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Surg Cdr K CHATTERIEE

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Addressfor Correspondence Secretary MARINE MEDICAL SOCIETY Instituteof NavalMedicine, INHS Asvini Campus Printedand Publisl Mumbai 400 INDIA Colaba, 005. SenaBhavan,New Website: http://www.mmsindia.net 400 103.Editor: Sr 005"

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AssistantEditor 'ATs SUTgLtCdTKAMALMISHRA nit, u y wil 'f alll h eac rlar e e su( Addressfor Corcespondence tion r Editor pour JOURNAL OF MARINE MEDICAL SOCIETY wate Instituteof Naval Medicine, ion[3 INHS AsviniCampus, regic Colaba.Mumbai 400 005. :topo qual syste 'large Printedand Published and owned by DirectorGeneral of Medical Services(Navy), SenaBhavan, New Delhi I 100 1I . Printedon his behalfat Typo Graphics.Mumbai e, ra

400 103.Editor: SurgCdr IK Indrajit, C/o Instituteof NavalMedicine, Mumbai 400 , **Ce 005. I Mari OF MARINE MEDICAL SOCIETY Isi JOURNAL TSI SpecialIssue on Marifime EnvironmentalDisaster : PNS] The Tsunamiof 26 December2004 l. .' i' i'l CONTENTS ABST JJ Coast EDITORIAL marir mrng Chronicling the Tsunami of 26 Dec 2004 : An unprecedentedmarine environmentaldisaster hcrltl Surg Cdr IK Indrajit, Surg Lt Cdr K Mishra thresl t.9 Ri SPECTALCOMMUNICATION India, ottem Medical Aid, Disaster Relief and Maritime Enviommental Disasters : Tsunami of 26Dec2C[4 Surg VAdm VK Singh, PvsMAvsM vsM PHS KEY'

INVITED SPECIAL EDITORIALS Inconsistenciesin travel times and amplitudes of the 26th December20O4 Tsunami INTR TS Murty, AD Rao, N Nirupama ?to

Tsunamiand its implicationson CoastalHabitat l5 dynan PN Sridhan A Surendran, B Veeranaryan' MV Ramana Munhi nami Tsunarni "Waves of devastation" - A Hydrographer'sperspective 2l ocean Lt Cdr Han,inder Avtar volcal REVIEWARIICLES ment. The Tsunami of 26'hDec 2004 : Crunching the numbers and facts seawi Surg Cdr IK Indrajit, Surg Cmde MJ John submi waves Effective Disaster Management Plan for Naval Hospitals 35 trf'l of 50( Surg Rear Adm VK Singh VSM, Surg Cdr AI Ahmed severz ORIGINAL ARTICLES ON TSUNAMI t'i fromf perioc A RetrospectiveAnalysis of Post Tsunami Morbidity Trends : Campbell Bay Experience 40 Surg Lt Harminder Singh Inr wave! Medical needson day l-3 at Air Force Station Carnicobar after the Tsunami disaster: 26 December 2004 pogral Surg Lt Cdr Sushil Chawla theda The Tsunami Experience at a Forward Medical Aid Camp in Port Blair - A Report causin Surg Lt Cdr Samir Kapoor are ca Study of Indian Naval Medical Relief Operationsfor Tsunami victims Dec 04 - Jan 05 by 54 duetc EasternNaval Command inglar Surg Cdr GD Bhanot, Surg Cdr A Bhardwaj, Surg Lt Cdr J Sridhar Surg Cdr P Gokulkrishnan the sh flood Tsunami 2004 : Role of SouthernNaval Command in Naval Medical relief measures erties. SurgCnxle VK Saxena VSM, Surg Capt A Banerjee SC waves Medical Relief operations of Rainbow West - (Southem Naval Command) 66 'l Surg,Lr Cdr G Parthasarathy, Surg Cdr N Chawla, Surg Cdr R Ray, Surg Cdr R Koshi, Surg Cdr KK Mishra, iOcear ! Surg Lt Cdr R Sivasankar Surg Cdr R Panicker Surg Lt Cdr S Chanerji, SurgLt S Taneja "r .t Remott t o'.I Manag Jour.fu InvitedSpecial Editorial TSUNAMI AND ITS IMPLICATIONS ON COASTAL HABITAT

PN SRIDHAR',A SURENDRAN*,BVEERANARYAN' IVIVRAMANAMIJRTHI*'

ABSTRACT

Coastal zone is source of low-cost livelihood and prone to frequent disasters. There are several small and targe ti marine found ecosystems the Indian coast. Among rhem 1) coral reefs of Andaman and Nicobar Islands; 2) mangrov€s of Pichavaram and 3) Pulicat Lagoon are more closely interlinked to socio, economic, cultural and health aspects human settlement in this region and around. These coastal marine habitats are already in the threshold of collapse under constant threat from anthropogenic stresses. On 26th December 2004, the earth of 8.9 Richter scale followed by great tsunami in Indian Ocean had affected several coastal and marine habitat of India. In the following sections a quick review of post tsunami implications on different coaslal habitat are rttempted.

KEV WORDS : 26 Dec 2004 Tsunami ; Coastal habitat; post tsunami implications

INTRODUCTION andlagoons) causing heavy breaching of thechan- /^toastal zoneis sourceof low-costlivelihood and nel mouthand barriersands. This causeschannel It-,attracts large numberof population.Coast is a widening and flooding more seawater in to the es- l5 dynamic region and prone to frequentdisasters. Tsu- tuarine aquatic system or stop the free exchange nami is one of such catastrophegenerated in the water to and fro due to choking of the channelby 2l oceandue to submarinedisturbance like earthquake, sand deposition.As the result coastalhabitats are volcanic eruption and subterraneanplate displace- stressedto long and short term impacts.In the fol- ment.The tsunamiwaves are also termed as seismic lowing sectionsa quick review of post tsunami seawaves as they are generatedby earth quake implicationson different coastal habitat 25 and are at- submarinedisturbances in the deep sea. These tempted. wavescan travel at the surfaceunnoticed at speed COASTALECOSYSTEM AND HABITATS 35 io of 500 to 1,000km/hr with.long wave lengthup to An ecosystemis a self-containedunit, where in severalhundred kilometers. Tsunami wavesrange i.r biological communitiescoexist largely with in its lr from few centimetersto a meterin height with a wave boundaries.An ecosystemis the sum ofall the spe- periodof few minutesto an hour []. 40 cies,their actionsand interactionswith eachotner In a closedcoast fast approachingshort tsunami and with nonliving mattersin a particularenviron- waves are controlled by near shore submarineto- 43 ment. [2] Ecosystemservices include such vital pography and lift up the waves severalmeters above functions as regulating the concentrationof oxy- pile the datum and water severalmeters over beaches gen, carbon dioxide and water vapour in the 46 causingheavy run off. Thesesurging tsunamiwaves atmosphere,filtering pollutantsin the water,regu- are capableof modifying the coastal topography latingglobal temperature and precipitation [3][ ][5].

3 Editorial CHRONICLINGTHE TSUNAMI OF 26DEC2OO4: AN UNPRECEDENTEDMARINE ENVIRONMENTALDISASTER

SurgCdr IK INDRAIIT*, SurgLtCdr K MISHRA**

fJere is somethingexclusive ! You arebrowsing a peacetime aid operationin history of mankind.Re- I lspecial issue of our Journal, that throws the acting swiftly to the sheer scale and severity of spotlighton the recentTsunarni, which was a natu- destruction,the IndianNavy prepareda deployment ral disasterof apocalypticproportions, impacting and logistic plan for its ships, aircrafts and shore us in an unprecedentedmanner. establishmentsto provide disasterrelief to coastal To begin with, let us reflect for a moment on a areasof IndiaincludingAndaman & NicobarIslands, fundamentalquestion. What was the compelling as also to the neighbouringcountries of Sri Lanka, needfor publishinga specialissue on the tsunami? Maldives and Indonesia.[2] Maritime passagesof ancientIndian seafarersduring the medeival ages Firstly, a tsunami is an uncommon,but serious werere-explored, albeit now for a humanitarianmis- maritimecalamity, that is particularlyrelevant to us sion of providing succour and relief, to the in the Indian Navy, engagedin protectingthe In- devastated. dian coastand littoral waters.This further assumes significance,by virtue of our professionalduties as Thirdly, this specialissue focuses on the experi- Medical Officers, earnestlyproviding health care ences of medical personnel from service and participatingin relief operationsin timesof na- headquartersduring deploymentof disasterrelief, tionaldisasters like therecent tsunami. in the aftermathof tsunami.Medical perspectives from all Naval Commands,as well as first handac- The 26'hDec 2004 tsunami,comprised of a seabed counts from medical officers of varied ranks, earthquakeand a tsunami,both ofextraordinaryse- appointmentsand specialities,working acrossIn- verityand magnitude, making it a "doublewhammy" dian coast and neighbouringwaters at south east disaster.Impulsively triggeredby a powerful shal- Asia.are compiled here. low megathrustearthquake, centred off the west coast of Sumatra,a seriesof sea waves endowed Numerousdisaster drills and SOPswere swiftly with a rare but frightening combinationof soaring put in practice,aboard ships and aircrafts,at hospi- height, perilous length and treacherousbreadth, talsof theNaval Commands, commencing on 26 Dec mercilesslyapproached the coasts of southeast Asia 2004.Every momentwas an experience.And every countries,including India, traversingatjet speeds experiencewas ultimately an insight.An insightinto ranging800 to 1000km per hour.Consequentially, thedestructive potential of nature.Few lessonswere within fifteenminutes, the waves had hit theNicobar learnt.Important suggestions and critical inputs to group islands,and by two hours. the waves were improve our SOP's have come forth. Indeed, we shearingthe shoresof Chennai and the South In- must now pay attentionto theserecommendations, objectively. dian coast,nearly 2,000 km from theepicentre. I I ] Secondly,thisglobal geophysical event, inflicted Fourthly, this issuedwells on the role of hospi- such a serioushumanitarian, economic and envi- tals at times of disaster.During disasterrelief ronmentaldamage, that it promptedthe biggest operations,intense activity is often locatedat two

*Editor, Journal of Marine Medical Society,Classified Specialist (Radiodiagnosis. CT & MRI): **Asst. Editor. Journal of Marine Medical Society; INHS Asvini. Colaba, Mumbai 40O 005.

Jour.Marine Medical Society, 2405, Vol.7. No. l t$ - .20 itt 6l endsofthe theatreofdisaster, "ground-zero" at one lishingof thisspecial issue of thejournal: perhaps ^0 t endand the hospitalsat theother. Hospitals are the theonly healthjournalin Indiadevoting an entire 3 o final destinationin the chainof evacuationof the issueto the"Tsunami of Dec 2004". injuredcasualites as well as the dead.An article Weend with aninspirational quote from lateLeo highlightingthe important role of hospitalsin disas- t19 F Buscaglia[3] , aneducation expert. who aptly has r.g? ter management,is also featured in thisissue. stated privi- Finally and importtntly,we aresingularly "There are two hig forces at work, Iegedto havea teamof expertswriting on a rangeof external and internal. We have very exclusivearticles on thetsunami. Foremost amongst Iittle control over externalforces such $ themis ProfessorTadMurty from Canada,interna- as tornadoes,earthquakes, floods, blir tionallyhailed as a renownedtsunami expert. Along disasters,illness and pain. Whal really with ProfessorA.D. Rao.from Indian Instituteof mattersis the internalforce. How do I Technology,New Delhi, and ProfessorN. Nirupama, respondto those disasters? Over that ,otn from Applied Disaster& EmergencyStudies, I havecomplete control," BrandonUniversity, Canada, they investigatethe "Inconsistenciesin traveltimes and amplitudes of REFERENCES Tst the26 December 2004 tsunami". In addition,articles l. NOAA and the Indian Ocean Tsunami : Available at nam written by PN Sridharet al from NationalRemote http://www.noaancws,noaa.gov/stories2004/s2358.htm : Accesscd on 0l Jun 2005 SensingAgency, Hyderabad, Lt CdrHarvinderAvtar Atl her at DehraDun, all 2. Indian Navy Tsunami Relief Operations: Available at from Chief HydrographerOffice http://www.indiannavy.nic.in/tsunami.htm;Accessed on 1,8 highlightingdifferent aspects of thetsunami is avail- 0l Jun 2005 ic s' able. 3. Attitude : Buscaglia, Leo Available at http:// rianI Theeditoriat team expresses their sincere thanks www.quotationsbook.com/quotesll4y''4lview ; Accessed Catt to all contributors,who havemade possible the pub- on 0l Jun 2005 iew slide inov 1 lns .sher

al St

Jour Marine Medical Society, 2005, Vol. 7, No. I SpecialCommunication MEDICAL AID, DISASTERRELIEF AND MARITIME EI{VIORNMENTALDISASTERS : TSUNAMI OF 26DEC2OO4

I Surg VAdm VK SINGH pvsnAvsMvsM pHs

fiver the pastyears, there has been an increase what could be termed as the largest humanitarian Ufin the numberof naturaldisasters and with it. exercise in the post-independenceera of India has increasinglosses on accountof urbanizationand establishedthat the Indian Armed Forces is capable populationgrowth. As a resultof this,the impact of of dischargingits taskscommensurate with regional naturaldisasters is now felt to a largerextent. responsibilitiesof India The continentof Asia is particularlyvulnerable The quality of medical aid rendered by Armed to disasterand between the years 199 I to 2000,Asia ForcesMedical Serviceswas highly appreciatedfor accountedfor 83 percentofthe populationaffected the early reaction and Medical teams reaching the by disastersglobally. Devastation in the aftermath scenesof devastation in the shortestpossible time, of powerfulearthquakes that stmck Gujarat, floods carrying with them adequate medicine and stores thatravaged many countries in Asia, droughtsthat for the immediate rescue and relief operations.The plaguedcentral Asia includingAfghanistan, the timely evacuation of critical patients by air and by super-cycloneof Orissaare someof the global sea,the efforts made to care for the elderly, women eventsin recentmemory. and children and also the valuable advice towards However,what will remainin theminds of people community health came in for much praise.The ca- the word overand especially in the mindsof those pability of the Indian Navy to convert three of its belongingto countriesthat were affected, is thetsu- survey ships at extremely short notice and dispatch nami that struck southeastAsia on 26 Dec 2004. them to Sri Lanka and Indonesia to render help to While the islandof Sumatrain Indonesiasuffered these beleaguerednations has been of tremendous the maximumdamage, countries in the pathof the help both from the humanitarian as well as diplo- hugetidal wavesuch as Sri Lanka,Maldives, and maticpointof view. India especiallythe Andaman& NicobarIslands References and southeasternpart of India werebadly affected l. SouthAsia Tsunami situation reports WHO Health with largescale destruction of livesand property.[] actionin crises Situationreport 3l of 29 January I2l 2005 : Available at http://www.who.int/hac/crises/ The swiftnessin whichthe Indian Armed Forces international/asia_tsunami/sitrep/en/ ; Accessed on 3l May 2005 respondedto the Tsunamicatastrophe and the [3] 2. VanRooyen M, Leaning J. After the tsunami-facing deploymentof Medicalresources and hospital ships the public health challenges. N Engl J Med 20O5 to the devastatedislands of Sri Lanka,Maldives ;352(5):435-8 andIndonesia in additionto theAndaman& Nicobar 3. Indian Naval Tsunami Relief Operations : Available at Islands,as well asthe south eastern part oflndia in http://indiannavy.nic.in/tsunami.htm; Accessed on 3l Mav 2005

Director General Armed Forces Medical Forccs, Maha Nideshak Sashastra Sena Chikitsa Sewa, M Block, North Block, Ministrv of Defence. New Delhi ll0 001

JounMartne Medical Society, 2005, Vot.7, No. I Invited Special Editorial INCONSISTENCIESIN TRAVELTIMES AND AMPLITUDESOF THE 26THDECEMBER 2OO4 TSUNAMI

TS MURTY*, AI) IIAO**, N NIRUPAN,IA,*T.*

ABSTRACT

In the aftermath of the highly destructive tsunami of 26thDecember 2004 in the Indian Ocean, dozensof tcams worldwide surveyedthe affectedareas and carried out surveysof varied nature, physicaldamage, loss of life, economic aspects,social aspects,engineering view point and scientific intcrpretation. Most of the survey results were made availsble through the Internet. Here we specificallyand critically exanrinethree scientific parameters,namely trsvel times of the tsunsml to various coastlines,amplitudes of the tsunami at different locationsand finally the horizontal extent of coastalinundation by the tsunami waves.It is shown that there are very fundamental inconsist€nciesin the data posted on the web. Suggestionsare made as to how to achieve a consistentpicture. KEY WORDS : Tsunami; Travel times, Amplitude

INTRODUCTION onceevery 10 yearsor so. The two previousmajor first truly global tsunamiin historicaltime is tsunamisin the Indian Oceanwere on2TthAugust Th. I the event on 27th August 1883 following the 1883due to the Krakatoavolcanic eruptions and on eruption of the volcano Krakatoa in the SundaStrait 27th November 1945 in the Arabian Sea which betweenJava and Sumatrain Indonesia,causing a causedloss of life and greatdevastation in India (at loss of life of about 36,000. This is referred to as a that time Pakistanwas part of India) and the coun- global tsunami becausethe tsunami travelled into tries surroundingthe PersianGulf and the Red Sea. other oceansas well. The secondtruly global tsu- It has beengenerally stated that the reasonsfor nami in historical time, and the first one after modem the great loss of life during the 26th December2004 instrumentationis put in place, is the tsunami of tsunamiare the lack of an early warning systemfor 26th December2004 in the Indian Ocean. the Indian Oceanand socio-economicfactors, such In terms of loss of life, this is the biggest tsunami as high density of population and lack of public event in historical time and is among the most disas- awareness.Since major tsunamisare occurring in trous natural disastersevents. More specifically the India, on the average,once every 60 years,there is loss of life attributed to this tsunami, which by the no tsunami memory among the public, the media official estimateof the United Nations, now pegged andthe politicians. Early waming systemsare avail- at over 310,000is higher than the total cumulative ablein India for more frequentnatural marine hazards loss of life from all the Pacific Oceantsunamis com- such as cyclones,monsoons, river floods etc. bined for the l9th and 20th centuries. In terms of Murty et al [] studiedthe far field dispersion frequency, there are 6 to 9 tsunamis in the Pacific characteristicsof this tsunami. For some data on Oceanper year,although most of them are small and earliertsunamis in the Indian Ocean,see [2,3]. For local. On the other hand, for the Indian Ocean, a the basic mechanismsof tsunami generationfrom very destructivemajor tsunamiappeilrs to occur once underocean earthquakes, see [4]. Tsunamiscan also every 60 years on average and a minor local one be generatedby submarinelandslides, either trig-

*Departmen! of Civil Engineering, University of Ottawa, Ottawa, Canada. **Centre for Atmospheric Sciences.Indian Institute of Technology, New Delhi, India. ***Applied Disaster & Emergency Studies, Brandon University, Brandon. Canada.

