Feature ArticleDMR

The Sri Lanka Tsunami ExperienceSeiji Yamada, MD, MPH, Ravindu P. Gunatilake, MD, Timur M. Roytman, MD, Sarath Gunatilake, MD, DrPH,Thushara Fernando, MPH, MD, and Lalan Fernando, MD

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.

Seiji Yamada is Clinical Associate Professor of FamilyMedicine & 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.

Funding support provided by the University of Hawaii JohnA. Burns School of Medicine International Program forMedical Education in East Asia, Gordon Greene, PhD,Director.

Reprint requests: Seiji Yamada, MD, MPH, University ofHawaii John A. Burns School of Medicine, 651 Ilalo St, MEB401G, Honolulu, HI 96813-5534; E-mail: seiji@hawaii.edu

Disaster Manage Response 2006;4:38-48.

1540-2487/$32.00

Copyright � 2006 by the Emergency Nurses Association.

doi:10.1016/j.dmr.2006.01.001

38 Disaster Management & Response/Yamada et al

On the morning of Sunday, December 26,2004, a 9.0-magnitude earthquake off thecoast of Sumatra sent several tsunami waves

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 Lanka’s 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,

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.

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.

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(GDP) is $3540 per year (2002).6 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-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

.a leading elevation wave of less than 1 M

was followed 10 minutes later by a second

wave up to 10 M in height.

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Figure 1: Map of Sri Lanka. From the CIA Factbook, available at http://www.cia.gov/cia/publications/factbook/geos/ce.html.

females (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

The total adult literacy rate for Sri Lankans is 92%,10

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-

larly in the health care sector. The peripheral healthnetwork has limited development of human resourcesand inadequate geographic distribution.12 Limited

The total adult literacy rate for Sri Lankans is

92%, and its health system is staffed by a well-

educated workforce.

April-June 2006

resources have affected the country’s ability to imme-diately respond to the disaster and continue to impedethe long-term recovery.

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).

Evaluation of the Sri Lanka Post-tsunamiExperience

Needs Assessment, Objectives,and Methods

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

Disaster Management & Response/Yamada et al 39

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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-sponse. 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 LF’s direc-tion and interviewed survivors. Finally, the authorsalso used secondary data from government databasesand reports from various international organizations.

40 Disaster Management & Response/Yamada et al

Results

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.

Emergency PhaseCauses of morbidity and mortality. The survi-

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

more 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.

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

One characteristic feature of the tsunami was

the small number of persons who were injured

compared with the number of deaths.

Figure 2: Lalan Fernando, MD, providing medical assistance to tsunami survivors.

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minor, and local physicians, along with physicians vis-iting from unaffected areas, were able to manage thesepatients adequately.

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.

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.

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.

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.

Table. Major themes identified with emergencyresponse in Sri Lanka following the tsunami ofDecember, 2004

� Ordinary citizens responded in the initial rescue efforts� Dead bodies brought to hospitals hampered the

provision of services� Infectious disease epidemics were avoided through the

provision of clean water and vector control� The health system was unprepared for mass

psychological morbidity� A strong public health system otherwise proved

resilient in the face of mass casualties� Reconstruction has been slow to take place

April-June 2006

Military 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

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).

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 customary tobring all dead bodies to the hospital when deaths occuroutside the hospital. Hospital morgues are usuallyequipped to handle fewer than 5 to 10 bodies.

With relatively few minor morbidities to address, theretrieval of dead bodies dominated the immediateresponse efforts of volunteers and survivors, many of

During the immediate aftermath of the

tsunami, all roads to the tsunami-affected

areas were inaccessible.

Disaster Management & Response/Yamada et al 41

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Figure 3: Crowded conditions at Mahamadora Hospital, Galle, Sri Lanka.

whom were looking for the bodies of their relatives andfriends. The pre-existing morgues could accommodateonly a small fraction of the bodies brought in; therefore,the excess bodies were deposited on the grounds of thehospitals, in the hallways, and even in the wards, andnormal hospital operations were completely disrupted.According to informants, more than a dozen hospitalswere completely deserted by both staff and patientsas they were inundated by dead bodies.

Identification of the deceased was a major problem.Some hospitals fingerprinted and photographed thefirst few bodies that arrived at their morgues. How-ever, as the premises were overwhelmed with deadbodies, and as rapid decomposition from prolongedwater immersion set in, most procedures for identifica-tion of the dead were abandoned. DNA identificationtechnologies were not available. Many bodies wereburied in mass graves, circumventing traditional SriLankan burial rituals.

