              17           11                    15          22              40             26                   12            30
Urban
                                                                                                      Source: Population Division, Ministry of Health


             Impact
             Physical and Infrastructure Damage

             The Tsunami had a substantial impact on health care facilities in affected regions.
             Based on figures from the Ministry of Health, 17.3% of curative institutions were
             damaged (Table 5).

                                                  Table 5: Damage to health care facilities
             Type of facility                  Curative        Preventive               Other                                                        Total
              Completely
                                                     12                             1                             2                                   15
               damaged
                Partially
                                                     21                             51                            12                                  84
               damaged
                                                                                                                      Source: Ministry of Health website
62                               Male meeting report April 2005




Vulnerability to sea-related and other disasters was not considered when selecting
the sites for various facilities, even though the national building research
organisation mapped out areas vulnerable to landslides. Most of the secondary and
tertiary care facilities had disaster management plans to cater to a rush of
casualties. However, they did not have plans for hospital evacuation, leading to
much confusion when it was necessary to quickly vacate affected facilities.

161 school were destroyed or damaged by the Tsunami (Table 6).

                               Table 6: Schools in affected areas
 Total number of schools in affected districts                                             3,547
 Total number of students in the 3,547 schools                                             1,551,324
 Number of schools fully destroyed                                                         59
 Number of schools partially damaged                                                       102
 Number of students in the 161 affected schools                                            76,911
 Number of teachers in 161 affected schools                                                3,172
                                                                    Source: Centre for National Operations


Mortality

According to the National Disaster Management Centre (NDMC), 31,187 are
estimated to have died as a result of the Tsunami. The estimate of those missing is
4,280. Among the dead and missing the largest number are women and children,
the most vulnerable in disaster situations. The estimated total population in the
affected districts (based on figures for 2003) is 1.331 million. On this basis, the
mortality rate was 2.67%. The great majority of those who died probably
drowned, while a minority may have died as a result of injuries sustained. There
were no reported deaths from related causes.

Oxfam reports that women died disproportionately in the Tsunami. In some areas,
four times more women were killed than men, creating a gender imbalance that
will lead to long-term social problems for the devastated communities. In some
areas, up to 80% of those killed were women. The Oxfam report suggests this
occurred because many men were working inland or fishing offshore when the
waves hit, while the women were at home. It also suggests that men are more
likely than women to learn to swim and to be more adept at climbing trees. Camp
surveys also suggest a serious imbalance in the number of men and women that
survived.

According to the National Child Protection Authority (NCPA), of those affected
more than 36% were children. The newsletter of the Sri Lanka College of
Paediatricians estimates the number as 80,000.

Morbidity

NDMC estimates put the number injured at 23,189. The ratio of injured to dead is
1:1.53. No specific data is available regarding the nature of injuries sustained.

Epidemics and Infectious Disease: Table 7 shows the incidence of reported cases
of communicable diseases in the welfare camps in the affected areas up to 18
March 2005. It is difficult to calculate rates, since the population in the camps was
                                                                Male meeting report April 2005                                                             63


            not static. In the south, sporadic cases of food poisoning were reported in the first
            few days, mainly due to donations of cooked food that spoiled during transport.
            This problem ceased once food was prepared in the camps. The provincial
            Director of Health Services in the Southern Province personally noted some cases
            of conjunctivitis and scabies and two cases of non-fatal adult tetanus, but these
            cases are not reflected in the official statistics of the epidemiology unit. The
            morbidity pattern reflects the endemic background morbidity, exacerbated by the
            overcrowded conditions in welfare camps that promote both waterborne and
            water-washed diseases.

            It is noteworthy that there were no reports of epidemic outbreaks, despite the
            apprehensions of the World Health Organisation (WHO). This reflects the
            strength and resilience of the Sri Lankan health system, as well as the experience
            and expertise of welfare camps in providing primary health care (PHC) to victims.

              Table 7: Cumulative incidence of notified cases of communicable diseases in the welfare camps
                up to 18 March 2005. (Total population in welfare camps as of 4 March 2005 was 123,298)
                          Viral   Respiratory                              Chicken
             Disease                             Diarrhoea Dysentery                  Mumps Malaria Measles
                          fever    infections                                pox
            Incidence     3,083      2,163         1,538           90         30         25         15      2
                                                                   Source: personal communication from epidemiology unit, Ministry of Health


            Reproductive Health: The sole maternity hospital in the south, Mahamodera
            teaching hospital, was evacuated to the adjoining main hospital, Karapitiya,
            thereby interrupting the management information system. Information from the
            Ampara general hopital shows a slight reduction in the number of total births,
            incidence of stillbirths and abortions for the period January – February 2005, as
            compared to the same period in 2004. Statistics from Matara general hospital are
            similar, except for a slight increase in the number of stillbirths. The fact that the
            majority of Tsunami-related casualties were women, some of whom were
            undoubtedly pregnant, accounts for these trends.
                           Table 8: Estimated numbers of pregnant women at the time of the Tsunami
                                       Hambanotota