Joun Marine Medical Society, 2005, Vol.7, No. I geredby an earthquakeor completelyindependent ofan earthquake[5,6].

UNIQUE FEATURESOF THE INDIAN OCEAN Besideslack of an earlywarning system and high populationdensity, there are severalphysical ocea- nographicfactors, which acting togethermade the tsunamiof 26'hDecember 2004 extremely violent on the coastsof Sri Lanka and South India. In fact as far as India is concernedthe highesttsunami ampli- tudeof 8 m was dwarfedby the I1.2 m amplitudein theGulf of Cambayforthe 1945tsunami. We now examine the unique features of the In- dian Ocean.As can be seenfrom Fig. l, amongthe four oceans,it is only the Indian Oceanthat does lonlnudc jc!t'6 not extendinto the higher latitudesof the northern Fig. 3 : A tsunarnitravel time chart for a hypothetical hemisphere.Fig. 2 shows that indeedthe northern tsunamioriginating at Mumbai, India. part of the Indian Oceanends with the Bay of Ben- Indian Ocean is much smaller in physical size. A gal on its easternside and into the Arabian Seaon tsunami travel time chart for a hypothetical tsunami its westernside. The Arabian Sea,in turn endsin its originatingat Mumbai, India (Fig. 3) showsthar the two marginalseas, namely the PersianGulf and the tsunamiwill travel to Middle Eastand Africa on the RedSea. westernside and to Bangladesh,Myanmar, Malay- Conrparedto the PacificandAtlantic Oceans, the sia, Thailand and Indonesiaon its easternside in just a few hours. as compared to some 23 hours for a tsunami to cross the Pacific Ocean. The repercus- sions of this are quite serious.What this meansis that, the available warning time is at most a few hours, which is considerablyless than the several hourswarning time that is availablefor the Pacific and Atlantic Oceans. -'i, -- J:' ' - " Becausethe Indian Oceanis much smaller in its Fig. I : Geographiclocation of Indian Oceanamong the geographicdimensions, usually it is the secondwave four main oceans. that hasthe highestamplitude. as happenedduring the 26thDecember 2004 tsunami. In contrast, for the Pacific Ocean,it is usually a wave betweenthe 3d and 5ththat has the highest amplitude.Again this providesmore time for warning in the Pacific Ocean. The averagedepth of the Indian Ocean is smaller than for the Pacific Ocean. This means,for the Pa- cific Ocean,frequency dispersion occurs more than in the Indian Ocean. and the tsunami waves lose someenergy due to dispersionduring their propa- gation.On the otherhand. for the Indian Ocean,rhe energydissipation through dispersion is minimal. Sincethe PacificandAtlantic Oceansextend into the higher latitudes of the northern hemisphere, Fig. 2: Indian Oceanand surroundingseas. someof the tsunamienergy is dissipatedthere. How-

8 Jour.Marine Medical Society, 2005, VoL7, No. l ever. since the Indian Oceandoes not extend into in Indonesiagenerally approached Sri Lanka from the higher latitudesof the northernhemisphere, the the eastand hit the eastcoast of Sri Lanka roughly Bay of Bengaland the Arabian Sea take the brunt of at the sametime the tsunamistruck the southcoast the tsunani. of Sri Lanka and then travellednorthward along its Sincethe Indian Ocean is muchsmaller than the westcoast. Hence the arrival timesshould be earlier Pacific and Atlantic oceans,unlike theseoceans. near the south easterncorner of Sri Lanka and the reflectionsplay a very important role in the water arrival times shouldincrease monotonically as one levelsand coastalinundation. Indeed it is not the proceedswestward along the south coast and then direct wavesthat did the damageand caused loss of northwardalong the west coast. life at the Kollam regionof Kerala,it is the waves The websitefrom wherewe obtainedthis data is that are reflected from the LakshadweepIslands. titled "Testifiedarrival time of tsunami". From this Reflectedwaves played an importantrole in theother title we infer that the times listed on the websiteare regionsas well. probably obtainedfrom eyewitnessaccounts. In Finallythe highest wind waveamplitudes occur principle, the travel times should increase in theIndian Ocean. The tsunamiwaves can extract monotonicallyas we proceedfrom location l4 to energyfrom thewind wavesthrough Reynold's Eddy locationl. TableI showsthat clearly this is not the stressesand grow to greateramplitudes. case.The arrivaltimes jump all over.from 7:30 to I l:30 AM. Tsunami,which is a long gravitywave. INCONSISTENCIESIN TRAVEL TIMES The following information and data is basedon TABLEI (in surveyresults posted on the web by Japaneseteams Arrival local time) of the first three tsunami waves (adapted from the survey results of the Japanese headedby Dr. Y. Tsuji, Dr. T. Suzuki,Dr. S. Satoand teams) Dr. K. Hirada[7,8]. Fig.4 showsthe arrival times of the first threetsunami waves (in local time) at the ldentification Location First Second Third No. wave wave wavc southwestand southerncoasts of Sri Lanka.Table I liststhe samedata. I Galle Face Green9:15 to 10:00to - The tsunamithat originated offshore of Sumatra 9:30 l0:l5 2 Dehiwela 9:45 l:.45 3.1 Mount Lavinia I 8:45 9:45 3.2 Mount Lavinia 2 9:45 l0:15 t.r l? tt J.-1 trt.t r.'aa trt{ Mount Lavinia 3 9:45 I l:35 tt.t frorS2rri$ A Moratuwa | 0:30 I l:00 I l:05 to l l:10 5 Panadura 7.30 9:30 10:30to I l:00 tis 6 Beruwala 9:45 10:30to -

frop-i1e I l:00 I \, 7 Be n tota 9:55 10:30to - I l:30 r-tg l5 Seenigama 9:45 t't.zt l0:30 l rta - | r:9'r 9 Hikkaduwa 9:30 to 9:50 to 1-til-!$ i,#- | llili 9:35 I 0:(X) a!o! | lf,r{ l0 Galle Fort 9:00 to 9:30to 9:50 is#:i l+-\ -{ t:J.s,, 9:30 9:45 t?? F;f'"*ll*,'"? | f,r& I I Talpe 9:45 l2 Matara 9:15 9:25 9:40 Fig.4 : Arrival times (local time) of the fist threetsu- I 3 Tangalla 8:45to 9:20 nami waveson the southand southwestcoast of 9:l5 l4 Hambantota 9:22 Sri Lanka. (adaptedfrom Survey dataposted on 9:35 the web by Japanesesurvey teams.2005).

Jour. Marine Medical Sociery,2005. Vol.7, No. I would not take 4 hours to travel such short dis- tances.Obviously one can put little faith in these reportedtravel times. Table 2 lists the tsunami arrival times at certain locationson the Indian coast,based upon datafrom various websites,including thoseof the SOI (Sur- vey of India, Dehra Dun) and the NIO (National Instituteof Oceanography,Goa,India) [9]. TABLE2 Tsunami(first wave)arrival time (local)at certain locations on the Indian coast (based upon data from various websites in India)

S No Location Arrival Time of the lst Wave

I Visakhapatnam 09:05 2 C hennai 09:05 3 Tuticorin 09:57 i Kochi 1l:10 5 Azhikkal l2:30 6 Mormugoa l2:25

This data also shows inconsistencies.It is hard to believe that the tsunami arrived at Vsakhapatnam Fig. 5 : Maximumtsunami amplitudes (m) in Sabangand and Chennai at exactly the sametime and it took BandaAceharea. another52 minutesextra to travel to Tuticorin. On the Kerala coast it is hard to imagine why there is so much time differencein the arrival times of the lst wave at Kochi andAzhikkal.

INCONSISTENCIESIN TSUNAMI AMPLITUDES ANbINUNDATION There are several discrepanciesin the reported tsunamiamplitudes also. According to Shibayama et al. (2005) tsunamiamplitudes rose up to 50 m in the BandaAceh area.Table 3 lists the maximum tsu- nami amplitudesand horizontal extent of inundation for Banda Aceh as reported by the same survey team. TABLE3 Mazimumtsunami amplltude (m) and horizontal distanceof lnundation (m) as reported by the Japanesesurvey team of Shibayamaet al., 2005)

Latitude Longitude Mrximum Horizontal ("N) ("E) tsunami distancesof amplitude inundation (m) (m)

5'35'35.9" 95'l9'45.3" 48.86 70 Fig.6 : Maximumtsunami amplitudes (m) in Centerof 5"23',3't.8" 95"I 5'l0.3' 21.39 940 BandaAceharea

t0 Jour Maine Medical Society, 2M1 VoI.7, No. l I

Figures5-8 showsthe maximum tsunamiampli- tudes (m) based upon the survey by the Japanese teamlead by Dr. Y. Tsuji. The highest value reported by this teamis 34.85q which is considerablysmaller than the 50 m reported by another Japaneseteam lead by Dr. Shibayama. Fig. 9-l I show that distribution of maximum tsu- nami amplitudesand Fig. 12 illustratesthe horizontal distance of inundation for the area near Phuket, Thailand, as surveyedby the Japaneseteam lead by Dr. Y. Tsuji. Similar plot for Sri lanka is shownin Fig. l3 (amplitudes)and Fig. l4 (horizontalinundation), for Indian mainland coast in Fig. l5 (amplitudes) and Fig. 16 (horizontal inundation) and for the Maldives in Fig. 17 (amplitudes)and Figure l8 (hori- zontal inundation).

rr .lal CONCLUSION tal 4t, ,.rjl3lzl Our main conclusionis that thereare severalin- consistenciesand serious errors in the data posted t! on the web quickly by various international survey _?4. -.y -,_-, Fig. 7 : Maximumtsunami amplitudes (m) in WestCoast teams,particularly on the tsunamitravel times,maxi- ofBandaAceharea mum amplitudesand horizontalertsnl sginundation.

rs \; 'a l{'o

TO at? lat

ate ls

t*!s rr

h&|l- -rNaq hrI

Fig. 8 : Maximum rsunami amplitude (m) in Sigli areaof Fig.9: Maximum tsunami amplitude (m) in Khao Lak BandaAceh (north part) in Thailand

Jour Maine Medical Society, 2a05, VoI. 7, No. I tl .=g-:;'-- Fig. 12: Horizontlldistlnce of inundation(m) for the . alcl nclr l'huLct.'llrailaud.

Fig.l0: I\'laximrrrntsurr:rrni rrmplitude (m) in Phukct beaeir nrr'l irtThailand.

Fig.13 : Motimumtzunurni amplitudcs (rnt in Sri Lunka.

There is no easyway to verify the inundatiqr data. Honever,the navel tirncsand maxfrnum anrpliurdes can be verified through a systematicand cdtical analysisof all the dozensof tide gaugedata avail- able for the tsunamievent.

REFENENCTS l. Murty TS, Niruparu llf-IffirI md llandi S (2S5): Far ficld dispcrsioncharactcristics of the tsunami of Fig. I I : Maximum tsunamiemplitude (m) tul.'Phi Phi 26th DoctrnbcflXD4. lndian lournal of BanhErakc Don areain Thailand. Enginccring,Submittcd.

I2 Jow MartneMcdical Soctety,2m5, W1.7, No.I Fig. l4: Horizortt:rltlirlllnc€ ,rl inrrrr,l.rtir,n(m) for the altectcd arcas nl Sli Lanka.

Fr': ili: I l()il/i)nrAl(rt\tan\ c ol Itundirli()rllrn) for the 3.$ aflbcted aleas n lndia. 211 ZA 4.36 s 3S tq a on 1.4t 3r, 2A 6 14 1t9 ir(tr 2t t! 62! {7r ta a0 rt za u tt

29

tQ g l9 rt a a ro 8 r5 r6

Fiq. l7 M.rrirrrrirnl.rrliuni amplitudes (m) in the

Fig. l-5: Maximumtsunlnli arnplitudcs (rn) in Indianeast coast area.

1 Murty. TS, Bapat A: Tsunamis on the coastlinesof India. Science ofTsunami Hazards. 1999 : l7: 3. 167- 172. Murty TS. Rafiq M. A tentative list of tsunamis in the o marginal seas of the North Indian Ocean, Natural 5 Hazards.l99l: 4 : l. 8l-84. 5 ,o Murty TS. Seismic sea waves-Tsunamis.Bulletin o a number 198,Canadian Bulletin of Fisheriesand Aquatic 0 Sciences,Ottawa, Canada. 1977 : 337. \__ 5. Murty, TS: A review of some tsunamis in Canada, in "Submarine landslidesand tsunamis"Edited 728, by A.C. 0O@@t6- Yalciner. E. Pelinovsky and C.E. Synolakis, NATO Advanced Study Institute. Istanbul. Turkey, Kluwer Fig. l8: Horizontaldistance of inundatiorr(nr) lirr rhe Academic Publishers. Dordrecht. Netherlands. 2003a atfectedareas in the Maldives.

Jour Maine Medical Societv, 2005, Vol.7. No. I IJ I

:175-1E3. E. Japanesesurvcy tcam" Tsunmi of 26r Deambcr 2fiX the Indian Ocein. Availablc at www.drs.dpfl.kyoto- Murty, TS. Tsunami wavc height dcpcndcnccon in u,acjp/sumatra/maldivcs/Maldivcs.htm Ace6sspdon landslide volume, Puic md Applicd Gcophysics' 2fl)3b ; March 2005 : 16O.2147-2153. 3l 9. Indian survey teamg wcb aitc fc the tsunami of 266 7. Japanesesurvcy tesm. Tsunami of 26th Deccmber Deccmber2fiX in thc Indian Occm. Available at hnp:/ 2(XX in the Indian Ocean/qffailable at l*tp://www.cri.u- /www.tsunami.oregonstate.edu/Dcc2(XX/eeri/Runup tokyo,acjp/namcgaya/sumatera/surveylog/cdata.htm ; Results.html Accessedon 3l March AD5. Accessedon 3l March 2005 ;

t4 lour. Marirc Medical Society,2nj Uol.7, No.I Invited Special Editorial TSUNAMI AND ITS IMPLICATIONSON COASTALHABITAT

PN SRIDHAR.,A SUREI.{DRAN*,B VEERANARYAN MV RAMANAM{,JRTIIf***

ABSTRACT It Coastal zone is source of low-cost livelihood and prone to frequent disasters,There are several small and large marine ecosystemsfound the Indian coast.Among them l) coral reefs of Andaman and Nicobar Islands; 2) mangrovesof Pichavaramand 3) Pulicat Legoon are more closelyinterlinked to socio,economic, cultural and health aspectshuman settlementin this region and around. Thesecoastal marine habitats are already in the threshold of collapse under constant threat from anthropogenic stresses.On 26th December 2004, the earth of E.9 Richter scale followed by great tsunami in Indian Ocean had sffected several coastal and marine habitat of India. In the following sectionsa quick review of post tsunami implications on different coastal habitat are attempted.