Ethnic relations. In the immediate post-tsunamiperiod, the delivery of relief goods and services tran-scended ethnic and religious boundaries. Many reliefworkers, including Buddhist priests from the predom-inantly Sinhala-speaking South, traveled to the Tamil-speaking Northeast to provide aid. Persons residing inethnically mixed camps in the South reported a cultureof collaboration and unity among residents through-out the post-tsunami period. However, 3 months afterthe tsunami, with the slow pace of reconstruction,Tamils in refugee camps in the Northeast began toblame the government for withholding or not provid-ing enough aid.17 Informants provided mixed reportswith regard to the distribution of relief in the North-east, so the sentiments reported in the popular mediacould be neither confirmed nor denied.

42 Disaster Management & Response/Yamada et al

International medical efforts. Rescue, relief,and medical personnel quickly arrived at the scenefrom around the world. Immediately following thecatastrophe, USAID/Office of Foreign Disaster Assis-tance dispatched a disaster assistance response team.

In the early days after the tsunami, a lackof coordinationbetween the Sri Lankan Ministry of Health and variousnon-governmental organizations (NGOs) resulted inthe duplication of services.18 For example, informantsreported lack of a medical record keeping; as a result,some survivors received multiple immunizations andmedications from different providers. Some patientsreceived unnecessary vaccinations for cholera or anti-malarial prophylaxis because international medicalteams were working independently and had assumedthat cholera and malaria epidemics were imminent.

Foreign personnel encountered linguistic and cul-tural barriers. English is widely spoken by educatedpersons in Sri Lanka. However, most of the persons af-fected by the tsunami did not speak English. These bar-riers were especially notable in the care of patients withpsychiatric symptoms, for whom optimal diagnosis andtreatment is highly dependent on effective, culturallycompetent history taking. Considerable local resourceswere required to bridge the cultural and linguistic gapbetween nonlocal personnel and the victims.

Informants reported a lack of a medical record

keeping; as a result, some survivors received

multiple immunizations and medications from

different providers.

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Figure 4: A destroyed fishing village after the 2005 tsunami in Sri Lanka.

Pharmaceuticals. In the first few days followingthe tsunami, some pharmaceutical storage facilitieswere damaged, resulting in significant short-termshortages of medications. Medications and pharma-ceutical supplies from unaffected parts of the countryeventually were supplemented by international ship-ments of medications, which began arriving shortlyafter the disaster struck.

In many instances, medications from abroad wereneeded and welcome. However, their brand nameswere unfamiliar and led to confusion in dispensingthem. Some medications were expired, and thoserequiring refrigeration were stored inappropriately. Itoften was challenging to follow up on distributedmedications. Stores of shipped medications were not

April-June 2006

always inventoried or supervised by trained person-nel. According to informants, in some cases, medica-tion containers lay at ports while there wereshortages in the field.

Recovery, Rehabilitation, and TransitionShelter, housing, and basic needs. The tsunami

created a highly complex situation, with hundreds ofnew agencies arriving in Sri Lanka and existingagencies experiencing substantial growth resultingfrom a sudden surge of funding. This situation resultedin challenges in coordination among the central gov-ernment, the districts, and realities in the field. Italso hampered needs assessment and made the outputof assessments less reliable.

Figure 5: Tents provided for temporary housing after the 2005 tsunami in Sri Lanka.

Disaster Management & Response/Yamada et al 43

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The homes of many persons who worked in thefishing industry were located along the shoreline. Asa result of poor construction, coastal areas sustainedmassive loss of shelter (see Figure 4). Survivors whocould not find alternative shelter with relatives orfriends tended to gather in transit camps. ManyNGOs provided large numbers of tents as temporaryshelters. As well-meaning as those gestures were,many of the tents were not customized to the environ-mental conditions in Sri Lanka. The weather was

humid, and the conditions in the nonbreathable tentswere unbearable (see Figures 5 and 6). Some donatedforeign goods also were of poor utility. For instance,the contents of crates labeled ‘‘Aid for TsunamiVictims’’ included ‘‘winter jackets, expired cans ofsalmon, stiletto shoes, winter tents, thong panties,and even Viagra.’’19

Residents in the transit camps frequently were leftwithout vocational activities, teaching of life strategies,or coping skills. Local volunteers and international or-ganizations distributed basic aid, such as hygiene kits,beds, blankets, and cookware, but the local distribu-tion process lacked equity and coordination.20 Acces-sibility of drinking water was not a significant issue.Various organizations, such as the Red Cross, assistedin the regular distribution of drinking water usingtanker trucks and 2000-liter roadside storage tanks.

