J R Soc Med 2005;98:390-395
doi:10.1258/jrsm.98.9.390
© 2005 Royal Society of Medicine
Impact of the Tsunami on healthcare systems
M Carballo
S Daita
M Hernandez
International Centre for Migration and Health, Route du Nant d'Avril,
CH-1214 Vernier (Ge), Switzerland
Correspondence to: Dr Manuel Carballo, Executive Director, ICMH
E-mail:
mcarballo{at}icmh.ch
 |
INTRODUCTION
|
|---|
The Tsunami that hit countries in the Indian Ocean killed over
180 000
people, left some 50 000 others missing and presumed
dead, and displaced more
than 1.6 million
‘survivors’.
1
Coastal
regions and island infrastructures in the affected countries
were so
damaged that many of the economic, social and health
gains that had been
achieved in recent years were lost and hundreds
of thousands of people were
pushed back or further into poverty.
Natural and man-made disasters damage the infrastructure of countries in
many ways. One of the consequences of the December 2004 Tsunami concerned the
healthcare sector, which was affected more than some other sectors because of
the loss of scarce human as well as physical resources. The effects of the
Tsunami varied with factors including the physical geography of the region,
the force of the waves when they hit the shore, and the extent to which the
waves penetrated the shoreline. Although the disaster prompted a massive
relief operation by the affected countries and the international community,
several key challenges emerged and remain unresolved—in particular, the
ways in which the health sector should prepare for future natural disasters.
These include intersectoral cooperation, infrastructural preparedness, and
sensitivity to local knowledge.
|
DAMAGE TO HEALTHCARE SERVICES
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Table 1 gives an idea of the
health situation and number of
healthcare personnel in the affected countries
before the disaster.
In Indonesia, the most severely hit of the countries, the
Tsunami
destroyed 30 health clinics out of 240, seriously damaged 77,
and
caused minor damage to an additional
40.
2 The loss of
health
personnel was also substantial, and for a country that already
had a
low number of physicians, nurses and midwives, the deaths
(or still missing
status) of as many as 700 out of 9800 health
workers constituted a serious
blow to the healthcare system
and those it
served.
3 The fact
that 30% of all midwives in the
region died or are still missing is already
compromising safe
motherhood and newborn
care.
4
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Table 1. Pre-disaster health and health personnel [Source: WHO, World Health
Statistics 2005—Data on Singapore and Switzerland included for
comparative purposes only]
|
|
In the Maldives, where the average land altitude is about 1.5 m above sea
level and where at least a third of the country's population was affected by
the Tsunami, many healthcare facilities suffered
badly.1 On some of
the islands that were hit (not all islands were affected), clinics and
hospitals lost all their equipment including heavy X-ray machines and
generators.4
Computers and printed files were also lost and the health records with them.
Personnel losses were also proportionately high because many specialized
medical personnel were expatriates from India and Sri Lanka. Some were on
vacation and did not return; others felt the need to go back to be with their
families.1
Healthcare facilities along the affected coast in Thailand suffered
severely but there were, nevertheless, a sufficient number of proximate
hospitals not far inland that were able to take up the patient load. In Ranong
and Phang-Nga Provinces, 7 public health officers and 25 public health
volunteers died and 6 public health centres (PHCs) were badly
damaged.6 Elsewhere
three PHCs were heavily damaged in Phuket Province and in Krabi Province, and
the Phi Pho Hospital and 18 public health centres suffered considerably. In
Sri Lanka, it is estimated that over 17% of all curative care institutions
were severely
damaged,6 but as in
Thailand the presence of other healthcare facilities not far inland, together
with a large population of trained healthcare staff, meant that patient loads
could be shared.
The magnitude of the Tsunami's economic impact on the region's healthcare
systems was also great, especially since the costs of reconstruction will
often have to be borne by provincial governments
(Table 2).
In Indonesia, the World Bank estimates that the losses incurred by the
health sector amounted to around $91.9 million and the expectation is that
$131.14 million will be required for reconstruction of the health
facilities.7,8
Losses incurred in Sri Lanka exceeded $60 million and the costs of
reconstruction will be around $84
million.9 Health
sector damage in India amounted to $15.7 million and the costs of
reconstruction are estimated to be at least that
much.10 In the
Maldives, where the total cost of damages was $470 million, $5.6 million of
those losses were incurred by the healthcare sector and the estimated health
sector reconstruction costs are in the order of $12.2
million.11
|
LOAD ON THE HEALTHCARE SECTOR
|
|---|
Although none of the epidemic outbreaks that were reasonably
predicted by
the World Health Organization (WHO) actually occurred,
the load imposed on
healthcare services was high for many other
reasons. The first of these was
the number of injuries that
required treatment—estimated by WHO as about
500 000 in
the
region.
2 In
Thailand, hospitals in the affected areas recorded
10 000 patients in the two
weeks following the Tsunami. Of these,
2233 required hospital admission and
1254 needed major surgery.
398 patients had to be placed in intensive
care.