KEY WORDS : 26 Dec 2004 Tsunsmi ; Coastal habitat; post tsunami implications

INTRODUCTION and lagoons)causing heavy breaching of the chan- ('-toastal zone is sourceof low-cost livelihood and nel mouth and barrier sands.This causeschannel \-.attracts large numberof population.Coast is a widening and flooding more seawater in to the es- dynamic region and prone to frequentdisasters. Tsu- tuarine aquatic system or stop the free exchange nami is one of such catastrophe generated in the water to and fro due to choking of the channel by oceandue to submarinedisturbance like earthquake, sanddeposition. As the result coastalhabitats are volcanic eruption and subterraneanplate displace- stressedto long and short term impacts.In the fol- ment. The tsunami waves are also termed as seismic lowing sectionsa quick review of post tsunami seawaves as they are generatedby earth quake and implications on different coastal habitat are at- submarine disturbances in the deep sea. These tempted. :t waves can travel at the surface unnoticed at speed COASTAL ECOSYSTEMAND HABITATS of 500 to 1,000 km/trr with.long wave length up to An ecosystemis a self-containedunit, where in several hundred kilometers. Tsunami waves range biological communitiescoexist largely with in its from few centimetersto a meterin height with a wave boundaries.An ecosystemis the sum of all the spe- periodof few minutesto an hour []. cies,their actionsand interactionswith eachother In a closed coast fast approaching short tsunami and wiih nonliving mattersin a particularenviron- waves are controlled by near shore submarine to- ment. [2] Ecosystemservices include such vital pography and lift up the waves several metersabove functions as regulating the concentration of oxy- the datum and pile water severalmeters over beaches gen, carbon dioxide and water vapour in the causingheavy run off. Thesesurging tsunamiwaves atmosphere,filtering pollutants in the water, regu- are capable of modifying the coastal topography lating global temperatureand precipitation [3][a][5]. due to beachesand sanddunes wash offtransport- A coastalhabitat is a narrow inter tidal region char- ing large volume of sedimentsinto and away from acterizedby uniquephysical entities like topography, the shoreline.These swelling waves inundateand substrata,waves, winds, tides, water quality and flood coastal habitats causing prop- loss oflife and biotic compositions.As a whole this system pro- erties. On the other hand in the open coast,tsunami videslivelihood, health and well being of largehuman wavessurge through channels inlets (rivers, creeks, population through fi shery, aquaculture, transport, if:t *Oceanography .l Division, National Remote Sensing Agency, Dept. of Space, Balanagar, Hyderabad 500 037, **Centre for il Remote Sensing and ***Integrated I Geomatics, SathyabamaDeemed University, Chennai 600119. Coastal and Marine Area TL Management,Department of Ocean Development, NIOT Campus, Chennai-602301 Jour Maine Medical Society,2005, Vol.7, No. I 15 tourism,recreation and humansettlement. It is eco- few hoursof t tsunamicould be monitoredin the nomicallyimportant, ecologically unique and also Andaman and Nicobar Islandsand southerncoast environmentally sensitive. of Indian.The inundationextent was found to be POSTTSUNAMI OBSERVATIONOF INDIAN around500 to 5 Kilometerfrom the low waterline COASTALZONE (Fig.2). The presencesuspended sediment concen- tration in OCM data revealedthat the sediment A broad category of the Indian coastalregions concentrationsin thecoastal waters and coralsreefs affectedby tsunami are I ) Andaman and Nicobar werehigher than previous days (Fig. 3). Tropical Islandsa coral reef ecosystemhighly susceptible Rainfall Monitoring Mission Microwave Imager inundationand submergencesituated in the prox- (TMI) datashowed a fall in seasurface temperature imity of the epicenter,and 2) East coast of Indian by I 'C aroundthe Islandswith a insignificantef- subjectedtsunami waves with in few hours of the fect on corals.The presenceof high concentration earthquake (Fig. l). The preliminarystudy of the of sedimentsin thecoastal waters is alsoan indica- aboveregions was carriedout with IndianRemote tion of sedimentsource from erosionof beaches. SensingSatellite Advance Wide InstantaneousField Fig.31 shoals,sand bars and sanddunes. But largequan- of view) (IRS P6,AWIFS) andP4 OCM anddetailed tity of debrisand sanddeposited over corals,sea studyof habitatinundation, morphodynamics and grassand sea weedshave damagingeffect on the changein the coastalmorphology and topography coralcolonies. was studiesin fielded and with satellitedata like IRS-LinearImaging Self ScannerIII (23.6m)to high POSTTSUNAMI IMPLICATIONS ON COASTAL resolutionIRS- Pan(5.6m) bird andIkonos ANDMARINEHABITATS Quick closely (0.75to I m) data.However, prior knowledgeon Thereare several small and largemarine ecosys- health coastal topography, morphology, tides and wave temsfound the Indiancoast. Among them I coral ) around churactcristicswere needcdl"or the assessmentof reetsof Andanranand Nicobarlslands li Man- the thrr posttsunarni impacts. grovesof Pichavaram3) Pulicat Lagoon are more anthrol From AWiFs data the extent of inundationwith tsunan can noi Corals Cor: ciumci algae.l sink an shoreli, ing dru Gulf o: system Andan sq.kilc [7] witt areinhi assemb severa! Ridley species found i Fig.2: AWiFsdata showing seawater inundation due to Tsunan marine habitatsin the tsunamiwaves in (a) Katchalli,(b) Trankatiand Fig. l: Distribution major coastal Wcr at'fectedtsunami Indian reeion. (c) Canrortllsllnds of Nicobar.

I6 Jour MariueMedical Societv,2005, Vil.7, No. I iour. Mt ln [nc bleaching,sedimentation, El Nino, global warming I COaSt and pollution. In addition to this, an earthquakeof Jtobc 8.9 on the Richter scaleshook entire Indian Ocean terlinc regionon 26th December20O4. Several islands and oncen- reef areaswith in 500 km from the epicenter have liment beendevastated by the quake[8]. As the resultsthe lsreel-s tsunamiwave run up to 2-10 meter height caused lopicirl losslives andproperties overAndaman and Nicobar Imager Islands.The Andamanand Nicobar coral reefs were eralLrre split andcanied away by the tsunamiwaves. In north :antef- AndamanIslands large tidal and sub-tidalreefs ar- ltratron eas were exposeddue to this event [9]. In south indica- d Andamanlow lying areaswere submergedto I to 4 eacnes. Fig.3 /.,B,C,D:IRS OCM ard.\WiFsCata showing pre meter seawater [0]. Corals and coral reef organ- l quan- and posttsunami suspended sediment concen- ismswere washed ashore and dislocated. Many stag rls,sea rrarion(A & B) andhigh turbidity(C & D) in horn coral were broken off by the force of tsunami on the coastalwaters Andaman & NicobarIslands. Fig- wavesand large boulders of coralsirave beerr moved ;re 3 E,F,GH:IRS OCM datashowing pre (E & towardsthe sea.A suddenspurt turbidity and sus- F) andpost (G & H) tsunamisediment flux in pended was (Fig.3). rSTAL theAndhra Pradesh and Tamihladu coast. load e.uidentin the satellitedata Many coral specieswithstand periodic sediment closelyinterlinked to socio,ecoromic, cultural and. loads high suspendedsediments tend to damage ecosys- healthaspects human settlementin this region and I coral soft coralsand the symbiotic algaeleading to coral ) around Thesecoastal marine habitats are already in N4arr- bleaching.Some of corals that can withstand sus- t the thresholdofcollapse underconstant threat from re morc tainedsedimentation to certainccncentration I l], anthropogenicstresses. It is imminent that effect of havesuccumbed to sustainedser!:nent load of 0.2kgl tsunamion corals could compouncithe issuesand n2lday [2]. Consequentlyhigh nutrient may trig- can noi.be ignored. gersexcessive prcduction and cause eutrophication. Corals of Andaman and Nicobar Islands: The eutrophicationcan lower the coral resistance Coral reefsare limestonestructures built by cal- and make more susceptibleto diseases[3]. Though cium carbonatesecreting animals and the calcifying coralsof southernAndaman and Nicobar Island is algae.The reefbuilding processesare linked to CO2 reported to have escapedthe tsunami impact, large sink anciglobal climatechanges. Hard coral protect volume of sand and debris deposited over the ccral shorelireand also supplyraw maierialsfor life sav- reefs can smother and choke off corals and other ing drugs [6] . Andaman and Nicobar Islandsand marinespecies Ii4]. There by the intricateecologi- Gulf of Mannar are the two important corals reef cal balancebetrveen the corals and other seaspecies systemsin the Bay of Bengal. The coral reefs of may be disrurbed.These beachesin the Nicobar Andamanand Nicobar islandscover a large I1,000 islandsextensive damage to coral reefshave exposed sq.kilcmeters and 2,700 sq. kilometers respecti.rely beachesto high waveserosion, the nestingground [7] with a totalpopulation abcut 88,741 (censusl98l) of large number of sea turtle are now in jeopardy. areinhabited in morethan 38 islands.Several faunal Fortunatelycorais and sea u,eeds in Gulf of Mannar assemblagessuch as dugong, a sea mammal and haveprotected from the tsunamiwave by Srilanka severalendangered species like hawksbill, Olive but impactfrom high sedimentflux in to this region Ridley and greatleatherback turtles with numerous can not be ignored. speciesof fish, algae,anemcnes and mollusks a:e COASTALWETLANDS found':: this region. Coastal wetlands act as a regulator cf atmos- :rndue trr Tsunarr.irelated damageto corals phericcarbon dioxide and absorbsolar rad:ation by rkatiand Wcrld corals are unde: coilstant threet fron the processof photosynthes:s.Dense rnangroves l.7. No.l iour MarineMedicai Sociem, 2005. ti:L 7 !'lo.l t7 vegetationscontrol the sedimenterosion by reduc- accretionof inlet channelshave occurredat differ- TA ing flow velocityof estuaries.Mangrove ecosystem ent locations(Fig. a). Thesemorphological changes Fer is a habitat fbr severalrnarine and brackishwater have direct bearing on water quality of Vellar. No animalsas crabs, shrimp, fish, birdsand other inver- ModasalodaiKollidam estuaries.At severalloca- tebrates.Many other little known speciesbream, tions, vegetationslike coconuttrees have failed to a mullet.milkfish, mojarras, snooks, barramundi, sea control the beachand sanddune erosion.which is I trout, snapper,drum, croaker,grouper and tarpon very acutein Parangipeetaito MGR Thittu coastal t arethe importantmangrove-dependent commercial stretch(Fig. 5 A andB). As the result,huge quantity 3 4 speciesof fish and animals[5]. Mangrovespro- of sedimentwashed away by tsunamiin to theVellar 5 vide bufferzone against coastal erosion During and Modasalodaichannels caused shoaling effect [6]. FE/ recenttsunami mangroves are known haveprotected in the tidal passagestalling the free exchangeof I the coastlinefrom tsunamiwaves. Pichavaram is on water betweensea and the estuary.In long term this ) of suchmangrove forests spread over 900 hectares, could result in the deteriorationof estuarinewater 3 provides230 tons of prawn fish and crab annually quality,biological productivity and socioeconomic 4 andlivelihood for 3000fishing folks. Socio economi- aspectof the local communities. cally the Pichavarammangrove provides nursery 6 Lagoonsand creeks grounds for 74o/openaeid prawns caught in adja- 7 Pulicat Lake anotherbreeding and nursing E cent coastal waters [7]. However many are groundfor tish andother marine organisrns is a brack- 9 incognizantof morphologicalchanges that these ecologically important and protective ecosystems l0 had undergoneduring recent tsunami and require review. lt TSUI Satellitedata and Posttsunami field observations t have shown that Pichavarammangrove ecosystem , have sutferedmoderate to severedamage in terms 3 of toporraphyespecially in theVellar. Modasalodai. 4 I'rcltavarirtttlrntl KolIirllrnr L'str.lllri('s. Lr,.rsion and 5

6 SATE I ) Fig.5A:Fieldphotographic of MGR Thiuu in Pichavaram 3 Nllrtt.grtlrc l, )r'c\t ShOwing lr(';lch eIt)siOn by tsu- 4 namr wave run off 5 6

7 E 9 l0 ll t2 l3 t4 15, l6 Premonsoon l7 Fig.4: The tidal inletsat l) Vellar.2) Pichavaramand 3) Fig. 5 B: Fieldphotographic of MGR Thittu in Pichavaram t8 Kollidam showinginlet ciynarnicsple and post Martgrrrvclorest showing beach erosiorr by tsu- t9 monsoonperiod nami wave run off. 20 t8 Jour Marine Medical Society,2005, Vol.7, No. I Jctur lv ish water lagoon situated north of Chennai in the surge, the open coasts were less prone to damage east coast of India. Several thousandsof coastal than closed coast inlets channels served as con- populationsliving in its periphery are engagedin duits to tsunamiwaves. The human settlementson the brackishwater fishing and tourism relatedac- the beachesand around the wetlands were easily tivitiesfor their livelihood.It is alsoa nestingground susceptibletsunami wavesdepending beach slope for various migrating birds. This brackishwater lake and nature'coast. For example the Chennai- is underthe peril of environmentaldegradation due Mahabalipuramstretch is denselypopulated coast. to anthropogenicinterferences [8]. Pre and post the damagewas moderateas tsunami wave were tsunamisatellite data of PulicatLake showeda mar- controlled by steepshoreline. Towards south from ginal inundationalong the shorelineof with out any Kalpakkam to Collachal in Kanyakumari district the remarkablechange inlet morphology (Fig. 6). But loss of lives and damageto properties were moder- the report[9] on returningof birdsto theiroriginal ate to severe,where ever the coastal topography habitatdue lack of water flow at the lake entranceof are gentle, beaches are narrow and with out any Pulicatlake due to tsunami,suggests tsunami wave artificial or naturalbarriers. Dense vegetation like forcing was not effective at inlets channelsmouth mangroves have provided more protection but co- as in the caseof Cooum and Adyar river mouths. conut trees and other sparse vegetations are whereinlet channelbars were clearedto wide mouth ineffective(Fig. 7). The coastalstretch from Point sincethe Ennoreshoals acted as barrier [20]. Calimer to Gulf of Mannar are leastaffected since the Island of Srilanka provided protection against IMPACT OFTSUNAMI ON COASTAND HUMAN waves DIMENSION tsunami both in terms magnitudeand direc- tion. Along stretch 2,260 km of densely populated On the nationalperspective the direct impact of human settlementon the beachesand rocky coast tsunamicould be immenselyrealized in fisheriesand of Andhra Pradesh,Tamilnadu and Kerala were af- tourismsas theseare two major domesticand for- fectedby tsunamiwaves apart from environmentally eign revenueearning sectors. In additionthose small sensitive areas.The magnitude of the damage was and marginalfishermen survived tsunami have lost more perceptiblein the coastof Tamilnaduduring their boats,gears and their man power took several the field visit. Satellitedata and field observations monthsto reviveas the fishermen are still in trauma. suggestedthat the severity of the damagewas de- They are in needof rehabilitationand counseling. pended on the orientation of coast, near shore After tsunami,coastal tourism, an alternativesource topography,coastal morphology coastal land cover of income during the lean fishing seasonbecame and land use. Where ever mangrove,coral reefs, sandyshoals, sanddunes and seawallswere presentthe damage was greatly controlled. During the $unami wave

I

Fig. 7: Damagecaused by Tsunamiwave t() ( A) Human Settlementin MGR Thinu, (B)Tiruchendurbeach under tsunami wave retreat,(C&D Damage to Fig. 6: IRS lD -LISS III data showing the pre and post coastal structures unprotected by sea wall in tsunarniinlet rrrorphologyat Pulicat lake. Manakkudi. Kanvakumari District.

