Th or collective redistirbution of this of any by photocopy machine, article or other portion reposting, means is permitted only THE OCEANS AND HUMAN HEALTH published in been has is article

BY MARK E. KEIM Oceanography Cyclones, Tsunamis, , Volume 2, a quarterly journal of Th 19, Number and Human Health

Th e Key Role of Preparedness Society. Copyright e Oceanography 2006 by Th

Besides the many benefi ts of the ocean, human and other and medical consequences of these disasters, the social, with the approval of Th populations living in coastal regions share in the risk for cultural, and psychological impact of cyclones and tsuna- meteorological and seismic hazards that originate from mis have an enormous and long-lasting impact through- the seas. Tropical cyclones (also known as typhoons and out the world, and a direct effect upon human develop- Permission reserved. Society. All rights is e Oceanography gran hurricanes) and tsunamis represent the most powerful ment in general (see Miller case study, this issue). Table 1 all correspondence to: Society. Send e Oceanography [email protected] or Th and destructive of all marine hazards. compares the public-health impact of cyclone and tsu- Tropical cyclones have caused an estimated 1.9 million nami disasters. deaths worldwide during the past two centuries (Nich- Drowning during the impact phase of the disaster olls et al., 1995). During 1980–2000, an average of causes the overwhelming majority of deaths from cy- 11,800 deaths per year were attributed to cyclones (United clones and tsunamis. Populations are at risk of death Nations Development Programme, 2004). The three simply by virtue of their physical proximity to low-lying deadliest cyclones produced catastrophic loss of life: land situated near the coastline. However, there is signifi - 300,000 deaths and 138,000 deaths in the Bangladesh cy- cant promise for the future in that nearly all these deaths clones of 1970 and 1991, respectively, and 100,000 deaths are preventable with the proper advance warning and ted to in teaching copy this and research. for use article Repu in the Chinese typhoon of 1922. Sixteen of the 18 deadli- population evacuation. Very few drowning victims would est tropical cyclones occurred in the Asia-Pacifi c region. be expected to survive the initial inundation, even with Tsunamis have the potential to cause an enormous im- the added benefi t of fully adequate emergency-response MD 20849-1931, USA. 1931, Rockville, Box PO Society, e Oceanography pact upon the health of millions. Since 1945, more people capacity. Preparedness is the key to preserving human life have been killed by tsunamis than by earthquakes (Noji, in the setting of cyclones and tsunami disasters. All other 1997; McCarty, 2002). In a 100-year period from 1895 to measures are less effective, less compassionate, and much 1995, there were 454 tsunamis recorded in the Pacifi c, the more expensive. deadliest 94 killed over 51,000 people (Boyarsky and Sh- Whenever there is a disruption of routine public health neiderman, 2002). The 2004 Indian Ocean tsunami killed services (like that which occurs after a cyclone or tsu- nearly 300,000 and affected over 2,000,000 two million nami), there is the potential for secondary adverse health lcto, ytmai reproduction, systemmatic blication, people in twelve nations. (U.S. Geological Survey, 2005). effects to develop among the disaster-affected popula- The human-health effects of cyclones and tsunamis tion. The best opportunity to prevent or lessen secondary cannot be understated. In addition to the public health health effects is during the emergency-response phase.

40 Oceanography Vol. 19, No. 2, June 2006 Preparedness is the key to preserving human health in the wake of cyclone and tsunami disasters.