                                                                                              Batticaloa &




                                                                                                                                                   Killinochchi
               Colombo &




                                                                                                               Mullaitivu
                                                                                  Kalmunai
                Kalutara




                                                                       Ampara




                                                                                                                              Mannar
                                                       Matara




                                                                                                Trinco




                                                                                                                                         Jaffna
                             Galle




                                                                                                                                                                     Total


District:


No.    of
expectant
mothers       18,833       9,480     3,500           5,050           1,847      5,516        17,634          3,430          1,380      6,990      4,730           80,390


                                                                                                                            Source: Family health bureau.


               Table 9: Pregnancy outcomes such as abortion, low birth weight, pre-term delivery in (a) GH
                                             Ampara, and (b) GH Matara
                (a) GH Ampara
                                            2004 January and February          2005 January and February
                     Total births                        600                                550
                      Abortions                          112                                101
                      Still births                        06                                04
                                                                                                        Source: Medical Superintendent, GH Ampara
64                                Male meeting report April 2005



     (b) GH Matara
                                  2004 January and February              2005 January and February
         Total births                       1637                                   1616
          Abortions                          241                                    222
         Still births                        13                                     15
                                                                    Source: Medical records officer, GH Matara


Psychosocial Health: According to Dr. Neil Fernando, a senior psychiatrist of the
Ministry of Health, the expected incidence of long-term mental health problems is
5 -10%, as per WHO publications. He claims that the incidence of post-Tsunami
mental health problems is lower than the figures quoted, which he attributes to the
resilience of the Sri Lankans. After visiting the Hambantota and Matara districts
and treating victims, Dr. Fernando and his co-workers identified nine groups
needing follow-up care (Table 10).

           Table 10: High risk groups for mental health problems – Southern Province
                                                                    No. of         Percentage of
                                                                 Individuals      Needy Population
 Pregnant women                                                                     134                          3%
 Persons with disabilities                                                          244                          5%
 Youth addicted to drugs                                                             20                     <1%
 Lactating mothers                                                                  686                     13%
 Single parents with preschool children or infants                                  405                      8%
 Elderly citizens (over 60)                                                         902                     18%
 People experiencing chronic illnesses                                              574                     11%
 School age children at the risk of abuse and exploitation                         1684                      33%
 Mentally ill people                                                                119                          2%
                                                     Source: Basic Needs, an NGO working in Southern Province


The Sri Lanka College of Psychiatrists published guidelines on a process of
helping while doing no harm to the dignity of the affected people. The guidelines
covered issues such as coming to terms with loss, restarting normal lives, the
needs of children, and counselling.

In some areas, the ability of people to re-establish their lives and to support each
other appears to have been adversely affected by the tight control held by certain
groups or individuals within communities over the distribution of relief supplies.

Displacement
Mass displacement, both external as well as internal, resulted from the Tsunami
(Table 11). Refugee camps were dotted across the Northern, Eastern, North-
Central & North- Western Provinces. Due to twenty years of ethnic conflict in Sri
Lanka, the health system had gained valuable experience in providing primary
health care and curative care to guest populations, without compromising the
resources of the hosts. In many cases this became an opportunity to strengthen the
existing health system in those areas. The secondary and tertiary care curative
institutions, which had developed disaster management plans to tackle mass
casualties consequent to suicide and car bomb attacks, were then able to adapt
these plans for use following the Tsunami.
                                                    Male meeting report April 2005                                             65

                                      Table 11: Population displaced as of 4 March 2005

                                                Displaced persons                                                 Damaged Houses
 Province/     Affected   Displaced                                                          In-        Miss-                             No. of
                                                      With                    Dead
  District     families    families     In                                                  jured        ing                              Camps
                                                    relatives                                                    Com-
                                      welfare                       Total                                                    Par-tially
                                                       and                                                       pletely
                                      camps
                                                     friends
Northern
Jaffna           14,767      10,827      7,625        33,381         41,006    2,640         1,647        540       6,084        1,114     12 **
Killinochch
i                 2,297        407          0          1,603          1,603     560            670          0         246             -        0

Mullaitivu        6,745       6,007     11,993        10,564         22,557    3,000         2,590        421       5,033          424        23
Eastern
Trincomale
e                30,547      30,545     13,778        59,208         72,986    1,078         1,328         45       4,830        3,835        33

Batticaloa       63,717      12,494     20,962        35,047         56,009    2,975         2,375        340      13,530        5,839        34