Jour Marine Medical Sociery,2(M5, VoI.7,No. I 19 less attractive. Since the ecotourism is gradually and the World Wide Fund for Nature-India initistives becoming major revenue, the tourist operatorsand fcr its conservation. Proc. Regional Workshop on the Conser. Sustain. Manag. Co:al Reefs Ecosystem severalcoastal populations other than fisherrnen in (Vineeta Hoor:, ed.), organised by M.S. Swaminathan Kanyakumari district are of opir:ion that their liveli- Research Foundation and BOBP of FAO/UN. 1997: hood jeopardized as the tsunami had brought dowr' 29-4't. the number of domestic and foreign tourists in the 8. R. K. Chadha,G Latha, HarryYeh, Cun Petersonand Tcshitama Katada. The tsunami of the great Sumatra peakseason (December to March). earthquake of M 9.0 on 26 December 2C04 - Impact CONCLUSIONS on the east coast of India, Curer.l Science 2005; Vol. 88, No. 8. Ecologicallysignificant anC socio economically 9. Anonymous. Coral reefs in the Andaman suffer linked coastalmarine habitas like corals,mangroves extensive damage: International Coral Reef Initiative. and coasial wetlands are under stressfrom climatic 2005 changesand human interferences.Episodic event i0 Sarang Kulkarni. Tsunami Impact Assessmentof Cci:ar Reefs in the Andaman and Nicobar. CARDIO News. like tsunami has short and long term influences on 2005; Interim Report.l-6. these narine coastal habitats causing further dam- 11. Solandt,J. L., L. Goodwin, M. Beger and A. R. Harborne ages to these ecosystemsand livelihood of the , Sedimentation and related hab "' characleristics in coastalcommunities depending in thern.The expe- the vicinity of Danjugan Island, Negros.Occidental, rience gained from recent tsunami revealed that Danjugan Island Survey Summary Report 2001: 5, pp low profile coasta! regions are more topographical 12. iodgron. G., Resource Use conflicts and solutions. In susceptibleto severedamage irrespective of its prox- Brikeland C Life and Death of Coral Reefs, Chapman imity to epicenter.Protection of ccastal zone as a and Hgll, London, 1997; pp 536. whole require rehabilitation and e;forcement of 13. Szmant, A. M., Nutrient Enrichment on Coral Reefs: coastalregulation zone act.andmanagement prac- Is it a Major Cause of Coral Reef Decline? Estuaries. 2O02; 25, 4b, 743-'166 tices basedon the outcome of a.bcveevents. t4. ICRVISRS (2005). Tsunami Damage to Ccral Reefs. for Rapid Assessment Ackncwledgement Guidelines and Monitoring. January 2005. Seychelles. 30 pages. We thank the Director, Nationat Remote Sensing Agency, 15. Hamiltcn, L.S. and Snedaker,S.C. (eds.) Handbook Deputy Directcr (RS and GIS), Gr. Director and HeaC for Mangrove Area Management Environment and Oceanography Division for encouiaging and providing Policy Institute, East West Center, IUCN/UNESCO/ guidance in this pursuit. UNEP, 1984:Honolulu.. REF'ERENCES K-hali! . S, " The Economic Value of The Environment: i. Anonvmous : Available at http:// Casesfrom South Asia", Eccnomic valuation of the e il c yc i oped i a. I ab o r! aw tal k. c o m/ Mangrove Ecosysterr, Along The Karachi Coastal Asia, Tsunami#Characteristics; Accessed on 24 May 2005. IUCN, Applied Economic Researchlnstitute, Karachi, 2. Sric Chivian. Environment and health: Speciesloss 1999;l-ll. and ecosystem di.sruption - the ir'plications for human t't. Krishnamurthy K ; Humans' Impact on the Pichavararn health CMAJ. 2001; 164(l):66-9. Mangrove Ecosystem: A Case Study from southern 3. Dally GC, editor. Nature's services: societal depqndence India. Proceedings of the Asian Syrnposium on on natural ecosystems. Washingtcn: Island Press; 1997. Mangrove Environment, Research and Management, Kuala Lumpur 2-529August 1980. Pp. 624-632. 4. Cohen JE, Tilman D. Biosphere 2 and biodiversity: the lessons so far. Science. 1996;274:1150-1. 18. lilanda Kumar NV Saritha K, Rajasekhar M, Ameer Basha S (Div Environ Bio, Dept Zoo, SV University, 5. Costanza R, d'Arge R, de Groot R, Faiber S, Grasso M, Tirupati sIi5C2, AP). Aquaculture effluent effect on Hannoh B, et al. The value of the world's ecosystem physicochemicsl cheracteristics and zoo plank-ton of services and naturai capital. l.lature.1997;3872 253- 60. Pulicat lake bird sanctuary.Eco En.r Conserv,200!: 7(r\, 25-29. 6. GcpinadhaPillai, C.S., A briefresume of researchanri 19. The Hindu, Tsunami caused najor changes in shoreline understanding of the reef corals and coral reefs around study, April 25,2005. lndia. Proc. F-egiona! Workshop on the Conser. Sustain. Manag. Coral Reefs (Vineeta Hoon, ed.), organisedby 2C. Department of Ccean Development(2005); M.S. Swaminathan ResearchFoundation and BOBP of Preliminary Assessment of Impact of Tsunami in FAC/UN. 1997r 13-21. 3elected Coasial Areas cf Irrdia ,IntegratedCoastal and Marine Area lvlar,agementProject Direclorate i. Krishrrakumar.The coral reef eccsystem of the Chernai Me-ch 2CC5.p 3!. AnCaman and Nicobar islands. P:oblems and Prospects

20 Jour. ldci.'.e Mei,ccl Sccle:t, 200.J, VtL7, No. i Invited Special Edilorial TSUNAMI ''WAVESOF DEVASTATION''- A Hydrographer'sPerspective

I-tCdTHARMNDERAVTAR

INTRODUCTION UNDERSTANDINGTSUNAMI SOURCE are impulsively generatedsea waves MECHANISM fsunamis I triggeredby a disturbanceat or nearthe ocean. As per the plate tectonics theory Earth's surface Earthquakes,submarine volcanic explosions, !and- is divided into rigid plates that move together and slides and detonationof nuclear devicesnear the apartlike piecesofajig sawpuzzle. Scientists have seacan give rise to thesedestructive sea waves. By long recognisedi3 major plates.In the 1970'sscien- far the rrost destructivetsunamis are generatedfrom tists first discoveredabroad zone, stretchingmore large sh.allow-focusearthquakes with an epicenter than 600 miles frcm east to west where the equato- or fault line near or in ihe ocean. Verticai rial Indian floor was compressedand deformed. The drsplacementsof the earth's crust resulting from Indo-Australianplate earlier identified as a single such earthquakescan generatedestfuctive tsunami plate cn which both India and Australia iie - appeais waves which can travel across an ocean spreading to havebroken apartjust scuth ofEquator beneath seriousdestruction across their path. However,these the IndianOcean. In relationto the Indian plate,the sourcesare consideredas point sourcestherefore Australianplate ls moving counterclockwise (Fig althoughtsunami waves generated can be very de- r). structirrelocally, their energy rapidly Cissipatesas The earthquakeshappen rvhen these plates that they travel acrossthe ocean. make up the Earth's surface suddenly move against eachother. On 26 Dec 04 the biggest earthquakefor HISTORICALBACKGROUND 40 years occurred due to compression between the Tsunarni are among the most tenifying natural Indian and Burmeseplates. The initial eruption hap- hazardsknown to man and have beenresponsible pened near location of the meeting point of the for tremendousloss of life and property throughout Australian,Indian and Burmeseplates. The scien- history. The historical record also documentcon- tists have shown that this is a region of cornpression siderable loss of life and alteration in the Western asthe Australian plate is rotatingcounter c.ockwise shoresof the North and South Atlantic, the coastal into the Indian plate.An earthquakemeasuring 8.9 region; of North Western Europe and in the on the Ricther scale off coast of Sumatra triggered seismicallyactive regionsaround Eastern Caribbean. Tsuna-miwhich l:d to wide spreadcatastrophe pa:. Japanhas beenmost vulnerable tc the Tsunamihaz- ard. A total of 66 destructive Tsunami'shavd struck Japanbetween AD 684 and 1984.In the Hawaiian Island Tsunami have struck at regular interval caus- ing immense damageto property and life. Tsunami are raier in the Indian Ocean as the seismic activity is less.There have been 07 records ofTsunami set offby earthquakesnear Indonesia,Pakistan and one in Bay of Bengal in the last century.

Fig. I : Platestectonic in Indran region

Deputy 9ydrographer (Operations), llational Hydrographic Office, 107 A, Rajpur Road, Dehra Dun 248 001

Jour Marine Medical Society, 2005, Vol.7, No. i 21 ticularlyin Sri Lanka,India, Maldives, Indonesia and () Positional shifts in Geodetic Stations Thailand with damagesalso in Malaysia, Bangla- establishedby Survey of India. desh,Somalia and Seychelles. ROLE OF NAVALHYDROGRAPHIC PREPAREDNESSAND PLANNING DEPARTMENT There is very little that can be done to prevent Naval HydrographicDepartment played a major the occurrenceof natural hazards.But while these role both in relief operationsand in ascertainingthe naturaldisasters cannot be prevented,their results, changesthat occurredin the topographyof the area suchas loss of life and property,can be reducedby The significanttasks undertaken by the department properplanning. Government agencies should for- is asfollows: - mulateland-use regulations for a given coastalarea (a) Check Surveys: Three Indian Naval Survey with the tsunamirisk potentialin mind, particularly Ships fitted with state of the art survey if suchan areais known to have sustaineddamage equipmenVsystemsundertook 20 check surveys in the past.Tsunami hazard perception by the peo- of various harbours/ports/creeksboth in A&N ple of a coastalarea is necessaryin mitigating loss Islandsand East Coast of India (Fig. 2). The of life and damage to property. Hazard perception surveyswere aimedat immediateclearance of by the public is basedon a technicalunderstanding approaches, harbours and ports for safe ofthe phenomenon,at leastat the basiclevel, and a navigation of vessels.During the course of behavioralresponse stemming from that understand- these surveys various changesall along the ing and confidenceof the public for the authorities Tsunami affected areaswere recorded. responsiblefor warning. (b) Tidal Observation:Tide poleswere established SIGNIFICANT CHANGESIN COASTAL in Tsunami affected areas to assessmajor GEOMETRY changesin sealevel. Tsunamiwaves that struckA&N Islandscaused (c) Issue of Navarea Warnings: A number of major changesin the topography and infrastruc- Navareawarnings and notices to marinerswere ture set in Islands.Significant changesthat occurred immediatelyissued by National Hydrographic on 26'hDec 05 can be summarisedas follows: - Office, Dehradun to ensure the safety of the mariners. (a) Major changesin physicalappearance of shore line/coastalfeatures due to massiveuprooting (d) JointSurvey with SOI: One surveyship carried of vegetation (Coconut plantation) and out a dedicatedJoint survey with Survey of mangroves. India (SOI) for GPS observationsof the SOI stationsto determineany shift in positionsdue (b) Submerging of some of the off lying rocks/ to Earthquake/Tsunamiin variousplace in A&N jetties/wharfs during the high indicating lslands. increasein generalwater level in someareas. (c) Drying up of someof the creeksdue to decrease in the water levels. (d) Erosion of some of the beaches. (e) Extensivedamage to Mangrovesall alorig the coast. (0 Shift in high waterlinetowards shore. In some cases the shift in high water line in A & N Islandsis about500-600 Mtrs. (e)Significantchanges in the coastlinewith water ingressof 100Mtrs in land in high water. (h) Inconsistentchanges i;r sealevel, Fig.2: Preparationfor survey operation

22 Jour Marine Medical Society.2U)5,Vol.7, No.l The Tsunami has causedserious damages to LESSONSLIlAITN'I' Navigationalaids and port facilities in coastalIndia l. India's ability to handle disaster of this including the A&N Islandsthereby affecting the magnitudein A&N Islands normal functioningof ports and harbours.The ma- Althoughrelief operations in Indiawere one of jor damagesobserved are as follows: - the better managedoperations allrong the (a) PortInfrastructures: Extensive damages caused effectednations (Figs. 3,4. & 5) efficiencyof to the Port/Harbours infrastructuressuch as such operationscan be further enhancedby a jetties, wharfs, moorings,channel buoys etc territorialcouncil electedby the peoplecan severelyaffecting the shipping activities/ effect betterliaison and links betweenthe berthing. peopleand administration. This will ensurethat (b) NavigationalAids: Navigationalaids suchas the administrationhas greateraccountability Light Houses.Coastal Navigationalmarks, to the people. leading/transitlights etc. sustainedmajor 2. Efficient communication organisation to alert damagesthus impinging on mariner'ssafety. population needsbe detected (c) Presenceof underwaterwrecks/obstructions in We can considerraising a modern special someareas posing serious hazard to navigation. pararnilitaryforce for the island territory,a (d) Changesin thebathymetry particularly near the combinationof the BorderSecurity Force and coast. theCoast Guard, exclusively for deploymentin this regionduring suchnatural hazards. This (e) Changesin the Dredged/Anchoringareas. forcewill havebetter local liaison and ability to (0 Creationof new shoalsand migrationof shoals communicatewith local populationthan the sedimentaryorigin. of presentset up. PLAN OFACTION FOR PUBLICATIONOF NEW 3. Need of hazard ass€ssment& absenceof NAVIGATIONALCHARTS reliable data to recognisethc risk Andaman& NicobarIslands being close to the Createan integrateddisaster management epicenterof the earthquakehave sustainedmajor councilunder the executiveleadership of the damageresulting in significantchanges in coastline Fortresscommander to regularlycarry out featuresand bathymetry.In view of thesechanges rehearsalsand training ofthe key unitsinvolved. survey ships are being deployed for detailed including governmentdepartnrents. and Hydrographicsurveys of importantharbours/ports educatethe people on their role in disaster in A&N lslandsto enableprinting of new naviga- management. tional chartsof theseharbours. A Need to integrate the Indian region in an carly warning systemforTsunami in Indian Ocean The governmentnow proposesto set up a

Fig. 3 : Embarkationof relief material Fig.4 : Unloadingof lboclgrains

Joun Murine Medical Societv,2005, Vol.7, No. I 23 to ensure that these constructions are well protected through natural/ manmade breakwaters. 6. Non-implementation of Coastal regulation zones In order to avoid causingany further imbalance / disturbancesin nature's regimes and to minimise the loss causedby suchdisasters we needto ensurestrict implementation of coasta! regulation zcnes

Fig. 5 : Settingup of a meCicalcar:rp CONCLUSION The Destructive Waves have caused numerous Tsunamiwarming systembased on very permanentchanges in the topography, bathymetry modernunderwater devices like DART (Deep and marine infrastructural set up in the effected ar- oceanAssessment and reporting of tsunamis). eas. The hydrographic aspectsof these changes They sensesmall variationsin sealevel and require detailed and time consuming studies before senddata through sateliite to laboratorieswhich any concrete conclusions can be drawn. The naval verify the presenceof Tsunamiand issue hydrographic department on completion of its im- warningmassages. mediate relief operation and navigational safety 5. Jettiesto be shelteredby natural / artificial surveys has commenced its data collecti.on proc- breakwaterc ess.The departmenthas finalised its future strategy While constructingJettiesr harbours we need for drawing useful findings to ensuresafety of mari- ners in Indian waters.