Prevention of epidemics. In the early aftermathof the disaster, there were concerns that more people

The weather was humid, and the conditions in

the nonbreathable tents were unbearable

44 Disaster Management & Response/Yamada et al

would die from communicable diseases than from thetsunami. Despite limited financial resources, Sri Lankawas successful in preventing epidemics because of itspublic health infrastructure and well-developed publichealth surge capacity. Every division with a populationof 60 to 100,000 has a medical officer of health (MOH)who coordinated the public health activities in thefield. The MOH is assisted by a staff of public healthinspectors (sanitarians) and midwives (maternal andchild health workers).

Immediately after the disaster, preventive healthstaff were mobilized. The public health staff visitedthe transit camps regularly to provide emergency treat-ment and conduct manual disease surveillance. Theygenerated daily epidemiologic reports, which weresubmitted to the MOH. Early symptoms of diarrhea,respiratory infections, and conjunctivitis promptedimmediate isolation and transfer to the nearest hospitalfor further evaluation and treatment. The sanitariansensured that water supplies and other facilities, includ-ing sanitary latrines in the camps, adhered to publichealth standards. The existing health care infrastructurealso was supplemented by other volunteer health careprofessionals and community religious leaders. Sri Lan-ka was able to care for almost a million displaced indi-viduals, two thirds of whom lived initially in camps.There was not a single significant epidemic of infec-tious disease in the aftermath of the tsunami. This out-come is a testament to the success of the Sri Lankanpublic health infrastructure and its surge capacity, asystem developed during the past 3 decades by theSri Lankan Ministry of Health.

Control of vector-borne diseases. One pressingissue in the immediate aftermath of the tsunami wasthe lack of an organized vector control strategy and

Figure 6: Temporary housing more compatible with the climate in Sri Lanka.

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proper waste disposal.21 Concern stemmed from a sig-nificant outbreak of dengue hemorrhagic fever, withnearly 300 deaths, that had affected Sri Lanka in2004.22 In addition, malaria also had been confirmedin parts of the lower South and the Eastern provincesrepeatedly during the previous years.23

Infestations of the common fly proved to be an im-portant sanitation issue in the transit camps. Looselydiscarded waste from the densely populated campscombined with wet weather conditions created theideal milieu for fly infestations and vector-borne dis-ease transmission. The WHO advocated fogging witha combination of malathion and kerosene to controlvector-borne diseases. The Sri Lankan Ministry ofHealth initially rejected these recommendations butlater promoted fogging around the camps. In the 3dry months following the tsunami, malaria and den-gue fever were not major problems in the affectedareas.

Psychosocial problems. An expected, long-termpsychological consequence of the disaster has beenpost-traumatic stress disorder (PTSD), which affectedthose who responded to the emergency as well asmany of the survivors. Children, in particular, sufferedgreat psychological trauma; 1200 children lost oneparent, and 1000 lost both parents.24 Psychologicaland psychiatric resources were limited. Prior to thetsunami, for a population of nearly 20 million, therewere only 20 psychiatric consultants in the country.25

In the aftermath of the tsunami, efforts were madeswiftly to train other health professionals to providecounseling services. For instance, medical graduateswho had not started their internships were trained bythe Faculty of Medicine of the University of Colomboand sent out to the field to provide counseling sup-port. NGOs such as Sarvodaya provided spiritual guid-ance and promoted Buddhist principles of meditationto promote recovery.

In addition to PTSD, there was an increase in sub-stance use and abuse. This trend was evident whenthe authors (LF, RPG, TMR, and SY) conducted clinicsin the camps for the displaced in the Galle district. Per-sons who previously were nonusers began abusingsubstances as a way of dealing with the psychologicaleffects. Persons who engaged in substance abuse priorto the disaster increased the frequency and quantity oftheir habits. One fishing village in Galle was com-pletely destroyed by the tsunami and suffered signifi-cant loss of life. According to some of the keyinformants, up to half of the surviving adults reportabusing alcohol, including homemade ‘‘moonshine’’and narcotics such as heroin.