Ampara           58,616      38,002     26,085        80,357        106,442   10,436         6,711        340      17,117       10,455        67
Southern
Hambantota       13,493       3,334      1,803        12,362         14,165    4,500           434       1,341      2,303        1,744        11

Matara           19,744       2,235     30,086         6,405         36,491    1,342         6,652        601       2,362        6,075        22

Galle            24,583      23,278      2,272       119,662        121,934    4,288           313        564       7,032        7,680        25
Western
Kalutara          9,752       7,707      2,306        32,641         34,947     279            401         68       2,683        3,835        10

Colombo           9,647       8,140      5,446        30,614         36,060      79             64         12       3,388        2,210        26

Gampaha           6,827        308        876            573          1,449          6              3       5         278          414         2
North
Western
Puttlam             232          18        66                           66           4              1       3          23            72        2

                260,967    143,302     123,298       422,417        545,715   31,187        23,189      4,280        64,909     43,697      257
                                                                                         Source: National Disaster Management Centre



              Local voluntary organisations, hotels and other private sector bodies visited
              welfare camps with raw provisions and cooked meals for the displaced.
              Government supplies then became available. Food stamps for the supply of
              essential items were distributed to the displaced populations by the government.

              Following the Tsunami, people sought shelter in schools, temples, mosques, kovils
              (temples) and other public buildings.

              Responses
              Local television stations successfully launched appeals for help following the
              Tsunami. The public response was immediate and generous. Television stations
              were inundated with relief materials and the 24-hour coverage they provided made
              deficiencies widely known and enabled an immediate response. For example,
              cooked food and raw provisions were collected in large amounts following
              appeals on local television stations and volunteer medical teams responded to
              requests for medical services. One television station even organised a mobile
              collecting service that crossed the country in convoys of lorries. The local media,
              especially the electronic sector, set up a network for gathering and disseminating
              information.
66                              Male meeting report April 2005




The armed services, assisted by local volunteers, carried out rescue and debris-
clearing operations. They were joined by armed services teams with specialised
heavy equipment from a number of countries, including the United States, India
and Israel. These foreign teams were in the country for about two months.

The international community also sent teams to help with search and rescue,
disaster assessment and coordination, telecommunications, data collection and
mapping, medical care, and water and sanitation. National community-based
organisations (CBOs), and local and international non-governmental organisations
(NGOs) also carried out relief operations. Sri Lanka received large amounts of
supplies, including medicinal drugs, medical equipment, temporary shelter, water
purification equipment, ambulances and other vehicles, refrigerators, generators,
helicopters, water tanks and body bags. Bottled water constituted a significant
portion of donations from local communities throughout the country in the
immediate aftermath of the Tsunami. Within days, large quantities began to arrive
from overseas. Chlorinated water was supplied by bowser by local authorities and
NGOs. Local communities, assisted by local voluntary organisations, quickly
began cleaning wells and the international community sent water purification and
desalinisation plants to create a supply of potable water.

              Table 12: Assistance provided by Ministry of Relief, Reconstruction,
                 Refugees and Ministry of Social Welfare as of 9 January 2005*
  Tonnage of basic commodities distributed                                                6,185.8
       No. of milk powder packets                                                          72,138
       No. of bread loaves & biscuit packets                                               45,320
       No. of units of canned fish                                                         46,888
                                                                 Source: Centre for National Operations
          *In addition to the above, the WFP donated 5,000 MT of basic provisions
          to feed 750,000 persons for 15 days.

The health system responded immediately and provided primary health care and
curative care. The Health Ministry website published lists of requirements and
committees were set up to tackle different aspects of the health sector response.
Mobile medical clinics were organised by district health authorities, volunteers
and health care institutions from throughout the country to cater to all the victims
of the Tsunami, particularly those in welfare camps. Disease surveillance systems
were implemented by the Medical Officers of Health (MOH), assisted and
supervised by the regional epidemiologists and the Ministry epidemiology unit.

Medical teams from the Indian rapid deployment force arrived within hours of the
Tsunami and were soon joined by medical teams from other countries. Most of
these teams brought their own drugs, equipment, generators, vehicles and tents to
accommodate team members. A Belgian mission set up a field hospital in the
premises of Karapitiya teaching hospital. Two hospital ships also provided
services. A number of local and overseas expert teams provided psychosocial
support services.

Immediately after the tragedy, the Sri Lanka College of Paediatricians met in
emergency session and formulated a plan of action to help children affected by the
Tsunami. A task force was appointed to establish ways to meet the physical and
mental health needs of the affected children and to mobilise the funds required.
                             Male meeting report April 2005                     67


They also proposed a ‘twinning programme’ to link affected schools with
specified schools abroad.