24 .Iour.Mc.nne Medical Society,2005, Vol:7, No. I ReviewArticle THE TSUNAMI OF 26THDEC 2.004: CRUNCHING THE NUMBERS AND FACTS

SurgCdr IK INDITAJIT*,Surg Cmde I\4J JOHN

ABSTRACT The Tsunami of 26 Dec 2004, comprised of two distinctly connectedgeophysical events, of severescale and magnitude : a megathrust seabedearthquake off Sumatra and a seriesof large tsunami waves striking and damaging South east Asian coasts.The earthquake's epicenter was off the west of the Sunda trench, which is a seabedsurface repr€s€ntationof the India-Burma plate interface. Here, nearly 1000 km of plate boundary "slipped in" the earthquake zone on 26 Dec 2004, reflecting its sJatusas a megathrust earthquake. In all, there were 9 countries in South East Asia and 3 countries in Africa, significantly affected by the Tsunami of 26 Dec 2004. The magnitude of the earthquake was so seyere,that it had radicaliy shifted the seabed landmass, modified the length of a day, altereC the rotation of the Earth, added wobble in its axis, as well as permanently changed the shape of earth. We present, in this article, a brief review of some of the salient numbers, key facts as well as pertinent issues,which set apart lhe Tsunamiof 26 Dec 2004,as an extraordinary marine environmental disaster. KEY WORDS : Marine environmentaldisaste:, Tsunarni, Earthquakes

INTRODUCTION fheTsunamiof 26Dec2ffi4 lvas an exffaordinary I marineenvironmental disaster. It comprisedof two Cistinctly connecteclgeophysical events of a severescaie and magnitude: a shallow megathrust earthquake,that set in motion next, a seriesof large and pcwerful tsunamiwaves that sequentially struck the coastlinesof South EastAsian countries.Since the day of tragedy,a wide rangeof material hasbeen written in various media forms, on the humanitarian, economic,environmental and scientific aspectsof the tsunami []. Significantly, thereis a largeamount - of varying data on the tsunami, ranging from the F!g. I : The Great.rVaveat Kanagawais one cf the earli 'cvertly est depiction Waves. woodblock hypothetical and theoretical papers,to those of Harbor This is from a seriestitled "Thirty-six Views of Mount analysedin scientific detail. It is evidently clear,that Fuji", paintedby KatsushikaHokusai (1760- the dataon the tsunamiof 26 Dec 2004. will continue r849), an Edo periodJapanese artist andpainrer. io be frrrther evaluated and updated, driven by a The scenedepicts a great wave about to swamp global pursuit for accurateanswers. men and boats, on a day of labor. Note that the distant Mount Fuji, a central theme of this fa- An overview of Seabedearthquakes and Tsunami mousseries, is minirnizedby the giant sizeof the The word tsunami, derived form Japanesechar- wave. acters'tsu' and 'nami', iepresents harborand wave series of travelling waves in water proCuced by the respectively (Fig. general, t2l 1). In tsunamiare a displacement of the sea floor. They are ge;rerated

*ClassifieC Specialist (Radiodiagnosis lC'l anCMRI), INHS Asvini. *+Director, INM, Colaba, Mumbai 400 005

Jour Marine Medicel Socierv, 20C5,'/ci.7, I'lc. 1 25 'point by oceanbased sources'ofdisturbances like TABLE 2 earthquakes,submarine volcanic explosions. land- Few generalcharacteristics of Tsunamis[5-8] slides. Key Parameter Physical Characteristics Moreover,it hasbeen well establishedthat most destructivetsunamis are causedby large shallow- Propogation Propagateoutward from their source focus earthquakeswith an epicenternear or in the Travel distance Travel great transoceanicdistances with little overall energy loss world's ocean.The largest recorded earthquakes Travel speed Speeds range from 500 to 1.0(X) km/h were all megathrustevents and occur where one (100 to 300 metres/s) tectonic plate subductsbeneath another [3]. A list Overall weight Possessthe weight and pressureof the of world's largestrecorded earthquakes is given in ocean behind it Thble l. Travelling depthMove with entire depth of the ocean Period Extremely long periods in hours (the Consequentially,megathrust earthquakes gen- time for wave to wave) eratelarge tsunamis that causes damage over a much Wavelength Long wavelengths(up to severalhundred wider area,as in the 26 Dec 2004. Once generated, kilometres) the tsunamiwaves can be very destructivelocally. Sea Levels Manifest as a sudden higher sea level Layers Shelvesof huge mass of water behind an At sea coast. "an endlesslyonrushing tide which initial wave front forces its way around and through any obstacle" Impact force Hits coastline with great force and [5] . The speedsare similar to jet speedsas exempli- & Height vertical height ('pile-up' phenomenon) fied by the tsunamiof 26 Dec 2004,travelling from Impact May have an asymmetrical impact Sumatracoastal earthquake to Tamil Nadu coastin Symmetery geometeryMay abouttwo hours [6]. In general,tsunamis have few Wave be diffracted depending on shore geography charactersticfeatures, that aredispalyed in Table2. Phsse Rarely forms standing waves, in plrase resonance with natural waters motion ("seiche" Tsunamisand India phenomenon),that amplifies onshore Tsunamis,though rare, have been recorded along destrucion thecoast of India t6l tgl. One of theearliest recorded Coastal damage A large tsunami can flood land up to more than 1.5 km from the coast tsunamiwas in I 881. A list of thetsunamis that have struckIndian coastsin the pastinclude a) 7.9 Rich- terearthquake at Car Nicobaron 3 I Dec 188I , which on 26 June l94l affecting east coast of India af- affectedthe entire east coast of India including fected and d) a 8.5 Richter earthquakeon 27 Andaman & Nicobar Islands; b) the August 1883 November 1945,off Karachi, that affectedthe In- tsunami,triggered by an explosionof KrakatoaVol- dian west coastupto Karwar. cano in Indonesiaaffecting east coastof India; c) 8.1 Richterearthquake in theAndaman archipelago Geologicalfactors was TABLEI The Tsunami of 26 Dec 20M. a shallow. Worlds largest recorded earthquakes (adapted from megathrustseabed earthquake occurring in the In- I4t) dian Oceanjust north of Simeulue island, off the westerncoast of northern Sumatra,Indonesia []. Magnitude Year Localion Specifically,it occurredat the oblique,subducting,

9.5 I 960 Chile convergenceinterface between the India andBurma 9.2 1964 Prince William Sound,Alaska platesunder the sea [0]. Subductionis a special 9.1 1957 Andreanof, Alaska tectonicterm describingthe slipping interaction 9.0 2004 Sumatra,Indonesia betweenthe platesIl]. The salientfacts of this 9.0 t952 Kamchatka earthquakeand tsunamiis given in Table 3. 8.8 I 906 Ecquador The profile 8.7 2005 North Sumatra tectonic at this areais complex.repre- 8.7 I 965 Alaska sentedby an irregular plate boundary with a continuousshearing force of India platemoving and

26 Jour Marine Medical Society,2il)5, Vol.7. No. l -

TABLE 3 Factoids on Sumatra earthquake & South east Asian Tsunami of 26 Dec 2004 [f]

Geophysical event Parameter Details

A) SeabedEarthquake Trigger l0 to 15 m sideways slipping movement and 4 to 5 m (13 to 16 feet) vertically along faultline between the India and Burma plates subduction zone, along a stretch of 1000 km rlpe Shallow, mega thrust undersea earthquake Mechanism Compression between the Indian & Burmese plates Number Two phasesof sideways slipping movement 100 seconds apan Location 3.316"N.95.854'E Depth 30 km (18.6 miles) below Intensity 9 on Richter scale Special features The tectonics of the region is complex Occurred near the location of convergence of Australian, Indian and Burmese plateslocated in the Indian Ocean just north of Simeulue island. off the western coast of northern Sumatra. Indonesia

B) Tsunami Trigger Caused by above seabed earthquake of magnitude 9 Mechanism Caused by the sudden displacement of water by earthquake Number A series of very long wavelength ocean waves Location of Indonesia, Thailand, Myanmar, Malaysia, Sri Lanka. India. Bangladesh. Countries Hit Maldives, Somalia, Seychelles,Tanzania and Kenya Speed At mid ocean : upto l0O0 km per hour At shallow waters : 36 km per hour [6] Wave length At mid ocean : l00km At shallow waters : 5 km Wave height At mid ocean : tens of centimeters At shallow waters : upto 30 metres or 100 feet Special features The waves did not originate from a point source, but radiated outwards along the cntire 1200 km length of the rupture subducting beneath the Burma plate in a neighbouringcountries, inherent asymmetry of im- northeastwarddirection (5 cm per year) [2]. The pactand the random occurrence of"focusing" effect earthquake'sepicenterjust offthe west ofthe Sunda of tsunamiat coastlines. Notwithstanding, atimeline trench, which is a seabedsurface representationof of thetsunami of 26 Dec20(X, concentrating on the the lndia-Burma plate interface. Nearly 1000km of firsttwenty four hoursis givenin Table4. plate boundary slipped in the earthquakeon 26 Dec An analysisof thetimeline brings out few impor- 2004, truly reflecting its status as a megathrust tant points, particularly when scrutinised earthquake. retrospectivelyat thispoint in time.They include Timeline and its Implications a) The tsunamiwaves, traveled radially outward causing wreckage It emergesnow, that the timeline, is one of the devastationand at coastlines most varying and volatile dataof the tsunamiof 26 on manycountries in southeast Asia. Dec2OM. No consensuson the exact travel times of b) Theunimpeded transoceanic flow acrossIndian the tsunamito variouscoastlines is availableat the Ocean.resulted in tsunamiwaves of lesser moment, perhaps forced by a combination of fac- intensity,in Africancoastlines of Kenyaand torslike lack of dedicatedtsunami buoys in the Indian Somalia. Ocean,varying geographyof the coastsof different

Jour.Marine Medical Society, 2005, Vol.7, No. I 27 TABLE 4 Timeline of Tsunami on 26 Dec 20C4[3]

Time ln GMT Unfolding Trave! Destinationof Tsunami

00.57 Between 00.57 GViT and 00.59 GMT, a 9 magnitude earthquake occurs off western coast cf norihern Sumatra,Indonesia 00.58 Many Tsunami Warning Centei acioss the world registers the earthquake on its seismic instruments 01.00 Earthquake hits several cities in Indonesia 01.20 Tsunami hits Andanan and Nicobar Islands 0r.30 Tsunami hits Phuket and Thailand Coast 02.00 Tsunami hits Colombo Sri Lanka and Eastent Coast of Sri I-anke 02.l5 Tsunami hits India's Eastern Coastline 04.00 Tsunami hits Male, Maldives I 1.0C Tsunami hits East Coast cf Africa, nearlv ten hours lat3r c) The speedof the transocea;,ictravel has been ResultantEffects of Earthquake/ T5unamiof 26 scientifically determinedbased on the time of Dec 2004 the earthquake,the distancebetween epicenter Numerousscientists, researchers and experts are and various coastlinesand :he time of coastal analyzingthe effectsofthe polverful earthquake[9]. irnpactat coastlinesof souih eastAsia. Prelirr,inaryanalysis indicate the following key geo- d) Physical effects of diffracticn on the tsunami graphic and physical effects of the earthquakeon wave causesdevastation at south west areas earth,given in Table6. not in direci path cf tsunami like Galle in Sri Few exclusiveand distinctive facts on Tsunami of La:rkaand Keralain India [5] 26Dec 2OO4 e) The presenceof tsunami rvarning systems could have alerted many coastalareas across Here arefew exclusiveand distinctiveiacts that cccurredin the aftermathof the tsunami: the SouthEast Asian region [4]. f) The importanceof India's meritime doctrineand a) Steepestrise in numerical parameters : The the pivotal role of Indian Navy is highlighted tsunami of 26 Dec 2004, has been an nct only by the fact that tsunami traveled extraordinarydisaster of sorts.A wide rangeof ex:ensively in Indian waters with its passage numeiical parametershas been revised often acicssBay ofBengal, but alsoby thernagnitude and periodically,right since it was unleashed anJ scaleof its destructionand devastationat on 26thDecember. Critica! numbersthat have Andaman and Nicobar islanCs,as well as the sigrrificantlychanged and drastically upgraded SouthIndian Coast [5]. until now, includesthe total casualty::umbers. th; overall economic impact, the quantum of Impact of Tsunami and the numbers global aid, fire magnitudeofthe earthquakeas In all, there were 9 countriesin South EasiAsia well asthe growing list of regionalaftershocks. and 3 ceuntriesin Africa, significantly affectedby It is now believedthat the world has'vitnessed the Tsu;ramiof 26 Dec 2004 [6]. The tsunamiwaves the steepestCeath count rise in histo;y, in this weredetected outside the IndianOcean region, with disaster[24]. tsunarnirelated wave fluctuations documentedat b) Underestirnation of the magnitude : In February American Samoa,Antarctica, Brazil, Chile, Fiji, Rus- 2005, nev, analysissuggested the rrragnitude sia,Mexico, l.lew Zealand,Peru and United States. was underestimated.That study, reported in A tabledispiaying the countriesdirectly affectedby mostscience journals, including Science, New the tsu;ami, along with the numb:r of peopledead Scientistand Nature,upgrades and estimatesit and mi:sing is displayedat Table5. at 9.3. It is now proposedthat the earthquake cculd perhapshave been the second largest

28 Jour Maine Medical Society,20C5, Vo!.7, Nc I TABLE 5 Countriesaffected by Tsunamion 26 Dec 2004 tl7l tlSl

Country Target Of Tsunarri Deaths Missing As Estimated As Estimated In End Jan 2005 In End Jan 2005

Indonesia The norlhern and west-.rn parts cf Indonesian Island of Sumatra includir.g Aceh r66,760 ,^27,7 49 Sri Lanka The southern and eastern coastal areas of Sri Lanka. 38,195 5664 India The southeasterncoast of India and Andaman and Nicobar . 16,3 83 555l Thailand The southwestern a;C coasta! areas of Thailand including Phuket, Phi Phi lslanC and Krabi \ 7)) 3i00 Somalia Ccastal region 298

Myanmar The western coast cn the tsay of Bengal and Andaman Sea. 9C J Maldives Entire country 82 26 Malaysia The northwest coast rf Malaysia especially, Fenang and Langkaw; 68 6 Tanzania Coastal region l0 Bangladesh The southern coast rn the Bay of Bengal. 2 Kenya Coastat region I Seychel les Coastal region

TABLE 6 Resultant effects of Earthquske/ Tsunami ol 26 Dec 2004

Parameter Details

Lantimass shift The Andaman and Nicobar Islands have shifted closer to mainland India by 3 metresGreat Nicobar, Car Nicobar and Port Blair have gone down b7 i.3m, I m and 80 cm respectively The North Pole has shifted by about 2.5 centimeters (1 inch) in the direction of 145 degrees east longirude [20] Length of a day The massive release of energy with a decrease in the oblateness of the Earth shcrtened the iength of a day by 2.68 microseccnds (2.68 ps) and earth spinning faster [21] Movement at Seabed l0 m (33 feet) mcvement laterally and 4 to 5 m (13 to 16 feet) vertically along the fauit line [l 0scillation effects Caused oscillation of the Earth's surface of about 20-30 cm Il] Rotation of the Earth The shift of mass and the massive release of energy altered very slightly the Farih's rotation du3 io a decreese in the oblatenesscf the Earth [21] Shape of earth Earth's oblateness(flattening on the top and bulging at ihe equator) decreasedby a small amount-about one part in l0 billion, making earth more rcund [21] Total energy released Estimatedas 2.0 exajoules(2.0xl018joules) This amountsto 475,000 kiiotons (475 negatons) of TNT. cr the equivalent of 23,000 Nagasaki bombs [22] Wobble in aris Caused the earth to minutely "wobble" cn its axis 5y uo to 2.5 cm in the direction of 145' easr longitude [23]

sarthquake, ever recorded ':l a seismograph. aftershccks [25]. Many aftershocks were Hcwever a final global consensus and observedimmediateiy after the main evenr, unanimousverdict on this is yet to be reached, nostly clusteredin Andaman anci Nicobar in view of ongoing scientific analysisat many Islands centres Ii]. 4 Andaman Sea Earthquake Swarrn : A large c) Aftershocks : Aftershocks have been numberof earthquakes,have occurredeast of continuing well into the ":fth month after the Nicobarislands, beneath the Andaman Sea, tsunami.Though lesserin intensity,the region eversince 26 January2005. In contrastto the26 is still riddled repeatedly with periodic Decembermain shcck, which occurredon the