Oceanography Vol. 19, No. 2, June 2006 41 TROPICAL CYCLONES Because warm ocean water is neces- two-thirds of storms develop), and one AKA TYPHOONS AND sary to power cyclone formation, only the below the equator (Schultz, 2005). HURRICANES planet’s midsection can conceive tropi- Background cal cyclones. Wind circulation within a Human-Health Impact of Cyclones Tropical cyclones are low-pressure weath- cyclone is controlled by an approximate Mortality Trends er systems that develop over the warm balance between pressure gradient and Prior to the implementation of early- waters of the oceans, typically between Coriolis forces; the bigger the pressure warning, evacuation, and shelter systems, the latitudes of 30°N and 30°S (Malilay, differential, the faster the winds. Because drowning from accounted 1997; Williams, 1997). Cyclonic storms the direction of the Coriolis force with with wind speeds surpassing 74 mph respect to wind velocity is opposite in Mark E. Keim, M.D. ([email protected]) is (118 kph) are termed tropical cyclones. the northern and southern hemisphere, Medical Offi cer and Team Leader, Inter- Depending upon geographic location, cyclones rotate in a counterclockwise di- national Emergency and Refugee Health tropical cyclones are referred to as “hurri- rection in the northern hemisphere and Branch, National Center of Environmental canes’’ in the North Atlantic, the Caribbe- a clockwise direction in the southern Health, US Centers for Disease Control and an, the Gulf of Mexico, the eastern North hemisphere. A corollary is that cyclones Prevention, Atlanta, GA, USA and Clinical Pacifi c, and the west coast of Mexico; can neither form at nor cross the equa- Associate Professor, Department of Inter- ‘‘typhoons’’ in the western Pacifi c; and tor. Consequently, tropical cyclones are national Health and Development, Tulane ‘‘cyclones’’ in the Indian Ocean and Aus- constrained to form within two tropi- University School of Public Health and tralasia (Malilay, 1997). cal belts: one above the equator (where Tropical Medicine, New Orleans, LA, USA.

Table 1. Public Health Consequences of Cyclones and Tsunamis

Consequence Cyclones Tsunami Developed nations - Low Death rates High Developing nations - High Severe injuries (% among survivors) Few Few to moderate Loss of clean water Widespread Focal to widespread Loss of shelter Widespread Focal to widespread Loss of personal and household goods Widespread Focal to widespread Major population movements Rare Rare Loss of routine hygiene Widespread Focal to widespread Loss of sanitation Widespread Focal to widespread Disruption of solid waste mgt Widespread Focal to widespread Public concern for safety High High Increased pests and vectors Widespread Focal to widespread Loss and/or damage of health care system Widespread Focal to widespread Worsening of existing chronic illnesses Widespread Focal to widespread Loss of electricity Widespread Focal to widespread Toxic exposures Possible Possible Food scarcity Common in low-lying remote islands Common in early stages only

