The Sri Lanka Tsunami Experience

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<ul><li><p>DMR(GDP) is $3540 per year (2002). Still, Sri Lankans en-joy relatively good health status, with a life expectancyof 68 years for males and 75 years for females (2003figures), and a mortality rate for children youngerthan 5 years of 17 and 13 per 1000 live births for malesand females, respectively (2003 figures).7 For compar-</p><p>Medical Education in East Asia, Gordon Greene, PhD,Director.</p><p>Reprint requests: Seiji Yamada, MD, MPH, University ofHawaii John A. Burns School of Medicine, 651 Ilalo St, MEB401G, Honolulu, HI 96813-5534; E-mail:</p><p>Disaster Manage Response 2006;4:38-48.</p><p>1540-2487/$32.00The Sri Lanka Tsunami ExpSeiji Yamada, MD, MPH, Ravindu P. Gunatilake, MD, TThushara Fernando, MPH, MD, and Lalan Fernando,</p><p>The Indian Ocean tsunami of 2004 killed 31,000people in Sri Lanka and produced morbidityprimarily resulting from near-drownings andtraumatic injuries. In the immediate aftermath,the survivors brought bodies to the hospitals,which hampered the hospitals operations. Thefear of epidemics led to mass burials. Infectiousdiseases were prevented through the provision ofclean water and through vector control. Monthsafter the tsunami, little rebuilding of permanenthousing was evident, and many tsunami victimscontinued to reside in transit camps withoutmeans of generating their own income. The lackof an incident command system, limited funding,and political conflicts were identified as barriersto optimal relief efforts. Despite these barriers, SriLanka was fortunate in drawing upon a well-developed community health infrastructure aswell as local and international resources. Theneed continues for education and training inclinical skills for mass rescue and emergencytreatment, as well as participation ina multidisciplinary response.</p><p>Seiji Yamada is Clinical Associate Professor of FamilyMedicine &amp; of Public Health, Hawaii/Pacific Basin AreaHealth Education Center, Honolulu, Hawaii. Ravindu P.Gunatilake is a Resident, Department of Obstetrics andGynecology, Banner Good Samaritan Medical Center,Phoenix, Ariz. Timur M. Roytman is a Resident, WashingtonUniversity School of Medicine, Division of Urologic Surgery,St Louis, Mo. Sarath Gunatilake is Professor, Health ScienceDepartment, California State University, Long Beach, LongBeach, Calif. Thushara Fernando is National ProfessionalOfficer, World Health Organization, Colombo, Sri Lanka.Lalan Fernando is Assistant Professor, Department ofAnatomy, Faculty of Medicine, Galle, Sri Lanka.</p><p>Funding support provided by the University of Hawaii JohnA. Burns School of Medicine International Program forCopyright 2006 by the Emergency Nurses Association.doi:10.1016/j.dmr.2006.01.001</p><p>38 Disaster Management &amp; Response/Yamada et alFeature Article</p><p>erienceimur M. Roytman, MD, Sarath Gunatilake, MD, DrPH,MD</p><p>On the morning of Sunday, December 26,2004, a 9.0-magnitude earthquake off thecoast of Sumatra sent several tsunami waves</p><p>radiating out into the Bay of Bengal, the Andaman Sea,and the Indian Ocean. The tsunami hit the eastern,southern, and southwestern coasts of Sri Lankadmorethan two thirds of Sri Lankas coastlinedcausing cata-strophic destruction and loss of life. At Matara, on thesouthern tip of Sri Lanka, a leading elevation wave ofless than 1 M was followed 10 minutes later by a sec-ond wave up to 10 M in height.1 As of February 2005,</p><p>official figures indicated that more than 31,000 peoplein Sri Lanka lost their lives in the tsunami. About 7000more people were missing, and more than 440,000people were displaced.2 Between 1 and 2 million peo-ple were affected by the tsunami, out of a total popu-lation of approximately 19 million.3 This articleexamines the effects of the tsunami and the dynamicsof relief efforts in Sri Lanka to draw lessons for futureresponses to such disasters.</p><p>Historically, the people of Sri Lanka had experi-enced few large-scale natural disasters other than theoccasional flooding of rivers. The Indian Ocean lacksa tsunami warning system of the type in place in thePacific Ocean.4 The public health system did nothave coordinated plans for responding to a disasterof this magnitude, and existing disaster plans couldnot be located or immediately implemented.</p><p>Sri Lanka is a country with an area of 65,610 sq km(slightly larger than West Virginia) and 1340 kmof coastline5 (see Figure 1). Its population is19,065,000, and its per-capita gross domestic product</p><p>6</p><p>.a leading elevation wave of less than 1 M</p><p>was followed 10 minutes later by a second</p><p>wave up to 10 M in height.ison purposes, its neighbor India, with a per capitaGDP of $1568 per year (2002 figures),8 has a life ex-pectancy of 60 years for males and 63 years for</p><p>Volume 4, Number 2</p></li><li><p>DMRfemales (2003 figures), and a mortality rate for chil-dren younger than 5 years of 85 and 90 per 1000live births for males and females, respectively (2003figures).9</p><p>The total adult literacy rate for Sri Lankans is 92%,10</p><p>and its