Jour.Meine Medica!Sociery, 2005, W\.7, I'lo. I western boundary of the Burma plate, the children. The high proportion of children has Andaman Sea activity is occurring on the been attributedto their small size and lack of easternboundary of the Burma plate with the resistanceto the surgingwaters [29]. Sundaplate, a zone of strike-slip and normal h) Finalnumberofdead : Theexactfinaltoll may faulting.This currentepisode of AndamanSea never be known due to the large number of earthquakesis classified as an earthquake bodies swept to sea. Using conservative "swarm" denoting "an episode of high methodologies,current studiesestimates that earthquakeactivity in which the largest the final figure of dead persons may range earthquakedoes not occur at the beginningof anywherefrom 200,000to 310,000.In particular. the episodeand in which the largestearthquake a news agencyreported that 500 bodiesa day is not substantially larger than other were still being found in February 2005, at earthquakesof the episode."126). The recent Indonesiawith the count expectedto continue Andaman Sea swarm is occurring in an area pastas late as June 2005 ICNN News February hundredkilometers across, within a 300-km long 10.200s1ul. plate boundary. i) Web logs and Videoblogs : A novel method of e) SeabedImagery : In February2005, a Royal disseminationof newsin the immediateperiod Navy Ship, HMS Scott surveyedthe sea bed after the tsunami struck, was "blog". Blog, around the earthquakezone. The equipment derivedfrom "Web Log" arefrequently updated, used was a high-resolutionmulti-beam sonar personalizedonline diaries, available as system.It revealedthe following prelimihary webpagesposted on the internet. Eyewitness color imagery data a) a huge impact of the Blogs of the tsunamifrom locals and tourist in earthquakeon the sea bed topography;b) the Southeast Asia, wereavailable on the Internet, creationof large 1,500m high thrustridges: c) featuring experiencesand survival stories of the presenceof large landslidesof several tsunamiwitnesses, with picturesand videosof kilometers;d) thedragging of individualblocks the tsunami devastation.Additionally, they of rock,weighing millions of tons,l0 km across contained useful listing of local and the seabed by the force ofdisplaced water and governmentalaid agencies.Few blogs were a e) formationof a new tranchseveral kilometres forum for searchingand locating missing wide in the earthquake zone 127I [28]. personnelacross South east Asia, as well. Geographical Factors and Tbunami : Coastlines Typical blog sites were Pundit gtty, Maxittg isolated from tsunami by land are generally Out: David'sJounnl[30], Lik Of AGuy Front protectedfrom tsunami,as in the caseof Goa, Asia [31]; Plruket Tsunani [32] and Shancly's Mangalore,Singapore and Kelang. However, BloS [33]. Furthermore.In addition to blogs, tsunami waves can by physical principles of many websiteswere availableon the lnternet. diffraction hit even shelteredcoastlines. This providinggeneral and scientificinformation on was evident in the presenttsunami. when thetsunami. Atable displayingfew Webportals westerncoastlines of Keralaand Sri Lankawere offering different types of information on 24 alsohit. Evendistance may not imply assured Dec 2004Tsunamiis given in Table7. safety or predict potential for severedamage. This was evident again in the presenttsunami, Predicting future disastersand Tsunami with distantSomalia was devastated more than While it is difficult to predictthe future,particu- nearbyBangladesh [5]. larly when it comesto mapping nature'sfury, the followingpoints give a diminutiveglimpse of what Profiling of the dead : A patternhas emerged in c) is to be expected. the analysisof the dead. Predominantgroups amongthe dead are children, fisherwomen, and a) Seabedunrest offIndonesian Coast: Three foreign tourists.Children Relief agenciesnow months since the tsunami of December.an report that one-third of the dead appearto be earthquakestruck approximatelyat the same

30 Jour Marhrc Medical Societv.2005. Vol.7. No. l ffer- TABLE 7 nges Few important websiteson Tsunami of 26 Dec 2004 :llar. No Portal URL Address 10ca- 3dto GOVERNMENT OF INDIA chis I Government of lndia http://indiaimage.nic. i n/tsunami.htm astal 2 NDMI http://www.ndmindia. nic. in .ntity 3 Indian Navy http://www. indiannavy. n ic. in/tsu nami.htm /ellar 4 National Institute Oceanography http://www.nio.org/j sp/tsunam i.j sp 5 National RemoteSensing Agency ,ffect http://www.nrsa.gov. in/tsu nam i/tsu nami_files/frame. htm FEATUREDTSUNAMI PAGES le of I Amateur SeismicCentre ht t p ://asc - i nd i a. o rg I gql 2004 l 226_bo x i ng. h rm r this 2 Age http://www.theage.com.au/issues/asiatsunami/ vater 3 BBC http://news.bbc.co.uk/2/hi/in_deprh/world/2004/asia_quake_disaster/ omic 4 CNN http://www.cnn.com/Specials/2004/tsunami.disaster/ 5 Lonely Planet http:// www.lonelyplanet.com/tsunami/ 6 Nature http://npg.natu re.com/ne ws/spec iuls/tsunami/i ndex. ht ml 7 NOAA hltp://www.noaanews.noaa.gov/stories2004/s2357.htm rsrng 8 Reuters http://www.alerrnet.org/the news/emerge ncy/S A_TI D.htm 9 Tsunami rl-UCK- Help http://tsunamihelp.blogspot.com/http://www.tsunamihelp.info/wi ki i ndex. ph p/Grou nd_Zero_l nformat i on l0 Wikipedia http://en.wikipedia.org/wiki/2004_lndian_Ocean_Earthquakehtrp:/ en.wik ipedia.org/wiki/Tsu nami ll US GeologicalSurvey http://earthquake.usgs.gov/eqinthenews/2004/usslav/ TSUNAMI VIDEOS I Asia Deadly Tsunami http://datawhar.blogspot.com/2004tl2l w aterworld_2g.html 2 Asian TsunamiVideos http://www. photoduck.com/photos.aspx?gid= I g5 6&pxo=0 3 Asian Tsunami Videos http://www.asiantsunamivideos.com 4 Cheeseand Crackers http://homepage.mac.com/jlgolson/candc/ 5 Master New Media http ://www. masternewmedi a.org/ Z00S l0 I /02 fu Il_tsu nami_v ideo_footage_pi tl ctures. h t m 6 Tsunami Video Itlog http://www.waveofdestruction.orq/ SATELLITE PHOTOS I ASTER http://asterwebjpl.nasa.govl 2 CRISP http://www.crisp.nus.edu.sg/tsunami/tsunami.html 3 Dartmouth http ://www.dartmouth.edu/-floods/ 4 Disaster Chart http://www.disasterscharrer.org/disasters/CALLID_0?7_e. hrml 5 Digital Globe http://www.digitalglobe.com/tsunami_gallery.html 6 DLR http://www.zki.caf.dl r.de/applications/2004/i ndi an_ocean i ndian_ocean_2004_en.html 7 ESA http://www.esa. int/esaCP/l ndex. html I Formosat http://www.nspo.gov.tw/ 9 Global Security http://www.globalsecurity.org/miritary/worrd/india/car-nicobar-imagery. ht nr IO MODIS http://modis.gsfc.nasa.gov/ 1I NRSA http://www.nrsa.gov.i n/ 12 NASA http://www.nasa.gov/vi sion/earrh/look i ngatearth/i ndonesi u_q uake. html I3 ORBTMAGE http:,//www.orbimage.com/news/featuredimage.html 14 RADARSAT http://www. space.gc.calasc/eng/defaul t.asp I5 SERTIT http://sertit. u-strasbg. frldocuments/asie/asi a_e n.htm I 16 SpaceImaging http://www.spaceimaging.conr/gallery/rsunami/ 17 Spot Image http;//ww w.spotimage. frl rvaram 1E UNOSAT http://unosat.web.cern.ch/unosat/asp/default.usp l)vtsti 19 uscs http://gisdata.usgs.gov/websitelDi saster_Response 20 Wave of Destruction http://www.waveofdestruction.org/satellite.php

7.No.l JounMaritrc Medical Society, 2005, Vol.7, No. I -tl MAPPING THE TSUNAMI I Computer-generatedanimation http://www.geophyswashington.edu/tsunarni/generai/physics of a tsunami runup.html 2 India SeismicityMap http://www.imd.ernet.in/section/seisrnolstatic/seismicity-map.htm) 3 Most Recent Seismicactivity http://earthquake.usgs. gov/recenteqsww/Maps/region/Asia_eqs.html ) 4 Tsunami Disaster Interactive Mapping http://mapsherpa.com/tsunami/ 5 USGSMap http://pasadena.wr.usgs.gov/shake/ous/STORE/Xslav_04/ciim_display.html 6 Tsunami simulation http://www.nio.org/j sp/tsu_simu.htnr MISCELLANEOUS I CNN Online Links http://fte.eanes.k! 2.tx.us/CurrentEvents/Tsunami.htm 2 December26 Tsunami Disaster http://www.drs.Cpri.kvoto-u.ac.jp/sumatra/index-e.html 3 Tsunami travel time map http://wcatwc.gov/ttt/tttsanfr.gif 4 Indian Ocean Tsunami http ://iri.col umbia.edu/-lareef/tsunami/ 5 NOAA Tsunami http://www.tsunami.noaa,gov/ 6 TsunamiMuseum http://www.tsunami.org/ 7 Tsunami Hazard http://www.pmel. noaa.gov/tsunami-hazard/ , Tsunami.gov http://tsunami.gov/ 9 Tsunami Journa! http://www. sthjournal.org/

locaiion. This earthquakeof magnitude 8.?, refractionand diffraction processesacross the ranking as the 7th largestearthquake since 1900, ocean;c) travel path of the waves; d) coastal struck at 23:09:37 local Indonesiantime on configuration[35]. March 28, 2OO5anC is referred globally by C,1 The Present status of Tsunami Warnings in experts,as "2005 Sumatranearthquake" [34]. India : Tsunamisare rare in India. Despitethe Considered as a very large aftershock of the presenceof a good seismologicalnetwork in original earthquake,it failed to producekiller india to recordearthquakes within the country tsunamis.It is thereforehypothesised that the and its neighborhood,there is a growing chancesof a repeat tsunami is unlikely and, concern for the need of a Tsunami Warning improbable,but not totally impossible. Centre (TWC) in India. Currently the b) Forecasting tsunarnis : Ever sincethe tsunami, Department of Ocean Development in awarenessof the importanceof tsunamiwaming cooperationwith Departmentsof Space and systems,has grown amcng the countries Scienceand Technologyis involved with the affectedby it. Cunently, thereis no functional introductionof a tsunamiwarning systemin system in the affected region, making it the Indian Coast. The data is expectedto be , vulnerableeven now. Expectedly thesesysterns derived using "bottom pressure recorder, . arecostly. Tsunami Warning System works in a acousticmoCern, acoustic release system " [6] real time frame of short duration, often with t361. inadequate data and information making o Impending ecologicaldisaster: A recentreport- wainrng a difficult task.It entailsccllection of the "Millennium EcosystemAssessment data from special buoys and other critical SynthesisReport" [37], warnsthat humanity is seabeddata that assistsin the final prediction headingfor ecological disaster.Compiled by of the terminal runup and destructivenessat 1300 leading scientistsfrom 95 countries,for distant shores.Amongst many factorsthat are the UN. the reportpredicts the ecologicalstate important in tsunami prediction few are a) ofthe world in 2050,by analyzing24 essential seismic parameterslike rr.agnitudeof tire ecosysten.services. The gloornyreport dwells earthquake,its depth,its orientation,the length on t:re progressive disappearanie of of the fault line, the size of thc crustal biodiversit;' and warns of pcssible displacements,and depth of the water; b) "accelerating, abrupt, and potentially

J/ .IourMaria.e Medical Societv, 20a5, Vol.7, Nc. I 'fsunami irreversible changes",a situation aggravated Natural Disastersby Prof. StephenA. Nelson hysics by "a world in which internationalcooperation Tulane University : Available at http://www.tulane.edu/ -sanelson/geol204ltsunami.htm Accessedon l2 May is lacking,economic competition is fierce,and ; ) 200s environmentalthreats are faced only afterthey nl) 8. Frequently asked Quesiions about Tsunamis from emerge"t37lt38l. InternationalTsunami Information Center UNESCO Available at http://www.prh.noaa.gov/itic/library/ lay.irtml CONCLUSION about_tsu/faqs.html ; Accessed on l2 May 2005 The Tsunami of 26 Dec 2004 was a "double Tsunamisrecorded along the coast of India : Available whammy"disaster, comprising of two distinctlycon- at http://wwwnio.org/jsp/tsunami.jsp; Accessedon l2 May 2005 nected geophysicalevents, of severescale and 10. Preliminary Assessmentof Impact of magnitude : a megathrustseabed earthquake off Tsunami in SelectedCoastal Areas of India Department of Ocean Sumatra,triggering off a seriesof large tsunami DevelopmentIntegrated Coastal and Marine Area waves striking and damaging South east Asian Management Project Directorate Chennai : Available coasts.Analysis of the earthquakeand tsunami as at http://dod.nic.in/tsunamil.pdf; Accessedon l2 May 2005 well as the assessmentof its humanitarian,eco- nomic, environmentaland scientificimpact is ll. Subduction Zone: Available at http://en.wikipedia.org/ wiki/Subduction_zone ; Accessed on l2 May 2005 underwayeven now acrossthe globe.It is evidently t2. Scientific Background on the Indian Ocean Earthquake clear that the dataon the tsunamiof Dec 2004, will and Tsunami.: Available at http://iri.columbia.edu/ continueto be further analysedand constantlyup- -lareef/tsunami/ rossthe I Accessed on l2 May 2005 dated, driven by a global pursuit for accuratg coastal 13.Timeline of the 2004 Indian Ocean earthquake : answers.Notwithstanding this, a brief review of some Available ?t http://en.wikipedia.org/wiki/ of its numbers,facts and issuesat this presentpoint 2004_Indian_Ocean_tsunami_timeline ; Accessed on 12 May 2005 lingsin in time, have been presentedin this article; all of t4. 26 countriesalerted in l5 minutes, ;pitethe which indicatesthat the tsunami of 26 Dec 2004, India not one of work in them : Available at http://www.indianexpress.com/ was indeedan extraordinarymarine efiironmental full_story.php?content_id=61674; Accessed on l2 country disaster,which mankind will not forget for a long May 2005 rowing time. 15. Indian Naval Tsunami Relief Operations : Available at ilarning I http://indiannavy.nic.in/tsunami.htmlAccessed on l2 rrJ rrr'- REFBRENCES May 2005 leut in l. 2004 Indian Ocean earthquake: Available at http:// 16. Ground Zero Information From Tsunamihelp: aceand' en.wikipedia.or gl wiki | 2004_lndian_Ocean_earthquake Available at http://tsunamihelp.blogspot.com/: with the ; Accessed on 12 May 2005 Accessed on 12 May 2005 istemin 2. Tsunami Terminology: Available ^a http:l/ The South east Asia Earthquakeand Tsunami Blog : www.pmel.noaa.gov/tsunami-hazard/terms.html; Available at http://tsunamihelp.blogspot.com/; ed to be Accessedon 12 May 2005. Accessed on l2 May 2005 :corder. 3. Preliminary EarthquakeReport U.S. Geological Survey, 18. South Asia Tsunami situation reports.WHO Health em" [6] National EarthquakeInformation Center World Data action in crises Situation report 3l of 29 January Center for Seismology, Denver Available at http:// 2005 : Available.at http://www.who.int/hac/crises/ www.solcomhouse.com/tsunamis.htm; Accessedon l2 international/asia_tsunami/sitrep/en/; Accessed on l2 rt repon- May 2005 May 2005 )ssment 4. Earthquake Hazards Program : Available at http:// 19. NASA Details How Indian Ocean Quake Affects Earth nanrtyls neic.usgs.gov/neis/eqlisls/l0maps_world.html ; Rotation ; Available at http://www.globalsecurity.orgi piledby Accessed on 12 May 2005 space/library/new s/2005/space-05 0 I I I - usia03. h t m: tries,for 5. Tsunami : Available at http://en.wikipedia.org/uiki/ Accessed on l2 May 2005 icalstate Tsunami I Accessed on 12 May 2005 20 Estimatesof the geodetic GPS survey in the Andaman & Nicobar Islands conducted by CESS : essential 6. Prevention/Protectionand Mitigation from Risk of Available at Tsunami Disasters-AConcept Note from http://www.seires.net/content/view/122/52/: Accessed rt dwells National DisasterManagement Division, Ministry of Home on 12 May 2005 ,nce of Affairs, Government of India : Available at http:l/ zt. NASA Details EarthquakeEffects on the Earth : rcss ib le ww w.ndmindia. n ic. i n/Concept Note-Tsunami Available at http://www.nasa.gov/home/trqnews/2005/ ential.l y Mitigation.doc ; Accessedon l2 May 2005 jan/HQ_0501I_earthquake.htmli Accessed on l2 May nl.7,Nc. l Jour. Marine Medical Societv, 2005, Vol.7. No. I JJ 2005 4383573.stm; Accesscdon 12 May 2005 22. Magnitudc 9.0 Sumatra-AndamanIslands Earthquakc 30. Maxing Out: David's JournalAvail;ble at hup:// FAQ: Available at http://carthquakc.usgs,gov/ maxingoutcom.siteprotect.net/davidjournal.html; cqinthencws/2004/usslav/neic-slav_faq,html; Acccsscdon 12 May 2005 Acccssedon 12 May 2005 31.Lifc Of A Guy From Asia : Available at http:// 23. Earthquakcsvs. thc Earth's RotationHow major brilliantxjoumalspace.com; Acccssed on 12 May 2005 ra tremorsaltcr thc planct's wobblc : by Sam Schcchncr 32. Phukct Tsunami : Availablc at http:// : Availablc at http://slatc,msn.com/id/2lll443l i phukcttsunami.blogspot.com/; Acccsscd on l2 May Acccsscdon 12 May 2005 2005 24. FionaF; Tsunamibody count is not a ghoulishnumbcrs 33. Shrindy'sBlog : Availablc at http://blogs.vbcity.cq;n/ gamc in WHO Ncws Bull rilorld Hcalth Organ shandy/archive/2004llil27.aspx; Accesscd on 12 May 2005;E3:2:E-91 ; Availablc at http://www.who.int/ 2005 cntity/bullctin/volumes/83/2/who_ncws.pdfi Accesscd on 12 May 2005 34. 2005 Sumatranearthquake: Availablc at http:// cn.wikipcdia.org/wiki/2005_Sumatran_earthquake; 25. Aftershockc : Available at http://www.nio.org/jsp/ Accesscdon 12 May 2005 tsunamijsp ; Accesscdon 12 May 2005 35. TsunamiForccasting, Prcparedness and Warningby 26. AndamanSca EanhquakeSwarm : Availableat httpi/ Gcorgc Pararas-Carayannis: Available at http:// /carthquakc.usgs. gov/cqinthencws/2004/usslav/ www.drgcorgcpc.com/TsunamiForccasting.html; andaman-swarm.html,; Acccsscdon l2 May 2005 Accissed on 12 May 2005 27. RoyalNavy Ship HMS Scottsurveys the scabed around 36. India's tsunami-warningsystcm in two and a half ycars the carthquakc zone : Availablc at http:// : 29th Apr 2005 http://www,indiaexpress.com/news/ wwrl.newscientist.com/article.ns?id=dn6994; Acccssed regional/maharashtra/bombay/20050429-0.html on 12 May 2005 Acccssedon 12 May 2fi)5 page 28. The tsunami : Available at http:// 37. Millennium EcosystemAssessment Synthesis Report : www.drgeorgepc.com/Tsunami2004lndoncsia.html; Availablc at http://www.millenniumassessment.org//en/ Accessedon 12 May 2005 hoducts.Synthesis.aspx; Accessedon 12 May 2005 - 29. Most tsunami dcad female Oxfam : Available at 3E. Dyer O. Globol ecologicaldisaster predicted in next http://ncws. bbc.co. uk/ I /hi/world/asia-paci fic/ 50 years.BMJ 2005;330:809