42 Oceanography Vol. 19, No. 2, June 2006 for an estimated 90 percent of cyclone- after cyclones and other natural disasters. Psychosocial Consequences attributable mortality in both developed There is also a potential for exposure to Behavioral health effects are among the and developing nations (Malilay, 1997). hazardous materials during the impact, most long-term and debilitating out- Storm-surge drowning deaths have as well as during the clean-up phase of comes of natural disasters, including decreased markedly in developed na- the disaster. tropical cyclones (WHO, 1992; Ursano, tions due to improvements in hurricane 1994). Some persons experience persis- forecasting, evacuation, and shelter pro- Infectious Diseases tent distress, post-traumatic stress disor- cedures (Centers for Disease Control and Outbreaks of in fectious diseases follow- der (PTSD), major depression, or other Prevention [CDC], 1989b). Now, most ing tropical cyclones are rare (World psychi atric outcomes. An ele vated preva- of the storm-related mortality, and much Heath Organization [WHO], 1979; lence of PTSD was specifi cally apparent of the morbidity, occurs during the post- impact period; however, if major infra- structure damage is sustained, it can be The world can no longer afford to diffi cult to document the true extent of mortality and morbidity. In developed sustain these significant losses in human nations, the most prominent causes of development caused by these types of death and injury are electrocutions from downed power lines, chain-saw injuries, catastrophic natural disasters. blunt trauma from falling trees, and motor-vehicle fatalities occurring dur- ing the early post-impact period (CDC, Toole, 1997; CDC, 1999, 2000; Guill and in three studies of hurricane survivors in 1989a; Philen, 1992). Unfortunately, Shandera, 2001). In developed nations, developing nations (Caldera et al., 2001; storm surge remains the primary cause post-hurricane infectious disease surveil- Goenjian et al., 2001; Sattler et al., 2002). of mortality following tropical cyclones lance has occasionally detected increases Rates of suicide (Krug, 1998) and child in developing nations that lack critical in self-limiting gastrointestinal disease abuse (Keenan et al., 2004) appear to rise preparedness measures (Chowdury et al., and re spiratory infections (Lee et al., following natural disasters. The National 1992; Diacon, 1992). 1993; CDC, 2000, 2002), but more typi- Institute of Mental Health (NIMH) has cally, no increase in communicable dis- been quite proactive in seeking to address Storm-Associated Illness ease is found (CDC, 1993; Toole, 1997). mental-health issues of those disaster and Injury There have been a few reports of isolated victims affected by Injury represents the major cause of outbreaks associated with vector-borne (Insel, 2005). death and the primary cause of morbidi- illness in developing nations. For ex- ty for tropical cyclones (Meredith, 2002). ample, interruption of health services TSUNAMIS The top three cyclone-related injuries are including an anti-malaria campaign may Background lacerations, blunt trauma, and puncture have con tributed to a malaria outbreak The Japanese word tsunami translates wounds, with 80 percent of these inju- in following Hurricane Flora in in English to “harbor wave.” A tsunami ries being confi ned to the feet and lower 1963 (Mason and Cavalie, 1965; Bissell, is a series of ocean waves generated by extremities (Noji, 1993). An increased 1983). Following in any disturbance that displaces a large incidence of animal and insect bites fol- 1998, rates of dengue fever increased in water mass (Boyarsky and Shneiderman, lowing tropical cyclones has also been Guatemala and Honduras, and the num- 2002). About 90–95 percent of tsunamis noted (CDC, 1986, 1996, 2000). Chronic bers of malaria cases increased in Gua- are caused by large earthquakes (usually diseases (such as asthma and emphy- temala and Nicaragua (Pan American magnitude 7.5 or greater) at subduction sema) are also known to be exacerbated Health Organization [PAHO], 1998). zones (where one tectonic plate slides

Oceanography Vol. 19, No. 2, June 2006 43 over another); the remainder are pri- of kilometers long. Vertical movement of extremely low-frequency, long-wave- marily due to volcanic eruptions (like on the fault may displace tens of cubic length (~300 km) waves propagate in an the eruption of Mt. Krakatoa in 1883) kilometers of water. The December 2004 expanding radius from the area of dis- or landslides (like the 1998 Papua New tsunami, for example, caused the seabed placement. These waves differ important- Guinea tsunami generated by a subma- to uplift (or subside) 6–10 m in places, ly from surface waves (i.e., those caused rine landslide). There are also compos- displacing an estimated 30 km3 of water by wind) in that tsunami waves are prop- ite events such as the 1946 subduction (Dalrymple et al., 2006). Depth of fault agated throughout the entire depth of earthquake in the Aleutian Islands that movement is also an important factor in the ocean. For this reason, tsunamis rep- triggered a landslide-generated tsunami determining whether a tsunami will be resent a tremendous amount of potential killing 159 in Hawaii (Fryer et al., 2003). generated; shallower ruptures that break energy, and can travel the speed of a jet Prehistoric geological evidence has im- the seafl oor will generate larger initial airliner (300–600 mph or 500–1000 kph) plicated meteorites or comet impacts as tsunamis. No tsunami was reported for in deep, open water. Because the energy a rare cause of tsunami (Bolt, 1978). the magnitude 8.7 earthquake that shook is spread throughout such a large volume Earthquakes caused by large, sudden Indonesia on March 28, 2005 (leaving in deep water, tsunamis may be only a fault movement at subduction zones are 2,000 people feared dead on the island of few feet high in mid ocean, making them most often associated with generation of Nias), likely because fault movement did capable of passing under ocean-going the largest tsunamis (e.g., the Sumatra not break through to the seafl oor. In ad- ships with little disturbance or detec- earthquake and tsunami of December dition, that earthquake occurred beneath tion. The physical characteristics of the 2004). The amount of fault slip is an im- shallower water, where less water dis- fl uid pressure wave allow it to travel great portant factor in determining tsunami placement would occur (Hopkin, 2005; distances with very little loss of energy. size. At subduction zones, the fault zone Kerr, 2005). For example, a subduction earthquake affected may be as much as hundreds Once the tsunami is generated, a series that occurred on January 26, 1700 at the Cascadia subduction zone, encompassing western Washington and Oregon, gener- ated a tsunami that destroyed the island of Honshu (Japan) (Anonymous, 1997; Satake et al., 2003). About 90–95 percent of the world’s tsunamis have occurred in the Pacifi c Ocean due to its relatively large size and its bordering “Ring of Fire” comprised of major subduction zones. Great trans-Pacifi c tsunamis are typically caused by massive earthquakes located at these subduction zones and occur at an interval of about once a decade (McCarty, 2002) (Figure 1). As the tsunami enters shallow water near coastlines, the kinetic energy previ- ously spread throughout the large vol- ume of deep ocean water becomes con- centrated to a much smaller volume of water, resulting in a tremendous destruc- Figure 1: View of the western Pacifi c Ocean during a cyclone. tive potential as it inundates the land.

