Emergency doctor says WHO has key role in health crises.

88 Bulletin of the World Health Organization | February 2005, 83 (2) WHO News The massive earthquake off the coast of Indonesia and resulting tsunami waves that wrought havoc along the rim of the Indian Ocean did not produce the big- gest death toll from a single disaster but mark perhaps the steepest death count rise in history. No other disaster has drawn so much attention to the need for reliable infor- mation on deaths, disease and destruction as the tsunami of 26 December 2004. “We started with an estimate of 10 000 dead on the morning of 27 December, that grew to 153 000 within 10 days,” said Dr Alessandro Loretti from WHO’s Health Action in Crises department, who has been monitoring the crisis from Geneva since 26 December. In the aftermath of the disaster, WHO has been an important source of information on its scale and impact. Experts such as Dr Ties Boerma, Director of WHO’s Measurement and Health Information Systems, say counting bodies is vital — not out of ghoulish fascination — but as a way for governments and donors to gauge the size of a disaster and tailor an appropriate humanitarian response. Loretti, who has been working round the clock to keep the informa- tion flowing, said the tsunami death count has been even more difficult to estimate than that of other disasters. Political tensions and armed violence in Sri Lanka and Indonesia’s Aceh province have not made this task easier, he said Many bodies have not yet been discovered and may never be: some were washed out to sea, some were covered by debris and some were buried under sand churned up by the waves. The presence of tourists, migrant workers and other visitors in disaster-hit regions also made it dif- ficult to provide reliable figures on the dead, missing and wounded. Loretti told the Bulletin the task was most difficult in Indonesia’s Aceh province, where the combined impact of earthquake and waves had devastat- ing consequences. “In the immediate aftermath of the event, there was hardly anyone left or able to count and identify the dead, and inform their next of kin,” Loretti said. While the death toll reached more than 150 000 by mid-January, reliable figures on disease are now more ur- gently needed to prepare governments and humanitarian agencies to prevent outbreaks. Loretti said disease surveillance and early warning of epidemics was a priority but also a major challenge due to missing health workers and damaged or destroyed infrastructure. “It’s a very fragile system of health posts and helpers who may have been washed away, of roads that have been washed away, telephone lines cut off and traumatized staff who have lost their relatives, friends and colleagues,” Loretti said. Tsunami body count is not a ghoulish numbers game Counting bodies in a major disaster is important to gauge the impact and humanitarian response needed from governments and donors. The difficulty of obtaining reliable figures in the Asian tsunami crisis has underscored WHO’s recent work on geographic mapping of health facilities, particularly in developing countries. Shoreline of Banda Aceh, the provincial capital of Indonesia’s Aceh province, before (above), and after (below), the earthquake and tsunami struck. Cr ed it: D ig ita lG lo be 89Bulletin of the World Health Organization | February 2005, 83 (2) WHO News Loretti said WHO had helped to establish a skeleton early warning system using cellphones for disease surveillance in Indonesia’s Aceh prov- ince and that so far there had been no major outbreaks. The tsunami disaster has under- scored the importance of having sound pre-existing health and population information to prevent outbreaks of disease and food shortages, and to help disaster-hit regions get back on the road to recovery, Boerma said. Mapping or compiling detailed geographic information about the pop- ulation, health facilities and services and other key public health informa- tion is essential for this, he said. A global effort is under way with the help of WHO’s Health Mapper software to build these geographic information systems. Sri Lanka is a good example of a country where post-tsunami recon- struction efforts are now benefiting from such information, Boerma said. Furthermore, he said that if vital registration systems are also in place, it is much easier to count the dead, missing and displaced, and plan the response after disaster strikes. The Health Metrics Network is an initiative by WHO and its international part- ners to help countries establish such reliable information systems. Sri Lanka and the Maldives, which were also badly hit by the tsunami, have vital registration systems but reporting of births, deaths and causes of death is in- complete and delayed. Indonesia has no registration system at all, Boerma said. “Most developing countries don’t have good vital registration systems: you’re not counted when you are born and you’re not counted when you die,” Boerma told the Bulletin. O Fiona Fleck, Geneva WHO in the tsunami crisis • On 26 December, the fourth most powerful earthquake ever recorded occurred under the seabed off the coast of Indonesia. The magniture, 9.0 on the Richter scale, triggered a series of giant waves that wrought destruction in 12 countries from south-east Asia to the Horn of Africa, killed more than 150 000 people and left at least half a million people injured and as many as five million homeless with little or no clean water, food or health services. • Within days, a team from WHO’s Health Action in Crises department started colloborating with WHO’s Regional Office for South-East Asia in New Delhi, India, to collate information on the death toll and injured, coordinate relief work and monitor any disease outbreaks. • WHO started sending water purification tablets and health emergency kits with basic medical supplies for more than two million people, surgical equipment for more than 10 000 operations and emergency treatment of