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34 Jour Maine Medical Society,2A05, Vol.7, No. I ReviewArticle EFFECTIVEDISASTER MANAGEMENT PLAN FOR NAVAL HOSPITALS

Surg RearAdm VK SINGH VSM*, Surg CdrAI AHMED**

ABSTRACT

Disaster has been defined by World Health Organlzatlon (WHO) as "an occurrence that causesdamage, economic dlsruptlon' loss of human llfe and deterloration In health and health servlceson a scale sufflclent to warrant an extraordinary effort responsefrom outside the unaffec.ted,communltyor areat'. In todayts world, there is sn urgent need for pre-dlsaster plannlng wlth hospltal.centrlc contlngency plans whlle keeplng personnel In contlnuel tralning to be prepared for any type of dlsaster.

Thls artlcle revlews varlous lssues ln a hospltal based Dlsaster Management plan, focuslng on key areas llke activating the dlsaster plan' recelpt of Informatlon, the componentsand role of a dlsaster managementcell, the lmportance and slgnlflcanceof causallty evacuation& receptlon areas and lssuesrelated to trertment area. However dlsasters are nolorlous for laylng low the best of such plans, unless personnel keep thelr wlts about and carry out their well-rehearsedrole with applicatlon and dlllgence.

KEY WORDS : Disaster; Disaster ManagementPlan; QRMT; DART

INTRODUCTION TABLE I Tlpes of Disasters J-\isaster has been defined by World Health Or (WHO) l.zfganization as "an occurrence that Classificatlon llpe causesdamage, economic disruption, loss of hu- man life and deterioration in health and health Natural a Earthquake serviceson a scale sufficient to warrant an extraor- o Floods dinary effort responsefrom outside the unaffected a Landslides o Tsunami community or area".[] Sudden disastersrequire Machine & related a lndustrial accidents health professionalsto muster all their technical a Mechanical accidents abilities and exigenciesto solve problems under o Fire critical conditionsin which facilities and materials Man-made a Bombs are riot always available as they are in normal o Fire-setting situations. . NBC It is worth noting that however timely the healthcareresponse may be, its effort can be nulli- GENERAL PRINCIPLES FOR DISASTER PLAN fied if it is disorganizedand fragmented,hence, BYAHOSPITAL inefficient and ineffective. Thus. there is a need for Any disasterplan should be easy to understand pre-disasterplanning with hospital-centriccontin- and should be disseminatedIt should be flexible gency plans while keeping personnelin continual consideringany contingency.Consideration should training to be preparedfor any type of disaster[Ta- be given to the availability of medical staff, nurses ble ll. and administrative personnel of the hospital in- volved.The essentialob.iective should be limited to

*Commanding Officer, INHS Asvini; **Classified Specialist (Psychiatry), INHS Asvini, Colaba, Mumbai 400 005.

Jour Marine Medical Society, 2005, Vol.7, No. I -tj two aspects: a) probable demand and b) resources TABLE 3 available. Outline of Disaster Plan

In addition, the disasterplan should coordinate Broad Strategy Key Features the use of resourcesand make it more rational so as to avoid duplication of actlvities and functions.To I Activating the plan 2 Receipt of Information this end, details of a current inventory of human, J Disaster Management cell a Members material and institutional resourcesin the medical ! Rote care area,will be of immensevalue. A continuing Causality Evacuation o Zones cf Cas Evac educationand training programmeshould be main- & Reception o Reception Center: tained to ensurethat proper action is takenpromptly. o Members However,the completedisaster plan shouldbe put . Role . Triage into effect only when necessary. o Responsibilities Importantly,it shouldbe part of the regionaldis- o Equipment aster plan and higher formation should be liased 5 Treatment Area o Crisis Expansion Wards a Operation Theater with in theformulation. [2] This will needthe launch a Surgery/ Other wards ofan early, effective co-ordination and co-operation betweenthe hospitaland local administrative(serv- ice & civil) authorities.It is also importantfor any 2. Receiptof Information disasterplan to havea core list ofobjectives,which The importantmeasures adopted upon receiptof hasbeen outlined in Table 2. information will initially be at the communication unit or Hospitalswitchbord operator.He will either TABLE2 receive the call and connect to DMO (during off Objectives of a Disaster Plan working hours)or SeniorRegistrar (during working hours). The To be prepared to receive mass casualties at short notice information as a rule to be obtained at all times. comprisesof the following key elements: a) who is a To establishTRIAGE facilities. calling; b) telephonenumber of caller; c) natureof o To provide resuscitation. disaster;d) locationof disaster;e) numberof cases a To initiate correct documentation. being sentto hospital ; 0 estimatedtime of arrival a To admit to perform life and limb saving surgery. . and g) modeof conveyance( amb / helo others). o To avoid unnecessary mortality / morbidity and prevent disability. The SignalCommunication Officer (SCO),should o To co-ordinate mass casualty management be immediatelycalled by operator/DMO / Sr Regis- trar, to swiftly kickstart a series of important initiatives,which would comprise: SALIENT FEATURESOF DISASTERPLAN a) Quick transmissionof information on disaster The salientfeatures of a typical disasterplan in a to CO / EXO & Sr Registrar, to HOD Surgery, Hospital scenarioare given from hereon.The out- Anaesthesia,Pathology, Radiology, to PM, OT line of this disasterplan is given as Table 3. Matron, to MO i/C ICU & MO i/c Crisis ExpansionWard, to First Lt, Logistics Officer, l. Activating the Plan . O i/C MedicalStores, and to all inliving Medical Fundamentally,the disasterplan would be acti- Officers. vated receipt information upon of regarding b) Make available& keepin a functionalstate the general, occurence of disaster. In information re- TelephoneExchange and all Mobiles. gardingthe disasterand related mass casualties may c) Instruct operators not to provide any be received by any of the following channels:a) information to press / outside agenciesand communicationfrom administrativeauthorities; b) directthem to PRO. informatiorrfrom telephonicmessage and/or c) by casualtiesarriving at hospital. d) Instructoperators to direct calls from victim's

36 Jour Maine Medical Societv,2A05, Vol.7, No. l families to information center. cludes: e) Arrange over-ride facility to phonesof DMO a) Activation of a Quick ReactionMedical Team and DisasterManagement Cell (DMC) (QRMT), comprising of one MO, two MA's (POMA/LMA) and two other sailors. The 3. DisasterManagement Cell ambulance from the hospital should be The DisasterManagement Cell is the command accompaniedby QRMT nucleus.It should be establishedimmediately to b) Creation of a dedicated Disaster Reception exercisesupervisory control over any disastersitu- Center,which is essentiallya resuscitationarea (ExO), ation.It is headedby a Chairman assistedby adjacentto MI Room / Casualty.This area is (Senior a Deputy Chairman Registrar).The members easily accessiblefrom the entry point of the includeLogistics Officer, MTO, Deputy PM, SCO, hospital and its role would comprise of the RO, MaintenanceOfficer and l" Lieutenant.It following activities: shouldbe locatedcentrally in the hospital. i. Resuscitation The multifaceted and important role of a Disaster ii. Triage & further disposalof patients. ManagementCell includesthe following:- iii. Bl,oodgrouping of all patients a) To establisha Control Room: to supervise,co- ordinate.control. alloiate additionalresources iv.Documentation & receipt of patient and collect & generateinfo / data valuables b) To recall personnel,cancel all types of leave v. Renderingofcasualty reports[3] andfreeze all transfermoves vi. Monitor the movementof patientsto various c) To establishan information center wards d) To establisha crisis expansionward vii. Arrange for transfer of patients to other hospitals e) To establisha two-watch system viii. Completion of medicoJegalformalities f) To establish a cloakroom for safe custody of patientarticles / valuables ix Liaise with BTD and Medical Stores for requirements g) To establisha damagecontrol teamto safeguard own property and to ensure continuity of ir Keep the Information center updated of essentialservices like water, electricity, LPG & casualtyadmissions, condition, deathsetc. Oxygenetc c) Triage : The classic principles of Triage are h) To ensureproper disposal of death in hospital/ prioritizing all patients into Priority-I: Brought in Dead, with correct,identification, casualtiesrequiring immediateresuscitation and documentationand liaison with Municipal surgery; Priority-Il: cases requiring early Corporation and Civil Police surgery and possible resuscitation and Priority-Ill: all other woundedand sick. The j) To maintaindiary of event,to draw conclusions objectivesof Triage include a) receiving the and lessonslearnt disastervictims; b) makerapid classificationof 4. CausalityEvacuation and Receptionof casualties and direct them to appropriate Casualties treatment areas with proper Casualty Hospital may also be assignedspecific casual- Identificationtagging (White tags: Dead; Yellow ties evacuationrole by the administrativeauthorities. tags: Stable & likely to remain so for 30 The responsibilityfor the zonesfrom which CasEvac minutes; Red tags: Severe fi needing will be carriedshould be clearly identifiedand laid immediate further treatment) and c) provide down in consultationwith Command/Higher forma- only such basic treatment as necessaryfor tion. As per the mobilizationprotocol, provision of saving a personslife e.g. Tracheostomies, the numberof the ambulancesshould be clearlylaid Thoracocentesis, venous dissection, down. The other important aspectsof CasEvacin- homeostasisetc, The responsibilitiesof a Triage

Jour MarineMedical Sociery, 2a05, Vol.7, No. I 37 TABLE 4 Typlcelexampleo of Trlege

P.l Casec P-2 Cases P-3 Casee o Immcdiatc rcsuscitation& Surgery a Early surgcry & possibleresuscitation o All other woundedand sick a Acute Cardio rcspiratory insufficicncy o Ligature vascularinjurics a Scvere hemorrhage a IntestinalInjuries o Inrcrnal blccding a Open Joint and bonc lcsions a Rupturc spleen a Multiplc Injuries o Sevcrcchest injurics o Eyc Injuries o Scvcrefacio maxillary injurics o Closedfracturc and dislocations o Shock o Burns lcss than 20% a Scvcre burn greator than 20% o Skull injurics without unconsciousness o Skull Injuries

Officer will include supervisionof the entire causalitiesneeding surgery reaching from the re- triage area,classification the patientsinto ceptioncenter will beattended to undersupervision priority I, tr & [I, servingas head ofall personnel of Coordinator.Postoperative care will beprovided assignedto that areaand allocate their duties I in Post-oprecoveryroom,ICU, Crisis expansion ward jobs and ensurethat there are sufficient or otherwards as may be clinically warranted,in a identificationstags, wheel chairs & stretcheis. "stepdown" manner. c. SurgerXand other wards : Hospitalizedpa- 5. TheatmentArees tients in good clinical condition shouldbe a. Crtds ExpandonWard : CrisisExpansionWud discharged.No electiveSurgeries are performed. In shouldbe establishedon instructionfrom Chair- casethe magnitudeof disasterso requires,addi- man,Disaster Management Cell at a pre-designated tional bedswill be placedin the ward / corridor/ area,which shouldbe in vicinity of Receptionarea. verandahs.Additional manpowerof MO's, MNS, Themanning should be ideally One Medical Officet CPOMA/POMA,LMA/ MA-I / MA-II, Topassmay ThreeotherMedical Officen, Fourmembersof MNS be augmentedand positioned. detailedby PM, Tivo POMA / LMA, TWoSPO / LSA, TWelvemedical assistants and Four topass to ROLEOF HOSPITALAT DISASTER SITE be detailedby l't Lt. O i/c Medical Storeswill be Disastercould occur at variousdisBnces from responsiblefor provisionof Non-expendableand the hospital.It may be necessaryto senda medical expendablestores as per the relevantME scales. ieam to the site of disasterto carry out triage & LogisticsOfficer will beresponsible for provisionof srictly selectthose cases for hospitalevacuation, bedsmattresses, pillows, patients clothing. Mainte- whowould benefit, keeping in mindthe principle of nanceOfficer will aid him. The importantrole of MO savinglife and limb. The teamsso requiredto be i/C CrisisWard includes retriage; early institution sentwould be: a) QRMT; b) DART and c) MTSP of definitive diagnostics& therapeutics;placing MobileTechnical Support Platoons/ MSU. [5] caseon SIIJDIL, maintainingdetails of cases,medi- The ReactionMedical Team (QRMT) will cal documentation,arranging Medical & Naval Quick bedeployed immediately on receiptof information storesand keeping the Informationcell updatedof aboutdisastcr. The main functionsare to provide casualtydetails. [4] immediatefirst aid andassess the situation and con' b. Operatlon Theatre : On receivinginformation vey rclevantinformation like thenature of disaster, from DMO/ MO i/c MI Room/Chairman, Disasrcr thelocation, the number of expectedcasualties, the Managementcell,the following personnel will reach requircmentof DisasterAreaRelief Team (DART), thcOperation theater immodiatcly: HOD Anesthesia backto Hospital. They will also brief DART on (Coordinator);HOD Surgeryand OT Matron.The theiranival at site.