12 In
Phangnga,
the emergency department of the local general hospital recorded
an
intake of 986 patients on 26 December alone, and in the week
that followed,
2285 trauma cases were managed and 683 surgical
interventions
performed.
23 In
India, more than 1135 injuries
were reported by Cuddalore hospital in the 15
days following
the
Tsunami.
14 The
surgical load in Indonesia was so acute that
some amputations are reported to
have been performed without
anaesthesia,
15 and
the subsequent demand for artificial limbs exceeded the
capacity of the formal
healthcare system to provide the necessary
psychological counselling. Most
orthopaedic-injury patients
in Sri Lanka had to be transferred to Colombo, the
capital,
because hospitals ran out of external fixator equipment (Steinmann
pins
and Kirschner wires) and because the only other location with
sufficient
capacity was the Jaffna Teaching Hospital in the
Tamil-held area of the
country.
16
In addition to the injuries that placed a huge burden on healthcare
services, local hospitals had to deal with periodic but short-lived increases
in diseases such as viral fevers and diarrhoeal
infections.17
Although these often followed seasonal trends and were ultimately controlled,
the fear of epidemic outbreaks required many of them to be monitored with
laboratory/epidemiological investigations that were often costly and difficult
to arrange.1
One of the more complex loads on both health facilities and healthcare
personnel was the handling and identification of large numbers of dead bodies.
In Thailand, Indonesia and Sri Lanka few hospitals had enough refrigerated
mortuary space and the psychological burden on healthcare staff called on to
improvise facilities and identify bodies led to serious problems of
‘burn-out’ and
depression.1 In
Thailand, pressure from the media and from the families of tourists (43% of
the Tsunami victims in Thailand were
foreigners)18 who
arrived seeking some type of closure on their relatives presented an
additional load on already overworked and stressed healthcare
personnel.1 The
handling of bodies was also complicated by misconceptions about the disease
potential they posed; many healthcare personnel wrongly thought there was a
high risk of disease
transmission.19-21
Management of excess patient load was facilitated in some countries by
evacuation to other hospitals. In Thailand and Sri Lanka, which had
pre-existing disaster management plans, secondary and tertiary care
institutions further inland were quickly able to upscale their intake capacity
and accommodate patients transported from the coastal
areas.22,23
By day three after the Tsunami, the health authorities in Thailand had been
able to organize the evacuation of at least 1000 patients (103 Thais and 898
foreigners) to these
hospitals.12 In the
Maldives, the transfer (by boat and air taxi) of patients to the main hospital
in Male was also operational three days after the
Tsunami.4 In
Indonesia, on the other hand, the load quickly exacerbated pre-existing
deficiencies in the healthcare system in Aceh, and options for evacuation to
other hospitals were very limited.
Throughout this period there were also patients who fell ‘outside the
formal net’ of assistance. The assumed, albeit not proven, presence of
large numbers of Burmese unregistered migrant workers in Thailand remained a
concern. It was difficult to determine what their needs were or might
be,1 and much of the
work with unregistered migrant workers was left to non-governmental
organizations (NGOs) that were more familiar with
them.24 Independent
media and NGO sources suggest that, out of 250 000 Burmese legal and illegal
workers in the six provinces, 2500-3000 died and 5000-7000 are still
missing.25,26
In Somalia, political instability (insecurity) and inaccessibility (poor
condition of roads) along the coastline hit by the Tsunami were obstacles to
any rapid assessments, and even today the extent of the damage to the health
sector remains
unclear.27 There
are, nevertheless, reports that many of the needs of the people in the area
were met by pre-existing emergency supplies that had been placed in the
country.28
|
EXTERNAL SUPPORT
|
|---|
The magnitude of the disaster was matched by a relief effort
that brought
more than six hundred agencies together with material
assistance, personnel
and funds. By June 2005, almost $12 billion
had been pledged to the relief
effort, and contrary to experience
in previous disasters, the follow-through
on pledged assistance
was
high.
29 In May
2005, WHO alone reported that it had already
received contributions of $42.5
million and had firm pledges
of an additional $15.4
million.
30
Despite all the efforts made by the national governments of affected
countries, it is unlikely that much progress would have been achieved without
this rapid influx of external medical and emergency health assistance. Around
130 foreign relief organizations arrived in the region within two weeks of the
disaster and set up mobile field hospitals, deployed emergency healthcare
staff, procured and distributed medical supplies, and established vaccine and
cold-chain systems.1
The rapid introduction of well-drilling equipment, water desalination plants
and other water and sanitation equipment by these external groups was probably
one of the key factors that helped avert the epidemic outbreaks that had been
predicted.31
In India, the government decided early that it could manage without
external medical personnel support, but elsewhere the assistance was sometimes
overwhelming. In Sri Lanka, the arrival of foreign personnel was massive and
at one point the offer of an additional 700 expatriate medical personnel led
national health authorities to ask international groups to stop sending
staff;1,32
two of the larger international NGOs modified their plans and activities when
they realized that local staff were plentiful, well trained and capable of
doing more than the NGOs had
anticipated.32,33
In the Maldives, where large numbers of foreign staff likewise arrived, the
Ministry of Health commented that some relief personnel did not seem
technically prepared for the task and had less expertise even than nationals
who had not been trained in emergency
work.4 Indeed, in
some of the countries, expatriate staff came to be seen as a hindrance to the
national effort because they usually required housing, were difficult to
coordinate, and often had personal and professional needs that could not be
easily met.