In some districts all records of prenatal care, well baby care, etc. were lost. The
Family Health Bureau sent fresh supplies of printed forms to enable PHC staff to
reconstruct records. Comprehensive health education programmes were carried
out with the help of staff from adjoining MOH areas, volunteers and NGOs.
Among other resources, the central health education bureau provided expertise,
vehicles, health education materials and media releases.

Most of the secondary and tertiary care institutions in the affected areas had
disaster management plans to cater to a rush of casualties. Security forces and
local NGOs helped local communities transport casualties to local hospitals.
However, forensic services, as well as the mortuary facilities, were swamped.
Given the situation, forensic investigations were confined to attempts at
identification of victims. Photographs and personal effects were displayed in
hospitals if victims could not be identified immediately. Those not identified were
buried in mass graves after multi-faith funeral ceremonies. The bodies of those
thought to be foreigners were taken to a central location and teams from other
countries used ante-mortem records, DNA technology and other means to
establish identity. Post-mortem examinations, when performed, were cursory and
aimed at ruling out homicide as a cause of death.

Priority Issues Identified
Immediately after the Tsunami hit, the main priorities were rescue, treatment of
injuries and the erection of temporary shelters. Some hospitals, including the sole
teaching maternity hospital in the south, were affected and the patients and staff
evacuated. A caesarian section was being performed in this hospital when the
Tsunami struck. The electricity supply was disrupted and the doctors completed
the surgery with the light of a laryngoscope.

After the acute phase of the crisis, the response phase prioritised the supply of
food, potable water and sanitation facilities to the welfare camps. The government
appealed to local and foreign donors for drugs, medical equipment and
consumables.

Following the Tsunami, priority has been placed on planning and developing a
system of psychological care and support for children, adolescents, youth and
adults. Early psychosocial interventions have been initiated to minimise the
impact of trauma and reduce psychological distress, improve coping skills and
strengthen resilience. Children and adolescents have special psychosocial needs
and interventions need to be community-based, long-term, culturally appropriate
and sustainable to promote psychological recovery and social reintegration. The
experience of the NCPA in relation to child abuse and exploitation will be of help
in developing a programme of support for children.
68                           Male meeting report April 2005




Conclusions
Disasters invariably attract politicians, religious leaders, diplomats, international
NGO representatives, visiting ministers from foreign countries and other
dignitaries. District level heads of departments complained that after making
presentations and accompanying important visitors on field visits, they were left
with very little time to actually manage the disaster. Frequent meetings in the
provincial capitals and in Colombo made the situation worse. One solution may be
for the most senior deputy to have a continuously updated power point
presentation and for divisional level officials to accompany dignitaries on field
visits.

The Tsunami highlighted the need for hazard analysis and mapping for all types of
disasters. Although a draft national plan, with chapters on health sector
preparedness and management, existed, it had not been approved by the Cabinet
for political reasons. The experience and expertise of the NDMC, in existence for
over seven years, was inexplicably bypassed in the management of the disaster.
Although the NDMC trains a large number of general administrative services
officials in disaster management, mapping was conducted in very few areas. This
activity should be undertaken at the divisional level (a level of administration
serving a population of around 80,000) as an inter-sectoral activity led by the
Divisional Secretary.

As all emergencies invariably create the need for welfare camps, it is critical to
identify suitable sites for accommodating the displaced and to plan facilities, such
as water and sanitation, and services, such as food and medical care. A divisional
level disaster mitigation and management plan, based on national policy and
national plans, is vital. Without this, the location of temporary shelters may create
problems. Ad hoc decisions are taken without considering the lie of the land, its
surface drainage and other issues. Surface water increases the risk of the
contamination of water supplies, damage to toilets and dwellings and vector
breeding. Rainwater and rising floodwaters increase the risk of contamination. A
proper drainage plan, that addresses storm water drainage and wastewater disposal
using small-scale, on-site drainage facilities, should be implemented to reduce
potential health risks.

The most challenging aspect of disaster management is coordination, especially
when there is no administrative control over the different actors. The Sri Lankan
government tried to coordinate the entire response, relief and rehabilitation effort
at the national level, but given the vast number of government agencies, CBOs,
national and international NGOs involved, this proved unsuccessful. It is
questionable whether it is appropriate for Prime Ministers or Presidents, given
their other responsibilities, to head disaster management committees.

The mechanism set up to manage the landslides and floods in Sri Lanka of May
2003 could be taken as a model for general disaster preparedness. Then, the
Deputy Leader of the ruling party, who was also the Minister of Power and
Energy, chaired the national disaster management committee. This body had
representation from the key stakeholders but was of a reasonable size. The
sectoral coordination was left to the secretaries to the key ministries, who reported
to the national committee. A few visits were made to affected areas with major
                               Male meeting report April 2005                          69


issues to be settled at the political level. Implementation level committees should
be at the lowest practical level, such as the divisional level.

