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Garrett: Tsunami Disaster Highlights Need for Greater Coordination of Relief Efforts

Interviewee: Laurie Garrett, Senior Fellow for Global Health
Interviewer: Bernard Gwertzman, Consulting Editor
January 3, 2005

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Laurie Garrett, a Pulitzer Prize-winning journalist with expertise in global health issues, predicts many survivors of the recent tsunami disaster in Southeast Asia will die of preventable diseases. She says there is an immediate need to teach survivors simple methods of catching rain to provide clean water, and says that there are “shortages of everything.”

She predicts increased rates of both mosquito-born and human-spread diseases. An immediate problem will be respiratory ailments caused by inhaling sea water while fleeing the tidal waves: “I am afraid that in the absence of appropriate medical personnel and support, we will see thousands of people perish in the next few days from respiratory infections,” she says. Less obvious effects will emerge in the months and years ahead, such as blood-borne infections spread by reusing syringes.

Garrett, the Council’s senior Fellow for global health, says that the international response to the disaster is being undermined by coordination failures. “I am very concerned that we lack a sort of global governance capacity to coordinate an international response,” she says.

She was interviewed by Bernard Gwertzman, consulting editor for cfr.org, on January 3, 2005.

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Can you give us an overview of what we can expect in the areas hardest hit by the tsunami disaster?

The only way to approach something on this scale is to break it down into pieces, otherwise the enormity of it is so overwhelming that you actually can’t get a mental grasp of what has happened and what needs to be done.

I think we are finally out of the first phase of the disaster- which in every case lasts longer than it should, but which, for obvious social, psychological, and cultural reasons, can’t be shortened- the attempt to find and identify the dead. For the most part, what could have ended several days ago [continues], just as happened with us, after 9/11, when firefighters looked for remnants of their deceased brothers and sisters in the burning heap of the World Trade Center for weeks, long after there was any reason they would find anything.

Now what?

The real focus for relief efforts now has to be on saving those who have survived so far. The No. 1 issue is water. It is hard to think of anything that is more crucial at this moment. Every aspect of safe-water supplies, if they existed before, has been disrupted now. If there were separate sewer and drinking water supplies, it is almost certain that the integrity of those separate lines has been disrupted by the earthquake or the tsunami, or flooding and landslides, and so on. As a result, you cannot trust that anything that comes from a tap is safe to drink.

So you have to bring in bottled water or purify water on the scene?

Well, fortunately, most of the region is tropical and gets a tremendous amount of rainfall. As a result, there are ways to create right now what are called rain catchments- and rain water is usually safe to drink, if it is collected in clean containers and has a net cover over the top to prevent mosquitoes and other insects from getting inside. Such rain catchments can be made from any supplies that are left from the disaster. It simply requires getting information to people to tell them how to make them. As far as filtering the water to prevent mosquitoes from getting in, many types of simple fabric will do the job if stretched tightly over a cone-shaped collector.

I haven’t read anything about this. I’ve only read about purification machinery.

That’s because everybody thinks of hi-tech answers that require the arrival of relief supplies. I’m talking about saving lives before the relief people can even get there. And if anyone is paying any attention to the news, they know that much of the region, especially in Aceh province, in Sumatra, Indonesia, is so remote, so difficult to get to, that there are still thousands of people who have not yet seen any relief workers or obtained any food aid or water.

We don’t know if people have access to radios, but if I were in charge and waving a magic wand, I would say, “Broadcast 24 hours a day [information about] how to make rain water catchments, [and] how to make mosquito nets out of available supplies, to protect children from being eaten alive by mosquitoes carrying malaria and dengue fever.”

Among the things I am very concerned about right now is the potential respiratory disease problem. People have suffered traumatic injury to their lungs. They have inhaled salt water. They have drunk a lot of contaminated, muddy water, as part and parcel of swimming their way out of the disaster. And now, much of that will end up causing acute respiratory disease, either bacterial pneumonia, respiratory syncytial virus [a major cause of respiratory illness in young children], or a whole host of other respiratory viruses.

All of these are an order of magnitude more difficult to treat than a simple cut, scrape, or broken bone. They require the availability of vaccine and/or antibiotics. They require careful care in a dry space, preferably a warm, dry space, for the afflicted individuals. And it is very difficult for children or elderly to survive such infections if they are living out in the open, exposed to the elements, or in slap-dash housing as we assume millions of people are now being forced to live in.

So we have an acute immediate problem, and I am afraid that in the absence of appropriate medical personnel and support, we will see thousands of people perish in the next few days from respiratory infections.

I have been watching the news channels and there is considerable on-the-scene coverage from makeshift hospitals, which seem to be suffering shortages of all sorts of medicines, including anesthesia and antibiotics.

There are shortages of everything. This brings us to a second problem. In a relief crisis there is an obvious desire to just get in with whatever you’ve got and do whatever you can. And that’s admirable. However, as we have seen in past relief crises, sometimes one set of admirable solutions creates another set of problems. An example is the widespread, blanket use of antibiotics. This in the past has led to the emergence of strongly antibiotic-resistant bacterial diseases. I’m very worried in particular about cholera and Shigella [a family of bacteria that can cause severe diarrhea in humans], both of which have, in past relief operations, emerged with tremendous ferocity in drug-resistant forms.