As in previous disasters, the donations that were received by countries
varied in both relevance and quality. Unmarked and time-expired medicines were
reported by some countries, and in others there were contributions of food
that could not be used. Indonesian rice-eating populations were sent wheat
donations that often went
uneaten,14 and in
Southern India some areas received precooked food that people did not know how
to use.35 In
Thailand, there was concern about the impact indiscriminate distribution of
powdered milk might have on
breastfeeding.36 In
Indonesia, there were also reports that far more prosthetic appliances were
received than were required at the
time.37 On the
whole, however, lessons seem to have been learned from previous disaster
responses, and WHO guidelines on drug donations, for example, appear to have
been heeded more than in the
past.38
|
CIVIL/MILITARY COOPERATION
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|---|
Throughout the region, the military proved indispensable to
the relief
effort. National and foreign militaries helped civilian
relief teams to reach
people in outlying areas that had been
cut off and they also played a vital
role in evacuating people
in need of emergency medical care. In Indonesia, to
which over
30 countries sent military teams, the Australians and the Germans
set
up field hospitals that had operating rooms and a capacity for
acute care,
and their helicopter transports permitted staff
and materials, as well as
patients, to be flown in and out of
difficult-to-reach
areas.
39 Thus
despite the many misunderstandings
that often seem to plague collaboration
with the military in
humanitarian relief operations, the interventions of
national
and expatriate military forces appear to have been well received
by
national authorities and international organizations everywhere.
|
COORDINATION
|
|---|
Coordination of internal and external relief operations in both
man-made
and natural disasters is always problematic, especially
in disasters that
attract large numbers of external groups.
Both UN agencies and NGOs often have
difficulty in sharing information
and in conducting joint assessments and
planning.
40 This is
partly
because organizations tend to arrive with different mandates
and
expectations as well as having different methods of working.
The competition
for funds and visibility also seems to limit
their willingness to coordinate
or be coordinated.
The number of NGOs, bilateral government and UN agencies and
intergovernmental organizations working in health sector operations in
response to the Tsunami was high. In Indonesia there were 116, in Sri Lanka
129, in Thailand 77, and in the Maldives
54.41 Coordinating
the arrival and work of so many organizations, their staff, equipment,
procurement and shipments, became a challenge for ministries of health, many
of which did not have suitable staff in sufficient numbers. In addition, the
task of coordinating people, ideas, materials, and donations, and then
evaluating ongoing needs, was often made more arduous because of the
unwillingness of external groups to submit to centralized
coordination.1
|
CONCLUSIONS
|
|---|
The impact of the Tsunami will be felt by healthcare systems
in the region
for years to come. Physical infrastructure damage
was massive but in some
countries the loss of human resources
was an even greater calamity. The
rebuilding and re-equipping
of clinics and hospitals may well be guaranteed by
monetary
donations, but the task of replacing staff will be much more
daunting.
In some cases, the loss of staff may be compensated by healthcare
reforms
that allow primary health care staff to do more than would otherwise
have
been the case. In the Maldives, for example, the Tsunami highlighted
the
potential hazards of dependency on expatriate staff, and
could lead to a
re-evaluation of the role that existing well-trained
staff such as community
health workers and nurse-midwives can
play in the delivery of services.
The psychosocial burden on healthcare staff in all the Tsunami-affected
countries, especially those with exceptionally high numbers of fatalities,
will also merit follow-up. What many of them were called on to do exceeded all
previous experiences and expectations, and the physical as well as
psychological burn-out among them was considerable.
Although the value of external assistance was obvious, the competence of
some of the people who arrived in countries as ‘experts’ calls for
attention. Personnel who do not bring essential skills are often a burden to
nationals who have to accommodate them and address their needs. In the future
much will be gained by strengthening the capacity of ministries of health to
prepare for such challenges, including how to coordinate external inputs. Much
more should also be done by international agencies and NGOs to ensure that the
capacities of receiving countries are respected and where necessary
strengthened, and that the right type of people are sent on relief
missions.
The response to the Tsunami also highlighted the importance of advance
planning for emergencies. In Thailand and Sri Lanka the evacuation of badly
injured patients was facilitated by procedures that had been prepared and
discussed before the Tsunami. While these were not always perfect or widely
known, they did offer a framework for decision-making. In view of the
susceptibility of the region to other types of disasters, similar initiatives
merit development elsewhere.
|
Acknowledgments
|
|---|
We thank the participants of the ICMH Tsunami Expert Review
Committee
meeting that took place in Male, Maldives, 22-24 April
and the Taiwan
International Health Operations Center and others
for their support of this
project.
|
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|
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INTRODUCTION
DAMAGE TO HEALTHCARE SERVICES