The consolidation of data also becomes complicated when there are a large
number of organisations involved in relief and rehabilitation. The system should
be designed at the stage of preparation of the national disaster management plan.
The number of indicators should be pyramidal in nature, with the least number
being at the national level. Information (eg. percentage of wells cleaned) rather
than raw data (eg. number of wells cleaned) would make it easier to analyse the
situation. Information should be organised to help each level monitor and evaluate
their services.

In terms of the health aspects of natural disasters, it is critical to identify and target
vulnerable groups. These include pregnant mothers, infants and children, the
elderly, those prone to mental health problems and those needing long term care
for non-communicable diseases. The public health midwife (PHM) holds
information on maternal and child health by village. New lists have to be drawn
up for each welfare camp and the local PHMs should register and provide services
to displaced mothers and children staying with relatives. Community-based
organisations and NGOs can help in providing services and follow up on mental
health issues.

The threat of epidemics is ever present in welfare camps, given the overcrowded
conditions and less than ideal sanitation. This threat is also perceived by the host
community, which may lead to tension between the two groups. A mechanism has
to be set up by the Medical Officers of Health, in collaboration with trained
volunteers from within the welfare camps, to gather information on unsanitary
temporary toilets, uncleared garbage and mosquito and fly breeding and to report
on the incidence of disease.

In the case of mass burials, provisions need to be made for subsequent
identification of victims, such as fingerprinting and the collection of DNA
samples. This is important for death certification, the process of grieving and the
administration of last rites.

The South-Asian Tsunami posed a major challenge to the health systems of all the
affected countries. The fact that there were no outbreaks of epidemic diseases,
despite predictions by WHO, is an indicator of the relative strengths of the
existing health systems. The valuable lessons learned in the process of responding
to the impact of the Tsunami need to be institutionalised in order to enhance
disaster response in the future.
70                            Male meeting report April 2005




References and data sources
     1. Abeykoon, A.T.P.L. Director, population division, Ministry of Health.
         Personal communication.
     2. Centre for national operations. Presidential Secretariat. (URL www.gov.lk)
     3. Chaminda, W.V.I.K, Medical records officer, GH Matara. Personal
         communication.
     4. Children       Affected      by    the      Tsunami        Disaster.  (URL
         www.childprotection.gov.lk)
     5. Daily News, 08.01.05. Psychiatrists recommend ways of coping trauma of
         Tsunami affected.
     6. De Alwis, L. Judicial Medical Officer, Colombo. Personal communication.
     7. Hettiarachi, Nimal. Director, National Disaster Management Centre.
         Personal communication.
     8. Jayasinghe, L, Medical Superintendent, Base Hospital Ampara. Personal
         communication.
     9. Manouri P Senanayake. Newsletter of the Sri Lanka College of
         Paediatricians Volume 7 No. 1 March 2005.
     10. Munasinghe, Chintha. Country Programme Manager Basic Needs - Sri
         Lanka. Personal communication.
     11. Ministry of Health. Annual health bulletin 2002. (URL www.health.gov.lk)
     12. Ministry of Highways website (URL.www.mohsl.gov.lk)
     13. National child protection authority. Policy Framework and Guidelines for
         the Protection and Care of Children Affected by the Tsunami Disaster.
     14. National operations centre. (URL www.gov.lk)
     15. Oxfam website URL www.oxfam.uk
     16. Palihawadane, Paba. Epidemiology unit, Ministry of Health. Personal
         communication.
     17. Pathinayake, S.W. Provincial Director of Health Services, Southern
         Province. Personal communication.
     18. Perera, M.A.L.R. "Social justice for displaced populations, the Sri Lankan
         experience". Proceedings of the WHO Technical Committee meeting.
         Geneva 5-8 October 1992. WHO/ERO/EPP/92.9. Geneva, 1993.
     19. Perera, M.A.L.R. "Health and development for displaced populations -
         challenges and opportunities”. First Scientific Sessions of the College of
         Medical Administrators of Sri Lanka, December 1993.
     20. Rajaratne, N. Consultant Community Physician, Family health bureau,
         Ministry of Health.
     21. Senanayaka, Sunil. Director Information, Ministry of Health. Personal
         communication.
     22. Sunday Leader, 03.04.05; 10.04.2005.
     23. Sri Lanka Journal of Child Health. Aftermath of 9.0/2004 and the
         Tsunami (Editorial). March 2005.
     24. Virtual library Sri Lanka. (URL www. virtual library-Sri Lanka)
                             Male meeting report April 2005                      71


Appendix 6 – Kingdom of Thailand Country Report

                    Prof. Pimonpan ISARABHAKDI, PhD
      Institute for Population and Social Research, Mahidol University

Area Affected
The massive, earthquake-triggered, Tsunami struck the Andaman coast of
Thailand at approximately 10:00 am local time on 26 December 2004. Six
southern coastal provinces, Krabi, Phang-Nga, Phuket, Ranong Satun, and Trang
were affected (Figure 1). With the exception of some areas of Phuket, these
provinces are largely rural and the main industries are fishing, tourism and some
agriculture. Several resort areas, such as Patong beach in Phuket, Phi Phi Island in
Krabi and Khao Lak in Phang-Nga, are popular international tourist destinations.
In areas where tourism is growing, construction is another major activity.