diarrhoeal diseases for more than 15 000 people. • On 30 December, WHO warned that between three and five million people in the tsunami-hit region were unable to access basic requirements to stay alive: clean water, adequate shelter, food, sanitation and health care. • On 4 January, WHO Director-General Dr LEE Jong-wook visited Jakarta, Indonesia, and the following day flew to the province of Aceh, large swathes of which were devastated by the combined impact of the earthquake and waves. He joined WHO Regional Director for South-East Asia, Dr Samlee Plianbangchang there to help assess the damage, evaluate relief efforts and see what further help WHO could provide. • On 5 January, WHO said much of the aid it had sent was reaching disaster-hit locations but warned that access to safe drinking-water remained inadequate, particularly in the Indonesian province of Aceh and on the eastern coast of Sri Lanka. • Lee visited Sri Lanka from 6 to 8 January where he met Health Minister Nirmal Siripala de Silva and WHO Representative in Sri Lanka Dr Kan Tun. Lee witnessed the devastation wrought by the tsunami in the coastal regions of the island, and praised the efforts of the people there to rebuild their shattered lives. • On 6 January, WHO appealed to donors for US$ 66 million to implement its public health strategy in the disaster-hit region. WHO started working with the Ministry of Health and other agencies in Sri Lanka to provide supplies to reduce the risk of disease outbreaks and to help rebuild vital health infrastructure, such as hospitals, clinics, pharmacies and medical stores that were washed away or badly damaged when the waves struck. A World Bank/WHO team started to assess the damage wrought by the tsunami in Sri Lanka and the resources needed to rebuild communities. • On 11 January, donor countries pledged US$ 717 million in immediate cash in response to a United Nations appeal for nearly US$ 1 billion to help countries devastated by the tsunami to provide relief, food, shelter and medicines, for their people and help with reconstruction. • On 14 January, a joint Indonesia–United Nations team of 20 started a series of daily missions to isolated areas on the coast of Aceh to do rapid health assessments of survivors to gauge what kind of humanitarian relief is needed. In teams of four they flew by helicopter from their base on the Abraham Lincoln, a U.S. aircraft carrier anchored off the Indonesian coast, to see whether any medicines or vaccines were needed and whether survivors were injured, had enough food, and had access to safe water and sanitation. For more about these and other WHO news items please see: http://www.who.int/mediacentre/en/ About 20 million people across the globe live in crisis conditions due to war, conflict or natural disaster while about two billion people are at risk of crisis conditions and face some threat to their health. Crises can be caused by: • catastrophic events: natural disasters like floods, earthquakes, hurricanes and tsunamis that often affect several countries or regions, and man-made disasters, for example, toxic spills. • complex and continuing emergencies: violent conflicts and wars that often trigger displacement of communities. • gradual breakdown of a country’s social institutions due to economic decline; for example, the impact of high levels of a fatal disease, such as HIV/AIDS in sub-Saharan Africa; or widespread arsenic poisoning in the Ganges delta. 90 Bulletin of the World Health Organization | February 2005, 83 (2) WHO News Emergency doctor says WHO has key role in health crises W HO Dr David Nabarro Since Dr David Nabarro was appointed Representative of the Director-General for Health Action in Crises in July 2003, the work of his team has hardly been out of the headlines and their web site http://www.who.int/hac/en/ has become an important source of comprehensive health information on crisis-hit regions. In the last 18 months, WHO has responded to more than 12 major health crises across the world from natural and man-made disasters to armed conflict and barely functioning health systems in regions with a very high burden of HIV/AIDS. WHO’s Health Action in Crises helps governments reconstruct vital health services after a war or conflict, for example in Afghanistan, Iraq and Liberia; it provides basic health care to people who are being displaced by conflict, for example in Darfur, Sudan, and helps governments provide emergency health care, monitor disease and rebuild broken health systems in regions struck by natural disasters, most recently in tsunami-hit parts of south-east Asia. Q: What is a health crisis and what is WHO’s role in such situations? A: WHO has a special role in times of crises. These are moments when large numbers of people can’t get basic requirements for life: water, sanita- tion, food, shelter, public health services. That means their risk of disease, disability and death rises. They suffer illness and die and that is a correct concern for WHO. It doesn’t mean it’s our job to deal with all the underlying causes. We serve as a barometer in the progress of a relief effort. For example, we look at how they can improve shelter, change the layout of camps: that’s why health people have a role. You need one organization that provides the gold standard. It could be ICRC (International Committee of the Red Cross) or MSF (Médecins sans Frontières), but most countries prefer it to be WHO because they look to us for reliable statements about what’s going on. Q: Is WHO competing with other or- ganizations providing emergency health relief in emergencies, such as the ICRC? A: WHO uses its convening power to coordinate different organizations as they respond to crisis. If you have lots of different agencies trying to respond to health with different approaches and strate- gies, the result can be chaotic and bad. One of the moral duties of the world’s relief agencies is to coordi- nate when it comes to health. The only organization with