health system is staffed by a well-educatedworkforce.11 Sri Lanka has a countrywide comprehen-sive network of health centers, hospitals, and othermedical institutions, with about 57,000 hospital beds,and a large workforce engaged in curative and publichealth activities. In the public sector, human resourcesfigures reported for 2000 were as follows: 7963 physi-cians (4.11/10,000 population), 14,716 nurses, and5068 public health nurses and midwives. Nonetheless,Sri Lanka is a country with limited resources, particu-</p><p>larly in the health care sector. The peripheral healthnetwork has limited development of human resourcesand inadequate geographic distribution.12 Limited</p><p>resources have affected the countrys ability to imme-diately respond to the disaster and continue to impedethe long-term recovery.</p><p>Sri Lanka was torn by a civil war in the 1980s and1990s between the majority, Sinhalese, and the minor-ity, Tamils. Relative calm has been brought about bya ceasefire, by which the government has ceded polit-ical control of sections of the North and the East to theLiberation Tigers of Tamil Eelam (LTTE). The LTTEtherefore has controlled tsunami relief in these areas.In the remainder of the country, the government hasretained control over the process of post-tsunamirelief and rehabilitation but has worked in concertwith a variety of international and nongovernmentalorganizations (NGOs).</p><p>Evaluation of the Sri Lanka Post-tsunamiExperience</p><p>Needs Assessment, Objectives,and Methods</p><p>The specific objective of the assessment was to pro-vide an understanding of the impact of the disaster ondifferent groups of the population affected, with a par-ticular emphasis on the health sector and its response</p><p>Figure 1: Map of Sri Lanka. From the CIA Factbook, available at</p><p>The total adult literacy rate for Sri Lankans is</p><p>92%, and its health system is staffed by a well-</p><p>educated workforce.April-June 2006 Disaster Management &amp; Response/Yamada et al 39</p></li><li><p>DMRsponse. All 6 authors conducted follow-up interviewsin the Southern districts and the capital city of Colom-bo in March and April of 2005. Some areas that wereassessed during the immediate aftermath of the tsu-nami were revisited, and several key informants werere-interviewed during this follow-up phase. In addi-tion, LF has been involved continuously in managingtsunami relief in the Galle District (see Figure 2), andhe has conducted a survey of affected households there(not described in this report). Authors RG, TR, and SYparticipated in medical relief efforts under LFs direc-tion and interviewed survivors. Finally, the authorsalso used secondary data from government databasesand reports from various international organizations.</p><p>Figure 2: Lalan Fernando, MD, providing40 Disaster Management &amp; Response/Yamada et almore injured persons than dead persons. One charac-teristic feature of the tsunami was the small number ofpersons who were injured compared with the numberof deaths. In Nagapattinam, India, only 2000 personswere injured, compared with 6000 persons who died.Most people either drownedor escapedunhurt.14 Over-all, persons with a critical injury were a minority.</p><p>The main morbidities encountered in the immedi-ate aftermath of the tsunami included near-drowningsand traumatic injuries. The small number of ventilatorsin the provincial hospitals limited the number of pa-tients who could be treated for near-drowning. Over-all, the number and types of injuries were considered</p><p>medical assistance to tsunami survivors.during the rescue, recovery, reconstruction, and reha-bilitation phases. Information was collected throughdirect observation, interviews with key informants,and review of relevant documents. Two authors (SGand TF) conducted a needs analysis in the Southerndistricts for the World Health Organization (WHO) inthe days immediately after the tsunami. TF also con-ducted a needs analysis in the Northeast and East. Us-ing a modified version of the WHO Rapid HealthAssessment Protocol,13 they collected data on hospitalcharacteristics; damage to buildings and communica-tion, electricity, water, and sewage systems; adequacyand condition of health-care personnel, medical sup-plies, and morgue facilities; and anticipated medicalneeds. Questions initially were directed to provincialhealth office staff members. Other informants inter-viewed subsequently included hospital and relief or-ganization officials and workers, as well as survivorsthemselves. The objective of the initial key informantinterviews was to identify the main issues, problems,and response patterns during all phases of the re-</p><p>Results</p><p>The observations of this study are summarized intoseveral main themes (see the Table) and are dividedinto theemergencyphase; recovery, rehabilitation, tran-sition; sustainable development; and lessons learned.