With the exception of island communities, asphalt roads connect almost all of the
areas affected by the Tsunami. The health facility network is also well established,
with at least one health centre in almost every sub-district, and one community
hospital per district.

                            Figure 1: Provinces of Thailand
72                                Male meeting report April 2005




Population Affected
                       Table 1: Tsunami-affected populations in Thailand
               Provinces               Number of         Total affected                    Number of
                                         affected                                           families
                                      communities                                           affected
     Phang-Nga                              69                19,509                         4,394
     Krabi                                 112                15,812                         2,759
     Phuket                                 58                13,065                         2,613
     Ranong                                 47                5,942                          1,509
     Trang                                  51                1,302                           660
     Satun                                  70                2,920                            82
     Total                                 407                58,550                         12,017
                                   Source: Department of Disaster Prevention and Mitigation, Ministry of Interior

Impact
Physical and Infrastructure Damage

Phang-Nga, Krabi and Phuket were the most seriously affected areas, with large
numbers of homes destroyed as a result of the Tsunami (Table 2). Takua Pa
district, Taimuang district and Kuraburi district in Phang-Nga were the most
seriously affected. Krabi, and its highly popular tourist resorts of Phi Phi Island in
Muang district and Ao Nang on Lantayai Island, were severely damaged. The
Tsunami waves also left a trail of destruction in three districts of Phuket, seriously
affecting Phuket’s international tourist industry. Most of the roads and canals
servicing affected areas remained in place. Several schools and childcare centres
were destroyed.
                     Table 2: Damage to houses in Tsunami-affected districts
                   Province                                 Damaged houses
                                                 Whole           Partial                          Total
 Phang-Nga                                        1,904            604                            2,508
 Krabi                                             396             262                             658
 Phuket                                            742             291                            1,033
 Ranong                                            224             111                             335
 Trang                                              34             156                             190
 Satun                                              2               80                              82
 Total                                            3,302           1,504                           4,806
                                   Source: Department of Disaster Prevention and Mitigation, Ministry of Interior


Fortunately, most health care facilities were not severely damaged by the
Tsunami. Only a small hospital on Phi Phi Island in Krabi and four health centres
in coastal villages and islands were damaged or destroyed.

Mortality

As of 21 March 2005, 5,395 people were reported dead, 8,457 injured, and 2,932
missing as a result of the Tsunami. The greatest loss of life was in Phang-Nga,
where over a thousand of those killed were foreigners (Table 3).
                                    Male meeting report April 2005                                              73

             Table 3: Tsunami-related mortalities in affected Thai districts as of 21 March 2005
 Province                   Thai                                  Foreigners                   Unknown
               Dead       Injured      Reported         Dead        Injured       Reported
                                        missing                                    missing
Phang-Nga      1,266       4,344         1,428          1,633        1,253           305         1,325
Krabi           357         808           329            203          568            240          161
Phuket          151         591           256            111          520            364          17
Ranong          156         215            9              4            31             -            -
Trang            3           92            1              2            20             -            -
Satun            6           15            -               -            -             -            -
Total          1,939       6,065         2,023          1,953        2,023           909         1,503
                                      Source: Department of Disaster Prevention and Mitigation, Ministry of Interior


   There are no official statistics on the composition by age and sex of the surviving
   population, but some demographic information was collected through informal
   surveys conducted in the temporary shelters (Table 4).

     Table 4: Demographic characteristics of the population residing in temporary housing as of 18
                                           February 2005
    Number of temporary houses                                               2,106
    Number of people living in temporary houses:
           Male                                                              2,669
           Female                                                            3,000
           Total                                                             5,699
    Shelter population characteristics:
           0-5 years of age                                                   449
           6-12 years of age                                                  151
           Pregnant women                                                     40
           Elderly                                                            260
           Orphans                                                            58
                                                           Source: Department of Health, Ministry of Public Health


   Morbidity

   According to the mission report of the United Nations Population Fund (UNFPA),
   there was no evidence of unmet health needs among the local Thai population.