44 Oceanography Vol. 19, No. 2, June 2006 Successive crests may arrive to shore at intervals of every 10–45 minutes. This phenomenon is particularly problematic when responders attempt to rescue vic- tims from the water after the fi rst wave, only to become themselves victimized by subsequent waves. A single tsunami may be comprised of up to twelve wave crests. Prior to inundation of the wave crest, the sea may recede for an unusually long distance. During the 1960 Chilean tsu- nami that struck Hilo (Hawaii), this phe- nomenon tended to attract more people to the shoreline and into the ocean itself, where they were then caught up in the oncoming wave crest. One village in Pap- ua New Guinea reportedly recognized this as a sign of an impending tsunami and took protective actions for shoreline Figure 2. Author surveying tsunami damage in Banda Aceh, Indonesia. evacuation. In Simelue (Indonesia), an old song about moving to high ground when the earth shakes is reported to have saved lives, and resulted in a relatively low death rate compared to neighboring the world have been recorded in the past Average death rates are believed to be Sumatra (which was further from the 2000 years according to interpretation 50 percent for the population caught quake epicenter). of the sedimentologic and geomorphic up in a tsunami (McCarty, 2002). The A tsunami is usually 3–15 m high. imprints left by these events (Scheffers 30,000 inhabitants of Calang in Aceh Wave heights averaged 24 m above sea and Kelletat, 2003). The highest tsunami province (Indonesia) suffered an esti- level along the western coastline of Su- wave ever witnessed occurred at Lituya mated 70 percent mortality rate during matra during inundation of the 2004 Bay (Alaska) in 1950. It was triggered inundation of the December 26, 2004 Indian Ocean tsunami earthquake (Paul- by a magnitude 8.0 earthquake-induced tsunami (Brennan and Rimba, 2005). son, 2005). A 70-m wave was recorded landslide, and reached the height of Most deaths resulted from drowning. following the 1964 Alaska earthquake 524 m above the shoreline (i.e., a height However, a tsunami does not consist (Alaska Division of Emergency Services, three stories higher than the World Trade only of water. It also contains a great 1992). Extremely rare mega-tsunamis Center of New York City) (Boyarsky and amount of debris traveling with tremen- produced by giant submarine land- Shneiderman, 2002). dous momentum. The same 2004 Indian slides have been implicated globally Ocean tsunami is estimated to have been (McMurty et al., 2004). Evidence of soil Human-Health Impact of Tsunamis traveling at 30 mph (48 kph) when on stripping and coral deposits purportedly Mortality Trends shore in Aceh province (Indonesia). caused by tsunami inundation has been The vast majority of tsunami-related Figure 2 reveals extensive destruction reported up to an elevation of 365 m deaths occur immediately (McCarty, and debris left in the wake of the tsuna- in Hawaii (McMurty, 2004). At least 2002). In a large tsunami, deaths fre- mi in the city of Aceh (Indonesia). 100 mega-tsunamis in different parts of quently exceed the number of injured. According to a survey recently car-