au- thority in this field is WHO. People feel we haven’t done it well enough, but the issue is whether anyone else can do it and the answer is “no”. Q: Did WHO get involved sufficiently quickly in response to the tsunami and what sort of assistance have affected countries been requesting? A: We got in quite quickly: in Sri Lanka in the first few hours, in Indonesia a bit later. In emergencies and humanitarian disasters, we look at the situation on the ground, at what’s being provided, we identify gaps and make sure someone else fills the gaps or – if necessary — we fill the gaps. We did that in the tsunami crisis providing water purification tablets and emer- gency medical kits (see box on opposite page). We also do measure, surveil- lance and coordination work with local groups to make sure supply lines are open for medicines and food. One gap area in the tsunami crisis which we have helped to fill is to provide consistent public health information and advice. Countries and communities look to us to help their own personnel get back on their feet and start providing health services again. Q: But what exactly is WHO doing on the ground? A: High-order operational work, gap filling, capacity building. Just because WHO is operational it doesn’t mean we are not on the ground. You can’t do coordination work, you can’t identify gaps, you can’t do all of this unless you have people on the ground, and we have the best possible public health experts you can find. Q: How does WHO’s response fit into the overall UN family response? A: We are usually chair or co-chair with the ministry of health of a coordinating group to provide an environment in which everyone can agree. In Aceh, for example, we have been coordinating at least 28 organizations, nongovernmen- tal organizations, governmental groups, military groups, etc, to make sure they can perform effectively. Q: WHO has been criticized for hyp- ing the extent of the tsunami crisis, for example, WHO said 150 000 people were at risk of death because they had no access to clean water and sanitation and that suggested the death toll of 150 000 reported in January could double. A: WHO has been calling attention to the extent of the crisis and the number of people lacking regular and predictable access to basic needs like water, food and shelter. Even now, health assessments of people living outside Banda Aceh are only starting Dr David Nabarro, 55, qualified as a physician in 1973 and worked in the UK National Health Service for three years and as district child health officer in East Nepal for two years. He held posts at the London School of Hygiene and Tropical Medicine and the Liverpool School of Medicine as well as in South Asia as regional manager for Save the Children. In 1989, he joined the British Overseas Development Organization and worked in Kenya and the United Kingdom. In 1999, he joined WHO as Project Manager in the Roll Back Malaria Department. Since 2000, he has held senior posts in the Office of the Director-General where he has been Representative for Health Action in Crises since July 2003. You need one organization that provides the gold standard … most countries prefer it to be WHO because they look to us for reliable statements about what’s going on. 91Bulletin of the World Health Organization | February 2005, 83 (2) WHO News and information about their health status is patchy at best. WHO has put a great deal of effort into building or rebuilding simple disease surveillance systems — early warn- ing systems — in the affected areas. The idea has been to ensure that any disease outbreak would be rapidly iden- tified and a response could then be put into operation. With this early warning system, we are more confident that we would detect an outbreak, but the risk has by no means passed. Waterborne diseases continue to be a threat and there is continuing, possibly increasing, risk of mos- quito-borne diseases such as malaria and dengue fever. Q: What lessons has the UN learned from recent emergencies in being better prepared to deal with them? A: WHO has been building up its capacity to respond to emergencies over recent years, as part of the wider UN system. The main lesson we have learned is the importance of coordination and of a strong logistics base. In the first hours and days after the tsu- nami hit, two clear needs were identified: first, to get as much information as pos- sible from the affected areas and second, to put in place a strong operational platform from which other work can be done. Put simply, there is little point sending a team of epidemiologists to the field if they have no water, nowhere to sleep and no way to send information to anyone else. Q: What are the main challenges for WHO in addressing the health effects One WHO emergency medical kit contains three-months supply of essential drugs and equipment for 1000 people. Each kit is divided into 10 packages, which are intended for use by community health workers in remote areas, and a supplementary kit for doctors. in the aftermath of the tsunami? What are the chief obstacles to providing emergency relief and to reconstruction of communities and rebuilding health systems? A: The key challenge is still informa- tion. Intensive efforts are under way to improve the flow of information, particularly from Aceh. That way, the health response can be better targeted to the real situation on the ground. Initially, the challenge has been to provide relief to respond to the urgent needs of people affected by the tsu- nami. That need continues, but at the same time efforts have begun to plan the reconstruction and rehabilitation of communities. O The key challenge is still information. Intensive efforts are under way to improve the flow of information, particularly from Aceh. That way, the health response can be better targeted to the real situation on the ground. Survivors of tsunami in Aceh walk through the rubble at the place where their home once stood. W HO /D . T at lo w