   Epidemics and Infectious Disease: According to a report by the World Health
   Organisation (WHO), there were no reports of disease outbreak. The Bureau of
   Epidemiology carried out disease surveillance on a daily basis. Between 26
   December 2004 and 25 January 2005, a month after the Tsunami, the four hardest-
   hit provinces reported the following incidents of disease: 2,511 cases of acute
   diarrhoea, 389 wounded infections, 222 cases of pneumonia, 177 cases of pyrexia
   of unknown origin, 152 case of dengue haemorrhagic fever, 58 cases of viral
   conjunctivitis, 53 cases of food poisoning, 47 cases of malaria, 42 cases of ENT
   infections and 38 cases of flu. Five deaths were reported. Two of these were
   attributed to pneumonia, one to acute diarrhoea, one to sepsis/cellulitis, and one
   unknown. Disease surveillance activities were later handed over to the provincial
   health authorities.

   Reproductive Health: It was not possible to undertake an extensive survey of
   pregnant women in the affected areas following the Tsunami and there were no
   relevant records. However, the Ministry of Interior database reports that 77,287
   Thai women lived in the affected areas. A health promotion team set up by the
74                              Male meeting report April 2005




Department of Health reported two mothers who had pre-term deliveries due to
stress. Breast-feeding for some babies was interrupted as a result of stress and the
wide availability of donated formula.

It is thought that many people, including many pregnant women, went to stay with
relatives in other provinces immediately after the Tsunami. As a result, emergency
obstetric care was not a problem in Ranong, Phang-Nga and Phuket. However, the
emergency obstetric needs of communities on Lanta Island in Krabi province may
not have been met. Family planning services remained available, but motivation to
use them decreased in severely affected communities.

Effects on the reproductive health of migrant workers were not well documented.
In Phang-Nga province, 600 - 700 workers remained in nine sites. In the first
week after the Tsunami, according to community health workers from non-
governmental organisations (NGOs), three abortions and three premature
deliveries were reported. Approximately 20 pregnant migrant workers remained in
the camp at Tablamu community, housing around 500 workers.

Psychosocial Health: Mental health support was one of the most important
activities carried out by the government and other agencies following the
Tsunami. Immediately after the Tsunami, the Department of Mental Health set up
a command centre and established mobile teams to help the victims (Table 5).

Table 5: Summary report of mental health services for Tsunami victims. Cumulative reports for 4
                                 January – 8 February 2005
                                                        Types of services
                            Psychiatric                 Counselling                  Medical           Referral
 Province       No. of        drugs                                                 treatment
               services                         Group            Individual
Phang-Nga       5,067          1,154             2108               2,409               430                33
Krabi            1,921          551               830                966                423                56
Phuket           1,328          212               448                786                111                45
Ranong            949            74               137                641                 23                27
Trang             175            0                 39                126                 28                 3
Satun             682            35                34                130                398                 5
Total           10,122         2,026             3,596              5,058              1,413              169
                                               Source: Department of Mental Health, Ministry of Public Health



The Thai government recognizes the severity of the psychological trauma
experienced by those affected by the Tsunami. The Department of Mental Health
has therefore established a mental health facility in Takua-Pa district, Phang-Nga
Province, to provide psychological intervention and care for Tsunami victims.
This centre is scheduled to remain in operation for two years.

Displacement
It was estimated that 12,068 households with a total population of 54,672 were
directly affected by the Tsunami through the loss of, or injury to, a family member
and the loss of homes and means of support. Thousands of people were displaced
and it is anticipated that there will be substantial changes to population structure
in the affected areas.
                             Male meeting report April 2005                      75



In addition to the displacement of local Thais, up to 7,000 Burmese migrant
workers and their families are likely to have been affected by the Tsunami. In
addition to losing family members, homes and jobs, many may have also lost the
immigration documents permitting them to stay in Thailand.

During the emergency period, affected people stayed in tents or with their
relatives or neighbours. During the rehabilitation and reconstruction phase,
temporary and permanent shelters were built for those displaced by the Tsunami
who did not want to return to their original localities. However, lack of
employment opportunities in these areas has led to dissatisfaction amongst some
of those displaced.

Responses
The Ministry of Public Health (MOPH) rapidly activated mass casualty plans and
deployed personnel and resources to meet local health care needs. On 26
December, a central command centre in Bangkok and command centres in each of
the six affected provinces were established to coordinate activities.

Ten hospitals, with approximately 2,000 inpatient beds and 24 operating rooms,
served as the primary referral centres for Tsunami-related medical care. Provincial
medical staff and volunteer organisations in some coastal communities established
temporary clinics in displaced-person shelters. Several shelters were set up in safe
areas close to affected communities. Deployments included approximately 100
teams providing emergency clinical care, 12 teams providing technical support
and health education, six teams providing mental health support and five teams
conducting active surveillance and investigating potential outbreaks of disease.