Oceanography Vol. 19, No. 2, June 2006 45 ried out by Oxfam (2005), four times as burial ceremonies due to the miscon- had minimal to moderate injuries to the many women as men were killed in the ception that the dead bodies themselves body and extremities. Causes of death tsunami-affected areas of Indonesia, Sri pose a health threat (Guha-Sapir and included drowning, entrapment inside Lanka, and India. Some of the reasons van Panhuis, 2005). It is well established, collapsing buildings, and being thrown postulated for this are similar across however, that dead bodies do not pose a under cars (Lim, 2005). No survivor these countries: women died because health threat, and it is more important of the Papua New Guinea tsunami was found to have head, spine, thorax, or ab- domen injuries, implying that survival of these life-threatening injuries was vir- tually impossible in that remote setting ...it is possible to detect tsunamis and with delayed resuscitative and surgical cyclones in advance of these hazards, care (Taylor et al., 1998). Bone fractures, soft-tissue injuries, and near-drowning and provide early warning before they were the most common conditions re- strike those vulnerable populations ported among survivors in Papua New living along coastlines in their paths. Guinea and of the Indian Ocean tsuna- mis (Holian and Keith, 1998; Lim, 2005; Watcharong et al., 2005). As mentioned before, chronic diseases (such as asthma and emphysema) are they stayed behind to look for their chil- for families to recover their dead for psy- also known to be exacerbated after natu- dren and other relatives. Women in these chological reasons than to bury them for ral disasters. And similar to cyclones, areas often cannot swim or climb trees, sanitary purposes (Morgan, 2004). tsunamis have the potential to cause which meant that they could not escape. exposure to hazardous materials during Deaths from tsunami injuries occur Tsunami-Associated Illness and Injury both the impact as well as the clean-up in three phases. Victims usually succumb A tsunami directly injures the victims phases of the disaster. After the 2004 to injuries that are incompatible with life by the mechanism of blunt trauma and Indian Ocean tsunami, documents writ- (severe head, chest, and spine injuries) penetrating injury (Taylor et al., 1998). ten about the tsunami were critical of within the fi rst few minutes. Then im- People are bludgeoned by concrete slabs the over-abundance of health resources mediate complications set in over the and felled trees, stabbed by jagged sheets focused on non-emergent trauma care next few minutes to hours (such as bleed- of metal and glass, tangled up in mana- as compared to relative lack of attention ing, lung collapse, and blood clots in the cles of wire, and impaled onto tree limbs paid to the needs of special populations, lung). Finally, these immediate causes and bamboo. Soil, small pieces of wood, including the elderly (Mudur, 2005) of death are followed by delayed com- glass, and metal in the contaminated and maternal-child and women’s health plications over the coming days that are saltwater penetrate the soft tissues of the (Brennan and Rimba, 2005; Mudur, mostly associated with infectious disease body at high velocity. 2005; Perera, 2005). (such as wound infections and aspiration When the 2004 Indian Ocean tsu- pneumonia) (Kongsaengdao, 2005). nami hit the western coast of southern Infectious Diseases The large number of dead bodies be- Thailand, six to eight huge waves mea- Near-drowning is common in tsunamis came an issue of public concern in the suring 5 to 7 meters high destroyed al- and is frequently associated with aspi- wake of the 2004 Indian Ocean tsunami. most everything along the beach and ration pneumonia or “tsunami lung” Many families were not allowed to re- inundated areas more than 300 meters (Holian and Keith, 1998; Allworth, 2005; cover their dead or to observe traditional from the seashore. Most of the survivors Chierakul et al., 2005). Wounds are in-

