When I first arrived in Meulaboh, a city on the west coast of Aceh, Sumatra, I went down to see the harbour. It was completely devastated, and although most of the corpses had been removed, the smell of dead bodies still filled the air. There were not many people around, but some were still sorting through the muddy debris, trying to salvage belongings. Although I didn't witness the actual moment when the tsunami hit, I caught a glimpse of the huge physical devastation in the words and minds of the people I met and patients I treated.
Médecins Sans Frontières (MSF) was the first international organisation to begin providing medical care in Aceh. The province, at the tip of Sumatra, has long been off-limits to outsiders due to a long and brutal violent struggle between the Acehnese separatist movement know as ‘GAM’ and the Indonesian military.
The first team of eight MSF volunteers arrived in Banda Aceh, the provincial capital, on the 28 December and started setting up mobile medical clinics. I arrived the following week. By the end of the month, there were more than 250 MSF staff working in the province, giving an average of 4000 consultations each week in more than 30 different locations; running measles vaccination campaigns; providing individual and group psychosocial support; working in several hospitals; and setting up an epidemiological surveillance system. MSF was using six helicopters, several chartered planes, a fleet of cars, a barge and a battery of fishing boats to transport staff, medical supplies, food and a wide range of relief goods around the region.
THE LIMITS OF CARE
Despite the intense relief effort, the experience was fairly disheartening for some medical volunteers. In a catastrophe as massive as this tsunami, peoples' fate, if they managed to survive the initial event itself, is decided in the first 24–48 hours. Without immediate medical and surgical care, they either survive because they only suffered minor injuries, or they die because their injuries are major. An enormous surgical capacity would have been required on the spot in the first 2 days to have had any really substantial medical impact on saving lives.
Although local doctors in heavily hit towns such as Meulaboh worked around the clock before outside help could reach them, they simply didn't have enough staff, equipment or supplies. They didn't even have the capacity to remove dead bodies from the hospital wards. They just kept on working in the emergency room with bodies piling up around them. As a doctor it's a terrible situation to be in. The surgical support that arrived several days after the tsunami was mainly engaged in cleaning up some wounds, carrying out amputations and preventing further infection and septicemia.
When MSF arrived in Meulaboh the hospital was barely able to continue functioning. Half of the staff had been killed or were missing and others were away caring for their own families. There was no one to provide post-operative care to patients. MSF staff helped open up the post-op ward and it was soon expanded to cope with 50 patients. We also took on the medical and paediatric wards.
URGENT NEED FOR PSYCHOSOCIAL SUPPORT
As well as working in several hospitals, we set up numerous mobile clinic teams to assess the health condition of people living in remote communities and ensure them access to medical consultations. These teams increasingly saw patients complaining of breathing problems, muscle pains, headaches and total numbness. Some patients experienced a tingling sensation all over their bodies and many suffered from insomnia. In many cases, physical examinations revealed no medical problems — in fact the general physical health of the population appeared to be quite good — and I felt that some illnesses were probably psychosomatic, due to the stress of the tsunami.
The most that I could do in these cases was to listen to the patient's story and explain that what they were feeling was a very normal reaction to a totally abnormal experience. I always asked them if they saw the tsunami, if they had had to swim, how long they had had to fight for their lives, the number of relatives and loved ones they had lost, and the damage to their homes. I felt it was extremely important to take the time to talk with them and listen to their experiences, even though I felt pretty helpless as a doctor in such a situation.
One man told me how he was clutching his wife in his left arm and his child in his right, trying to swim and stay afloat. He lost hold of his wife and then couldn't hold onto his child any longer — he could only watch as they floated away. He was extremely depressed. Another patient told me that every night he began to feel pain all over his body and he couldn't sleep. He was fine when he kept moving. It was not a physical pain he was feeling, but a mental pain that manifested itself in physical symptoms.
A survey of 1200 displaced people living in the grounds of an elementary school carried out in mid-January showed that a striking 90% of people questioned expressed a wish to talk about the tsunami disaster and receive psychological support (MSF, unpublished data, 2005). In recognition of the vast need for psychosocial care, MSF brought in psychologists to work alongside the mobile clinic teams so that patients could be immediately referred to a mental health specialist.
The psychologists were able to suggest ways for people to regain control of their own bodies, for example by touching or massaging the places where they felt pain or numbness. As a doctor, I was very happy to have the psychologists working alongside me. It gave me the opportunity to understand more about the psychological aspects of providing treatment after a traumatic disaster. In the African settings in which I have previously worked, I haven't usually had the time to really address psychological problems in the same way, since we were so busy just taking care of the severe and often life-threatening somatic diseases.
DISEASE OUTBREAK
Given the large number of displaced people living in crowded conditions with poor water and sanitation facilities, and the low level of vaccination coverage in many parts of Aceh, concern about potential epidemic outbreaks was understandably high. MSF and Epicentre, a partner organisation specialising in epidemiological research, set up a surveillance system to scan the province for outbreaks of watery diarrhoea, dysentery, leptospirosis, measles and malaria. In the 5 weeks following the tsunami no outbreak of any communicable disease was detected. We saw very few cases of malaria — during 1500 consultations my team detected only five cases of falciparium malaria. At first I thought that we might be just missing it clinically, so we took some tests but they all came back negative.
MONEY MATTERS
The tsunami received enormous media coverage around the world and prompted an unparalleled outpouring of public sympathy and money. Paradoxically, with huge amounts of money being donated in a very short space of time, the question of whether aid organisations would actually be able spend all the funds on tsunami-related relief became increasingly pressing.
Within 1 week of the disaster, MSF had already received over €40 million in donations in support of tsunami relief work. Given that this sum already greatly surpassed what we estimated we would need to fund first-phase emergency health care for tsunami victims, MSF decided to stop asking for funds specifically ‘ear-marked’ for tsunami work and to instead ask for donations towards our general funds. We took this decision in order to give us the flexibility to spend the much-needed funds where they could most be of benefit, rather than being obliged to spend them in the tsunami-affected region. MSF currently runs programmes in more than 70 countries and many of the places we work are conflict and post-conflict zones that have been largely forgotten by the world's media and receive little public attention or funding.
ROAD TO RECOVERY
For the tsunami victims in Aceh, the path back to normal life will clearly be very difficult. In some ways, people feel supported by the collective grief all around them. There is shared suffering, and patients are comforted by the fact that they are not alone in their terrible circumstances. Many also find strength in their strong religious beliefs. On the other hand, people still need outsiders to speak to. It is difficult for someone to talk to a neighbour about what happened to them when the neighbour has experienced the same loss. I think that people's active involvement in the reconstruction of their homes will enforce the feeling of regaining control of their lives and thus help alleviate some of their suffering. It will be a challenge for all of us to support them in this process.
- © British Journal of General Practice, 2005.