Status of women and children. Women and chil-dren have been particularly vulnerable to the socialdisruptions resulting from the tsunami. In addition tobasic needs such as health, nutrition, and shelter,they also are dealing with issues such as security

April-June 2006

and safety, feminine hygiene, and legal representa-tion. Women in Sri Lanka are politically underrepre-sented and do not adequately participate in theprocess of decision making. Many women wereforced into the role of head of the household whenthey lost their husbands. They have had problemsgaining access to land that previously had been intheir husbands’ names.26 There have been scatteredreports of rape in the refugee camps, and somewomen became victims of the sex industry, particu-larly in the setting of devastation superimposed onpre-existing poverty.27 There have also been reportsof children who became vulnerable to sexual andphysical abuse and involuntary/illegal adoption bypersons from abroad.28

Legal issues. The disaster caused not only the lossof human life and shelter but also loss of legal docu-mentation, such as birth certificates, driver’s licenses,marriage licenses, and property titles. The replacementof such documentation has been slow because of analready overworked and understaffed legal system.

Sustainable DevelopmentAs important as the emergency and recovery/

rehabilitation/transition phases are, they are meaning-less unless sustainable development is attained. Thegoal of sustainable development is to provide survi-vors of disasters with skills and tools that will enablethem to recover and return to their previous occupa-tions or acquire new trades/skills. Multiple issues mustbe addressed to ensure that development can occur.

Financing. Two months after the tsunami, lessthan $40 million of the more than $1 billion pledgedin aid to Sri Lanka had been received by the CentralBank of Sri Lanka. Meanwhile, private NGOs hadreceived $600 million. The finance secretary suggestedthat this disparity may be due to a perception of gov-ernment mismanagement.28a It has been a major chal-lenge to assess the funding currently available, thefunds already spent, and the type, amount, and distri-bution of aid, particularly by NGOs and philanthropicindividuals. Another problem has been assessing indi-vidual need. Examples were found where the aid hadnot been given to those who needed it the most butrather had been given to others who are more astute,vocal, or politically powerful.

Housing and land use issues. Three months afterthe tsunami, 500,000 of the displaced people were stillstaying in temporary shelters or with relatives.29 Few

Women and children have been particularly

vulnerable to the social disruptions resulting

from the tsunami.

Disaster Management & Response/Yamada et al 45

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of the more than 82,000 homes destroyed had been re-built. In the tsunami-ravaged areas of Hambantota,broken foundations and scattered rubble remainwhere homes once stood. Although the governmentallocated 250,000 rupees (approximately $2500) topersons whose homes where completely destroyedand 100,000 rupees (approximately $1000) to personswhose homes were partially damaged, available fundsfor rebuilding were scarce.30 Other factors, such as un-certainty regarding zoning, the scarcity of building ma-terials, and a shortage of skilled carpenters,electricians, and plumbers, also have contributed tothe delay in rebuilding.

The Sri Lankan government has issued a decreeprohibiting the reconstruction of homes within 100 Mof the coastline, leaving many of the displaced withoutland for rebuilding. This decree has become a politicallycontentious issue, with members of the oppositionparty calling for this rule to be rescinded. On March28, 2005, another earthquake off the coast of Sumatragenerated fears throughout the Indian Ocean of furtherinstability along the geological fault and of anothertsunami. It also helped to lend credence to the decree.

Income generation and livelihood. In the after-math of the tsunami, victims received an outpouring ofinternational aid. For the first few months after the tsu-nami, the government of Sri Lanka provided a stipendof 5000 rupees (approximately $50) per month perfamily as well as rations of rice, dhal (split peas),sugar, and coconut milk. During this time, many ofthe victims came to expect this basic aid and did notfeel the necessity to recover their livelihood. Thus,in the Galle district, an offer of 150 to 200 rupees fora day of labor in clean-up activities was met witha poor response. In certain refugee camps, fishermenrefused to return to the ocean, instead electing tospend their days idling. Some relief organizationshave cited this ‘‘culture of dependency’’ as a significantchallenge to fostering gainful employment and sus-tainable recovery.