46 Oceanography Vol. 19, No. 2, June 2006 evitably contaminated with soil, debris, Psychosocial Consequences THE CRITICAL ROLE OF and foreign bodies. Therefore, wound As mentioned before, behavioral health PREPAREDNESS infections are common. For example, effects are among the most long-term No man-made structure can be relied 16.9 percent of all diagnoses by Janu- and debilitating outcomes of natural di- upon to resist the incredible power of a ary 10, 2005 at the International Com- sasters, including tsunamis (WHO, 1992; large tsunami. Seawalls and reinforced mittee of the Red Cross (ICRC) fi eld Norris, 2005). The monumental devasta- construction are of limited benefi t (Mc- hospital in Calang (Indonesia) (Bren- tion of the December 2004 Indian Ocean Carty, 2002). The recent events of Hur- nan and Rimba, 2005) and 15 percent tsunami prompted a meta-analysis of ricane Katrina in the United States reveal of all consultations at the ICRC fi eld the psychosocial consequences of natural that even well-developed engineering hospital in Banda Aceh (Indonesia) were disasters in developing countries versus controls can fail in the event of a direct for wound infections (Guha-Sapir and developed countries (Norris, 2005). Gen- hit by a severe tropical cyclone. In the van Panhuis, 2005). erally, during a natural disaster, a much absence of emergency-preparedness Wound infections frequently involve higher proportion of the population in measures, the majority of tsunami- and multiple, relatively uncommon patho- developing nations sustains severe loss cyclone-related deaths will occur im- gens (Lim et al., 2005; Andresen et al., and extreme trauma, and experiences mediately during the impact phase when 2005). As was the case in populations that constitute clinically signifi cant dis- emergency response activities are the affected by hurricanes Andrew and Iniki, tress (Schultz et al., 2005). Table 2 com- most vulnerable and the least capable. tetanus cases increased after the 2004 pares the direct health effects of cyclones As previously noted, since 1945 more Indian Ocean tsunami as a result of in- and tsunamis. people have been killed by tsunamis than juries sustained at the time of impact. The number of cases then returned to baseline within one month of the event (Guha-Sapir and van Panhuis, 2005). Contrary to initial concerns for out- Table 2. Estimated Relative Frequency of Health Eff ects breaks of malaria, cholera, and dengue Associated with Cyclones and Tsunamis (Moszynski, 2005; Krishnamoorthy et al., 2005), the Indian Ocean tsunami, Type of morbidity Cyclone Tsunami like previous natural disasters, was not Crush injury ++ ++ associated with epidemics of infectious Head injury + ++ disease (Guha-Sapir and van Panhuis, Asphyxiation + ++ 2005). No increases in cases for cholera, Isolated bone injury + ++ measles, malaria, or dengue were noted Skin soft tissue injury + ++ in Aceh in the post-tsunami period Burns + 0 (Guha-Sapir and van Panhuis, 2005). Drowning ++ ++ Experience has shown that these dis- Asthma/emphysema + 0 eases, despite common beliefs, are not Hypothermia 0 + always a priority immediately after a Epidemics 0 0 natural disaster. Overall, the number of Starvation + 0 disaster-related health conditions need- Aspiration pneumonia 0 + ing emergency response decreased sub- Tetanus + + stantially within two weeks of the event, Wound infections + ++ and became negligible within four weeks (Guha-Sapir and van Panhuis, 2005). Psychological illness + +

Oceanography Vol. 19, No. 2, June 2006 47 by earthquakes (McCarty, 2002). How- protect human health from the hazards monia in survivors of the Asian tsunami. Medical Journal of Australia 182(7):364 ever, unlike earthquakes, it is possible to of cyclones and tsunamis, but they are Andresen, D., A. Donaldson, L. Choo, A. Knox, M. detect tsunamis and cyclones in advance also the most consistent with the pro- Klaassen, C. Ursic, L. Vonthethoff, S. Krilis, and P. Konecny. 2005. Multifocal cutaneous mucormy- of these hazards, and provide early warn- motion of human dignity and develop- cosis complicating polymicrobial wound infec- ing before they strike those vulnerable ment. The tremendous societal impact tions in a tsunami survivor from Sri Lanka. Lancet 365:876–878. populations living along coastlines in of hurricane Mitch in Central America Anonymous. 1997. Linking trees to tsunamis. 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