It is much more difficult to cure a drug-resistant strain of these diseases than a standard garden-variety strain. The other thing that worries me in resource-scarce crisis situations is how medical equipment itself gets used. You are in a situation where an individual has a wound, a broken leg, and a respiratory infection. You may not have a lot of syringes on hand. You may not have much sterile gear. You may not have electricity to power a generator which would then power an autoclave to sterilize your medical equipment. In the short run, your duty is to save that life, but in the long run, you may be spreading hepatitis B, hepatitis C, HIV, and a host of other blood-borne infections because you are reusing syringes, non-sterile scalpels, and other surgical equipment, and you lack proper sterilizing gear.

This is crucially important, especially when you are working in areas where the medical profession has a long-standing tradition of having a poor understanding of this problem to begin with. In fact, in South Asia right now, 80 percent of all medical injections- tsunami aside- are done with recycled syringes. So I am very concerned that in a crisis mode, we will see a tremendous escalation down the road in blood-borne disease as a result of reuse in the short-term of medical equipment that is not properly sterilized.

Again, if I had the power to wave a magic wand, I would beg all relief agencies to flood the region with auto-destruct syringes. These are syringes that can only be used once. Then the needle is retained back inside the syringe body and it can never be reused. That alone could tremendously reduce the spread of disease.

Do the aid agencies have these syringes? Do they use them?

UNICEF uses them for vaccines; the Indian government, just this summer, announced that it would switch to 100 percent auto-destruct syringe usage for vaccinations starting this month. But I am terribly afraid that in the emergency, syringes will be reused and will see what’s called nosocomial infection, which means spread of the disease by the medical profession itself.

The major Western governments are coming in now, pretty heavily, with their militaries. Can the military deal with these problems?

Yes, in the sense that in normal times and under normal constraints, they most certainly are able to cope. They are also set up with appropriate infection control standards regulating how health care workers protect themselves and each other. The key issue is how close naval hospital ships can get to these reshaped shore lines. We are literally getting into uncharted territory, because a 9.0 [magnitude] earthquake completely reshaped Indonesia’s Sumatra Island shore. The ships do not have the access to the coastlines they might have had three weeks ago. I don’t know to what degree they are able to provide onboard, shipboard hospitalization.

Regardless, I would think that U.S. military and other such physicians would be in good shape with infection-control equipment and understanding. At least I would hope so. If not, it would be inexcusable.

What is the next stage of the problem?

Coming up, with almost 100 percent certainty, I am afraid, are: drug-resistant widespread malaria, dengue and perhaps dengue hemorrhagic fever, Shigella, and cholera- particularly one of the virulent strains of cholera. And then tuberculosis- and we are in a region of widespread drug-resistant tuberculosis. All of these would be your second-line disease-disaster problems.

Your third-line disease-disaster problems are ones that will not show themselves, that will not be obvious for years to come. I alluded to them when I talked about blood-borne diseases like hepatitis. I am worried about conditions that will lead to more and more women being put in a position- their husbands and their livelihoods lost- of turning to prostitution in order to feed their children, and therefore being stricken with sexually transmitted diseases, such as syphilis, gonorrhea, and HIV. We’re looking at such intense disruption, and it is in areas where the rights of women have always been of a dubious standard, and the options for employment very narrow.

So, if we look down the road, we see clear interventions, one-by-one, that need to be taken to save the health and livelihood of people. The first, right now, is the crisis: fix bones, provide shelter, safe drinking water, clean up infected wounds, and prevent respiratory disease. Then, you go down the list until you get all the way to the point where you are talking about how to develop livelihoods that do not require women in particular- and little girls- to turn to prostitution in order to feed themselves.

Are there aid groups that do a better job than others?

Certain groups are better at emergency response than others. But I have not seen any group yet that knows how to go into a crisis like this and think ahead about the gender issues.

Summing up, you are extremely pessimistic.

I am pessimistic. I am very concerned that we lack a sort of global governance capacity to coordinate an international response. You have people sending in wool sweaters, donating their clothing from the eastern United States. Why are we spending money and resources to transport this unneeded stuff? We have medical supplies going in that make no sense.

Why are we sending $15-a-dose broad-spectrum antibiotics [effective against a wide range of infectious agents]? We need penicillin and other basic antibiotics. Get them in there now. We don’t need all this fancy, ultra-expensive stuff. We don’t need mountains and mountains of ibuprofen. We do need [basic] aspirin to bring down fevers. I just think we have a desperate, obvious problem that I hope the world is paying attention to and is learning from, [and] that is about global governance and lack of overall leadership. It is just chaos. It is everybody moving in and trying to do the right thing. I don’t think we see anyone trying to do anything evil or wrong. But we just don’t have a properly coordinated capacity. And I keep reminding people, when they get worried about cholera and so on, that the core budget of the World Health Organization is only $400 million a year. There is only so much you can do with $400 million a year.