</p><p>Emergency PhaseCauses of morbidity and mortality. The survi-</p><p>vors of the tsunami described being hit by 2 successivewaves of water that arrived a few minutes apart. Manypersonswho sustained evenminor injuries from thefirstwave were unable to move or swim and did not survivethe second wave. In most disasters, there are 3 to 5 times</p><p>One characteristic feature of the tsunami was</p><p>the small number of persons who were injured</p><p>compared with the number of deaths.Volume 4, Number 2</p></li><li><p>DMRminor, and local physicians, along with physicians vis-iting from unaffected areas, were able to manage thesepatients adequately.</p><p>It was noted that few survivors with traumatic in-juries were treated at the health facilities. Personswho handled the dead bodies reported observinga high proportion of bodies with traumatic injuries.</p><p>Community response. Several thousand ordinarycitizens began to provide food, clothing, and shelterbefore the state services could mobilize. On theirown initiative, informal networks of family, friends,or work colleagues traveled to the affected areas.They offered direct assistance in searching for survi-vors, transporting victims to hospitals, retrieving thedead, and delivering medical supplies. Many individ-uals in surrounding villages supported these opera-tions by collecting donations and organizing thedelivery of relief goods.</p><p>Buddhist temples, Christian churches, and Moslemmosques that survived tsunami damage were turnedinto camps for the displaced. The religious leadersof these institutions assumed roles in organizingcamps for the displaced and were assisted by thedecentralized government structure, spearheaded bythe provincial secretariats.</p><p>The government response. Faced with a human-itarian disaster of unprecedented onset and scale ona post-Christmas weekend, the Sri Lankan govern-ment struggled to respond to the needs of the affectedareas. Although the Sri Lankan military is accustomedto handling emergencies through their commandstructure, Sri Lanka had no formal incident commandsystem (ICS).15 Within the first 24 hours of the tsu-nami, the government established a Centre forNational Operations (CNO) under the direct authorityof the prime minister to coordinate both national andinternational relief operations. However, another 2days were required for this entity to be fully func-tional. Later, the CNO, working under the directauthority of the president, provided the essentialinterface between concerned government ministries,local authorities, the military, and the internationalassistance community.</p><p>Table. Major themes identified with emergencyresponse in Sri Lanka following the tsunami ofDecember, 2004</p><p> Ordinary citizens responded in the initial rescue efforts Dead bodies brought to hospitals hampered the</p><p>provision of services Infectious disease epidemics were avoided through the</p><p>provision of clean water and vector control The health system was unprepared for mass</p><p>psychological morbidity A strong public health system otherwise proved</p><p>resilient in the face of mass casualties Reconstruction has been slow to take placeApril-June 2006Military involvement. Military forces wereamong the first to respond in the emergency phase.The Sri Lankan military was assisted by the armedforces of India, Pakistan, United Kingdom, France,and the United States. Military personnel assisted inrescue and transport operations, clearing of debris,and restoration of basic services. Later many othercountries joined this effort. The USS Duluth, carryingearth-moving equipment, marines, and helicopters,anchored off the coast of Galle and provided immedi-ate assistance. Approximately 600 members of theUnited States Marine Corps worked to provide human-itarian aid. Approximately 11 U.S. military aircraftwere involved in flying relief missions in the Southand East. Approximately 43 foreign military forcesgave assistance during the emergency period. Coordi-nation of such a large number of forces is inherentlycomplex. On the whole, military operations were suc-cessful, and coordination was reasonably effective.16</p><p>Transportation of the victims. During theimmediate aftermath of the tsunami, all roads to thetsunami-affected areas were inaccessible. Clearingthese coastal roads became an immediate priority.Members of the Sri Lankan Air Force Medical Corps,with a small fleet of helicopters, were the first to arriveon the scene, and they triaged and transported theinjured persons to the closest unaffected hospitals.Because the tsunami did not affect ambulance servicesin the interior of the country, these vehicles weremade available for service in the affected areas andto assist the military with ground transport. Hospitalsalong the coast, such as the Mahamodara Hospital inGalle, were damaged, and all hospitals close to thetsunami-affected coastline were overwhelmed, neces-sitating the transport of patients to functional hospitalsin the interior (see Figure 3).</p><p>Handling bodies of the deceased. According tothe Sri Lankan Judicial System, the physicians in chargeof the district hospitals perform autopsies and otherforensic pathologic duties. Specialized judicial medicalofficers ( forensic pathologists) are available only inlarger provincial hospitals. As such, it is c...</p></li></ul>