Various organizations have taken steps towards sus-tainable development. NGOs have donated numerousfishing supplies such as fishing nets and boats becausemany of the villages that were affected were fishingvillages. This assistance has enabled some fishermento return to their pre-tsunami occupation. The impactof the tsunami also has opened a window for furtherexploitation of lower-income Sri Lankans. This situa-tion is illustrated by an increasing number of fishermen,acting as middlemen, who employ other fishermen byproviding them with fishing supplies and equipmentthat they themselves had received from NGOs inexchange for a large portion of their catch. Early inthe post-tsunami period, a fear of the ocean31 and areluctance to eat fish because of the belief that theymight have been feeding on corpses were barriers tothe re-establishment of the fishing industry.

46 Disaster Management & Response/Yamada et al

Lessons LearnedThis primary observational analysis of the Sri

Lankan tsunami experience suggests important lessonsfor both Sri Lanka and other large-scale disaster man-agement programs.

Need to coordinate rescue efforts. Sri Lanka willneed to address a number of salient issues such ashow local government agencies can assist neighboringareas and coordinate aid from internal and externalsources. Greater oversight of coordination betweenthe government and NGOs would lead to an increasedefficiency of relief efforts, prevent the duplication ofservices, and avoid the provision of unnecessaryservices.

The Sri Lankan experience also demonstrated theimportance of a resilient public health infrastructureand community development in the event of a disaster.Preparation for natural disasters and other emergencypublic health threats, such as emerging infectious dis-eases or bioterrorism, necessitates a well-developedcommunity health infrastructure supported by a highly

trained, efficiently managed, and coordinated work-force. The necessity for public health managers to co-ordinate efforts with other sectors and the provincialadministration cannot be overemphasized. The utilityof a decentralized, community-driven response wasevident in this case. Culturally competent, well-moti-vated community leaders and volunteers were invalu-able assets who enhanced response to the tsunami inSri Lanka.

Emergency response structure. An ICS must en-sure that resources are directed to the areas in mostneed. Many camps for the displaced persons were en-countered that had received excess clothing, food, andmany impractical items, while others were greatly inneed of such items, particularly in the North and theEast. An ICS also would have a significant role toplay in coordinating and directing the services of theNGOs, international agencies, and foreign assistance.Plans must be in place to mobilize and redirect healthpersonnel in the event of a future disaster.

Training of health care personnel. Healthworkers need to be educated and trained to partici-pate in a coordinated, multidisciplinary response.They also will need to learn clinical skills for mass res-cue and emergency treatment as well as the location,structure, and functioning (including their roles andresponsibilities) of the National and ICSs. Such

The necessity for public health managers to

coordinate efforts with other sectors and the

provincial administration cannot be

overemphasized.

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training may include basic and advanced life supportmeasures, such as providing care with a bag-mask ap-paratus if mechanical ventilators are unavailable. Withrespect to addressing psychosocial issues, followingthe tsunami, health workers were given rapid trainingand were able to provide some counseling services.Sri Lanka may benefit from expanding this type oftraining.

Management of the deceased and the disposalof dead bodies. Plans must be made to direct the de-livery of human remains to appropriate locations so asnot to impede the delivery of health services. In addi-tion, steps need to be taken to avoid the mass burialsof unidentified victims. Corpses of disaster victims donot pose a significant risk for the spread of infectiousdiseases, and the right of families to conduct religiousand cultural funeral rites should be respected.32,33 Theplans should include methods to identify the bodiessuch as collecting samples of DNA or using digitalcameras with adequate storage capacity to photo-graph the victim.

Conclusion

While Sri Lanka was able to prevent the feared out-breaks of disease in the immediate aftermath of thetsunami, long-term recovery and reconstruction havebeen slow. Lessons learned from the experiencewith the Indian Ocean tsunami in Sri Lanka shouldserve to improve responses to future disasters in SriLanka as well as elsewhere.Acknowledgment: We thank L. E. Upendra and Wa-santha Weerawarna for their support of this work.

References

1. Liu PL-F, Lynnett P, Fernando H, Jaffe BE, Fritz H,Higman B, et al. Observations by the InternationalSurvey Team in Sri Lanka. Science 2005;308:1595.

2. Government of Sri Lanka. The latest statistics [online;cited 2005 Apr 1]. Available from: URL: http://www.emergencyinfo.gov.lk/

3. Asian Development Bank. Report and recommendationof the president to the board of directors on proposedloans and grants to the democratic socialist republic ofSri Lanka for the tsunami-affected areas rebuilding pro-ject and the north east community restoration and devel-opment project, April 2005. Manila, Philippines: TheBank; 2005.

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48 Disaster Management & Response/Yamada et al

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