The first team from Bangkok arrived on 26 December, approximately six hours
after the Tsunami struck. Within twenty-four hours of the Tsunami reaching
Thailand, emergency response teams from both government agencies and NGOs
reached the affected areas. Rapid mobilisation of health professionals from many
areas in Thailand resulted in adequate numbers of staff. By 30 December, hospital
patient loads were returning to usual levels and the supplementary medical staff
was released. By 4 January 2005, provincial health officials reported that needs
for staffing and supplies were being met.

The Department of Health set up teams responsible for maternal and child health,
water and sanitation, and environmental health needs. Access to drinking water
was extremely limited as wells and all surface water sources were contaminated.

The Department of Mental Health conducted rapid assessments and set up a
command centre at their regional psychiatric hospital in Surat Thani, a two-and-a-
half hour drive from Krabi. Teams of psychologists and counsellors were
mobilised from psychiatric hospitals throughout the country and went to the
affected areas to organise mobile units and visit villages affected by the disaster.

A number of international organisations and local and international NGOs played
key roles in the emergency response. UNICEF sent teams of psychologists to
affected communities. UNFPA, in collaboration with the Department of Health,
76                           Male meeting report April 2005




Ministry of Public Health, World Vision Foundation of Thailand (WVFT) and the
Institute for Population and Social Research at Mahidol University, undertook a
rapid assessment of emergency relief and reproductive health needs in selected
communities of Ranong, Phang-Nga, Krabi and Phuket. WHO, the International
Organisation for Migration (IOM), UNICEF and MOPH conducted an assessment
on the situation of migrants.

WVFT was one of the first NGOs to respond to the disaster and started relief
assistance on the first day to those in most need. In the first 30 days, a total of
US$230,189 worth of relief assistance was delivered. Their one-year plan for the
relief and rehabilitation phase through to December 2005 continues to cover
emergency response, but also social and community recovery, economic
development and infrastructure recovery.

Priority Issues Identified
After conducting independent assessments, several agencies reported a focus on
different, important, themes. However, almost all of them stated the need for
continuous and long-term support.

UNICEF stated that the Tsunami can be expected to affect the HIV/AIDS
situation, particularly among migrant workers and young people, especially those
who have lost their jobs. UNICEF has also reported that many children who
survived the Tsunami continue to suffer from anxiety, recurring sadness or
nightmares. Psychosocial care and support is therefore one of UNICEF’s top
priorities.

Among local Thais, trauma counselling needs to be followed up and expanded to
cover men who lost their jobs or family members.

UNFPA is supporting the Department of Health in implementing a two-year
project to initiate reproductive health interventions to be implemented in newly
constructed communities. This project also aims to strengthen existing services to
ensure quality care during the reconstruction phases.

The reconstruction effort following the Tsunami helped focus attention on the
situation of those in the affected areas who have not benefited from Thailand’s
rapid development. These include the very poor, undocumented migrant workers,
ethnic minorities and isolated communities. Access to health care and health
promotion needs to be ensured for these groups. UNFPA are funding WVFT to
expand reproductive health services to the Burmese migrant workers. The IOM is
also working to implement health services for these migrants.

Service delivery point capacity has also been identified as an area that should be
strengthened. During the emergency phase, staff competency in providing health
services, particularly post trauma counselling, needs to be increased. Following
the emergency phase, additional staff are required to ensure outreach and mobile
team activities covering general health and reproductive health services. Staff
competency needs to be enhanced to provide services in newly constructed
communities.
                            Male meeting report April 2005                      77


The national database system developed for the Department of Disaster
Prevention and Mitigation contains data on loss of life, injury, property,
livelihoods, public places and environmental damage. Health data, particularly
reproductive health data, and gender data also need to be included. Subsequent
situation assessments, conducted either through surveillance or sequential surveys,
should monitor the results of interventions and identify emerging health needs.

Conclusions
During its assessment visits to affected areas, UNFPA team members agreed on
several issues and lessons learned from responding to the Tsunami disaster. For
example, using unaffected health centres as command centres for emergency
responses resulted in inconvenience to patients. Furthermore, health care efforts
often neglected the needs of men.

It was also noted that while supplies and emergency relief were delivered on a
massive scale, more effective coordination in relief efforts was needed. For
example, data and records were fragmented as several teams were collecting data
and each did so according to their own mandate. However, there was no
mechanism to share and consolidate findings. Donated items were piled up with
no evidence of any recording of storage and distribution. Furthermore, although
mobile teams from several government departments visited affected communities,
local staff were often not informed of planned follow-up activities.

Although a Tsunami on the scale of the one that struck Thailand on 26 December
2004 was an unprecedented event, incorporating the lessons learned into general
disaster planning will hopefully reduce damage, injury and mortality in future
emergency situations.
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