J8 JounMarine Medical Socicty, 2005, VoL 7, No,I DisasterArea Relief Team(DART) will be dis- 0 arrangingfor a securityplan immediately patchedfrom the hospitalwithin 30 minutesto the g) for optimal public relations,only one disastersite. Unique features of DART will be the designatedperson should deal with the media. mobilisationof Surgeon,Physician, Anaesthesia and h) addressingthe psychologicalaspects of GynaecologyTrainees on call alongwith Stretcher disasterby keepingstaff informedby regular bearers.Their functionsupon reaching the disaster communication,debriefing and gripe sessions. site will be : takebriefing from QRMT,onsite Triage andsegregation for resuscitationand evacuation to i) factoringneglected issues like: custodyof hospitaland addingPriority identificationtags of casualty'scash / valuables/ weapons;disposal evacueeswith detailsof treatmentgiven and burial of bodies;Electricity and water supply;requirement of generator,Fire fighting ADMINISTRATIVEMEASURES anddamage control; Crowd managementand It mustbe remembered,that the stationstrength TrafficFlow of Navy/Army areais normally a largepopulation in j) hospitalsshould plan for managementbf NBC resfictedarea, at danger,ofbeing exposed to differ- casualtiesand train personnal, keeping in view ent typesof disasterwhether man-made or natural. the localthreat perception [6]. The hospitalmainly will be taskedto catermedical attendanceto a varietyof victimsreaching the hos- CONCLUSION pital. DisasterManagement Plan for hospitalslays This articlecomprehensively reviews the hospi- downthe StandardOperating Procedure for all per- tal basedDisaster Management Plan and the various sonnelto respondto the call and to carry out the criticalissues that govern its successfulimplemen- dutiesassigned to themduring the event ofa crisis. tation.The article specifically focuses on following It shouldbe practiced periodically in orderto make key areasofthe disasterplan: activatingthe disas: thepersonnel proficient and make improvements as ter plan,receipt of information,the components and andwhen deemed suitable. roleof a DisasterManagement Cell, theimportance Whilst key coordinatorsand facilitatorsshould andsignificance of Causalityevacuation & recep- be identifiedand listed, it is the collectiveeffort of tion areasand issuesrelated to Treatmentarea. one andall that will determinethe successfulout- Periodicand sustained training ofthis practicaland comein timesof a disaster.Decision-making must implementableDisasler Management Plan will suc- continueeven if key plannersare not immediately cessfullyrealize the ultimate aim of timely medical available. careto maximumnumber of disastervictims. The referenceslisted will aid the administratorin Fewadminisfative measures, that will ensureef- designingtheir respectivehospital plans. fectiveimplementation of disasterplan includes : a) keeping the disasterplan availableat RETERENCES appropriatelocations. I. Zcbrllog JL, " Emergcncyprcparcdncss and disastcr relief programmc"in Hcalth ScrviccgOrganization in b) makingsure the staffis familiar with is contens thc evcnt of dieastcr, Pan Amcrican Hcalth andare trained to respondbefore the disaster. Organization,WHO WashingtonDC, 1983.443 c) identifying and inspectingall areasand 2, Indian Navy War Book - Part lI, WcstcrnNaval equipment,which maycause or be subjectto a CommandWar Ordcrs. disaster,throughout the year 3, NO (Spl)3/99,"Rcporting of Casualtioe" (Str) d) updatingthe supplyinventory least 4, NO 36/95, "Provisioningof bods for crisis at twice a cxpaneionin Naval horpitalo" year,noting in particularthe supplieson hand 5, Haadquartcrs,Western Navat Commandlcttcr No. OP and thosewhich needsto be purchasedin / 0l0l / NBCDM / WNC datcd0l May 2(X)3 emergency. 6. DOAFMS letterNo. 3048/ DGAFMS / DG3A datcd24 e) reviewingthe disasterplan regularlyand Dcc 2001. updatingas neceSsary

JounMarine Medlcal Soclety, 2(n5, W\.7, No, I 39 A RETROSPECTIVEANALYSIS OF POSTTSUNAMI MORBIDITY TRENDS: CAMPBELLBAY EXPERIENCE

SuTgLt IIARMINDER SINGH

ABSTRACT

Disasterslike Tsunami can occur at any time dnd generallycatch everybodyunaware, leading to tremendous destructionand fatalities, Tabulation and analysisof morbidity trends with respectto age and diagnosiscan help in post-disastermanagement in sn effective manner. KEYWORDS : Tsunami, Post Tsunami Morbidity, Trends

INTRODUCTION thesecamps where medicalattention was given by 26'hDec 2004, the most powerful Defenceand Civil authoritiesin tandem,which in- fin earthquake \-/in more than 40 yrs stuck deep under the In- cludeddoctors from CGHS on specialduty. A local dian Oceannear Banda Aceh, Indonesiatriggering censusfixed the camppopulation at 4635 in all. off Tsunami waves of tremendously destructive MATERIALANDMETHOD power.The killer waves.wereseveral meters high and they obliterated coastal habitations and planta- This is a retrospectivestudy and analysisof tions across10 countries,leaving more than 1.5 lakh morbidity patternsin the immediatepost Tsunami people missing or dead.This led to the launching of disasterscenario. Data was collectedfrom various oneof the most intensiveSearch and R6scue (SAR) OPD registersand enumeration was donein respect and Relief operations in the history of the Armed of Age Group andDiagnosis from 29'hDec. 2004 to Forces. l0'h Jan.2005 in the following headingsdescribed below:- The centre where this study was carried out is a small Medical Inspection Room with I medical of- a) Cases in Trauma ranged from superficial ficer and 2 medical assistantslocated in Campbell abrasionsand thorn pricks to multiple fractures Bay on Great Nicobar Island, the Southernmost In- andinternal abdominal injuries dian Tenitory barely 79 nautical miles from the b) Cases in Fever included respiratory tract epicentreof the earthquake.The whole CoastGuard infectionand unspecifiedviral infections,heat Base including the medial Inspection Room was strokeand sporadicmalaria casesmost of which washedaway. An adhoc centre was set up at higher werediagnosed clinically andtreated empirically ground within hours of the disasterin the only avail- while a few tested positive by QBC/slide able tent with medial storesborrowed from the local mibroscopy. Primary Health Centre, which was damagedin the c) Casesin Dianhoeaincluded symptoms of loose earthqirakeand grossly understaffed.Most of health stools due to indigestionand gastroenteritis workersof the PHC along with all otherinhabitants d) Cases in General comprised of malaise, of the island, which comprisesof tribals and ex-serv- weakness,general body pains and headache. icemen, were stranded without food, water and shelterin distanthilly locations,since the lifeline of e) Cases in Others comprised of Diabetes, ' the island,a single road had beenwashed away. Hypertension,Epilepsy, Asthma and other ailmentsof regularattendance in the OPD. As relief operationsintensified, 14 campswere set up as batch of rescued people were brought to Psychologicaland emotional trauma was the most

District Medical Officer, Indian Coast Guard District HQ-10, Andaman & Nicobar-744 302

40 Jour Maine Medical Society, 2005, Vol.7, No. I acrossAge Groups commonly encounteredcondition with each and % of Patients every personwho had experiencedthe Tsunamisuf- a0+b5yeaE fering from it to some degree. g5+b The samplesize was 1897and the objectivewas 10!€a6 a) to ascertain the Morbidity Patterns of post 110+bl5years Tsunami patients with respect to Age group E 15+b 25 years and days after disaster b) to detect out break of epidemics 125+ b40 years c) to create awareness in terms of Disaster i40+ b 80years Management

RESULTS Chart I : Pie Chart showing Percentageof patients across The total number of patients treated in various different age groups. OPD's from29Dec2oo4 to l0 Jan2005 is listedin Tablel. Age Group Morbidity

DISCUSSION The maximum patientswere found to be in the most activepopulation of society(25+to 40 yrs age group)at 594 (3l.3l%o)and 363 (19.147o) in 40+to60 yrs age-groupand 305 (16.08Vo)in 15 + in 40 age group as reflected in Chart I. The 25+to 40 yrs age group had highest trau- matic injuries 184 (39.M Voof total traumatic injuries) as reflected in Chart II. The geriatric agegroup (>60 years) sufferedfrom diseaseslike Diabetes,hyper- tension etc rather than trauma, diarrhoea and fever Chart2 : Line Bar Age groupand Com- asper Chart II. mon morbid"n"rln"*,", conditions across different age groups. All age groups had high incidenceof Fever as reflected in Chart II mainly due to Respiratory tract lowering of body resistanceleading to increased infectionsbeing acquiredin the cramps.High hu- susceptibilityto infections.Few slide positive Ma- midity and temperature compounded by improper laria casescontributed to the figure while several diet and physical and mental stresscontributed to caseswere diagnosedas Clinical malaria and were TABLE I Age groupmorbidity distribution

Age-Group Trauma Fever Diarrhoea General Others Total 29 Dec to l0 Jan

0 to 05 yrs 28 r28 64 5 l5 240 l2.65Vo 05 + 10 yrs 2l 69 35 l6 I4 155 8.179o 10 + 15 yrs 30 24 7 l0 9 80 4.22Vo 15 to 25 yrs 8'l 95 28 43 52 305 l6.08Vo 25 to 40 yrs 184 t43 64 lll 92 594 3l.3l7o 40+ to 60yrs 90 76 1A 64 109 363 19.l47o >60yrs 3l l8 t7 a) 62 160 8.437o

Total 471 553 229 28r 353 t897 IOOVo 7o 24.83Vo 29.r5% 12.597o 14.82Vo l8.6lVo r00.00%

Jour Maine Medical Society,2005, VoL7, No. I 4I D.y.*|3c Morbldih, ensure>lppm free chlorine level at userend. b) Basicfacilities like potablewater, trench latrinesand bathingplace with adequate privacy,proper sewage and garbage disposal etc to be arrangedbefore people are shifted to camps c) Chloroquineprophylaxis at 5 mg Base/Kg bodyweight per week d) Medicalto bereinforced by moreparamedics and Preventiveand Social Medicine rr@llstdd 1t6 16 1& l0 ld t& tt6 lu l@ ttu h Specialists.PHCs, CHC's and hospitals to be providedbasic facilities like water,food 1: ::]Jrun:+I3.'::!.m:"! priority. Chart3 : LineChart showing Percentage ofpatients across and electricity on Logistic differentage,groups and the three common mor- requirementsof medicalteam themselves in bidityconditions. tertiarycentres in thefield to belooked after byAdmin authorities. treatedempirically with goodresults. This areais a e) Provisionof balanceddiet for campdwellers holo-endemiczone for Malariaof all typesand Chlo- f; Mosquitocontrol measuresto be initiated roquineresistance is rampantbut the incidenceof at war footing slidepositive cases was not noticedto be higher thanthe baseline incidenceduring the time of this g) Co-ordinationmeeting between various study. departmentsconcerned with settingup and maintenanceof camps The initial low patientload followed by steep spikein overallporbidity trendas reflected in Chart h) Healtheducation for campdwellers towards III is attributedto the fact that rescuework was betterhygiene and sanitationto be aimed startedin full swing l-2 daysafter the disasterand speciallyon womenand children thecamps contributing to theOPD attendance were i) Psychologicalcouncillors for helpingpeople setup in thecourse of 2-3days. Also, this time was in overcomingemotional trauma requiredto consolidatethe medicalresources in 2) Long term termsof trainedMan powerwhich was stranded on a) Disasterprotocol with a holisticview to be distantlocations of theisland or wereinjured&illed formedwell in advancewith exceptions made in theTsunami and Resources which wereretrived in thegeneral plan for areaspecific problem after Tsunamior rushedto the island along with issues. reliefmaterial. b) Distanceof the island territoriesfrom Incidenceof Traumaticinjuries reduced steadily mainlandto begiven special consideration. with asdays since theTbunami increased as reflected in ChartIII. Traumarelated atteances in thelast days CONCLUSION of the studywere mostly review cases coming for Tsunami'soccur rarely but leavelife-long scars followup of ongoingtreatment. on thepeople who experience it. Awell plannedpro- Incidenceof Diarrhoeashows a largelyeven tocolwith morbiditytrends taken into consideration spreadwith no spikessignifying effective Preven- will goa longway in healingof thesescars and also tion/Containmentof Water/Foodborne epidemics. saveseveral precious lives. Suggestlono Acknowledgemento a) Dr, Alicc Bwa, Dr Antony, Dr Hemawatiand Staff of l) Shortterm: PHC,Campbell Bay. b) Dr SC Das,CMO (NFSG),CGHS, a) SuperChloronation of all freshwater sources Kolkatta.c) LN Singh,Sgt & CD Rohella,LMA, ICGDHQ- 10.

42 Jour Marine Medical Society, 2005, VoL7, No, I MEDICAL NEEDSON DAY 1-3ATAIR FORCESTATION CARNICOBARAFTER THE TSUNAMI DISASTER: 26 DECEMBER 20u

Surg Lt Cdr SUSHIL CHAWLA

ABSTRACT Background : Natural dlsaster rre a testlng tlme for any medlcal organlzatlon provldlng rellef at any site & place. They test the preparedness& Innovatlvenessol the medlcal setup of the organlsatlon. ObJcctlve: Thls artlcle descrlbegthe types of InJurles & illnecsecsuffered by the resldentsof Alr Force Station, Car Nlcobar followlng 26 Deccmbertsunaml dleacter. Result : The dlsacter had led to 25 deathc end 67 people mlsrlng. Leccretlon and cmotlonal sympotms were the maln presentatlonof the personnel Concluslon : Early avallablllty ol medlcal help proved llfc eavlng for patlents ol asplratlon pneumonltls and dehydratlon. KEY WORDS : Tsunaml: Dlsacter rellef

BACKGROUND METHODS I t 06:30am on December26th, 20O4, a powerful Duringa two-daymission in disasterarea, the ./learthquake with its epicenterat Sumatrahit the medicalaid providedto thedisaster affected popu- SouthEast Asia followedby Tsunami.TheUnion lationofAirForce Station, Carnicobarby the medical territoryof Andaman& Nicobarislands, closest por- teamfrom INHS Dhanvantariwas evaluated. The tion of India to the epicenter,faced the burnt of the initial prioritieswere to minimizemortality and mor- naturalcalamity, which killed andinjuring hundreds bidity,while avoiding further mortality. of people.This articledescribes the medical need of servicepersonnel and their families and the civilian RESULTS personnelaround the Air Forcescation, in theinitial Immediateand initial evaluationof the affected periodfrom 6 to 72 hrs,after the disaster had struck. arearevealed a complexsituation, in whichthe build- ingsof thestation had collapsed [Fig. 1,2,3].The INTRODUCTION majority of the population.wascamping near the During the last decades,several humanitarian runwayin the openground tFig. al. The medical emergencieshave occuned,with an increasing teamfrom INHS Dhanvantarihad reached the Air numberof humanitarianorganization taking part in ForceStation by the first aircraftabout 6 rnhours providingassistance Ul. All naturaldisasters are after the disasterhad struckCar Nicobar islands. uniguein thateach affected region of theworld has Theteam provided medical care to thepatients un- differentand variedsocial, economic, and health derprimitive conditions using tents for 2 days.The backgrounds[2]. However,some similarities do ex- t€amconsisting of onemedical officer and two medi- ist, amongthe healthissues of differentnatural cal assistants. disasters,which ifrecognized early, can ensure that Whenthe RapidAction Medical Team (RAMT) healthand emergency medical relief and limited re- from Bangalorearrived two daysafter the disaster, sourcesare well managed[3]. all casualtiesrequiring surgical intervention already

GradedSpecialist (Obstctrics & Gynaecology),INHS Dhanvantari,Port Blair 744103

Joun Marine Medical Society, 2005,VoL 7, No, I 43 a

Fig.4: Themajority of the populationwas camping near the runway in the open ground

TABLE I Detailsof casestreatcd by the team

S. No Dlagnosis Number of cases

I Aspirationpneumonitis 03 2 Fracture& dislocations 02 Upper limb 0l Lower'limb 02 Othcr site 02 3 Head injury 02 4 Acute gastritis 33 5 Sprain 07 6 Laceration 68 7 Crush injury 03 8 Preterm labor 02 9 Threatenedabortion 01 l0 Emotional/ Psychologicalsymptoms 52 I I Dehydration 17

TABLE 2 Case transferred to INHS Dhanvantarl Figs. l, 2 and3: lmmediateand initial evaluationof the S. No Diagnosis Number of cases affected area revealed a complex situation. in which the buildings of the station had collapsed. I Aspirationpneumonitis 03 hadbeen operated on. Additionally, thoserequiring 2 Fractures 02 3 Head injury 0l intensivecare were transferred to INHS Dhanvantari 4 Acute gastritis 05 afterproviding necessary first aid andtriage. 5 Sprain o2 In all, our Medical teamtneated 128 patiens. The 6 Laceration 05 team also helped in the cremationof the 25 dead 7 Crush injury 03 bodies,which hadbeen recovered until then. 8 Preterm labor 02 a 9 Threatenedabortion 0t Table I shows the distribution of the different l0 Dehydration 0l casesffeated by the team.Table 2, further shows

/U Jour Maine MedicalSociety, 2405, Vol.7, No. I the details of the 24 cases referred to the nearest 2Ql earthquake in Gujarat, India. Prehospital Disaster service hospital for advancedcare. Med 2003: 18:372-84. 2. Hsu EB, Ma M, Lin FY, VanRooyen MJ, Burkle FM Jr. CONCLUSION Emergency medical assistance team response following Taiwan Chi-Chi earthquake.Prehospital Disaster Med To optimizethe effectivenessof limited resources, 2002:.17:17 -22. disasterpreparedness and the provision of feasible 3. Noji EK.Natural disasprs. Crit Care Clin 1991;7:271- and necessaryaid is of utmost importance[4]. 92. 4. Asari Y. Koido Y . Nakamura K. Yamamoto Y. Ohta REFERENCES M. Analysis of medical needson day 7 after the tsunami l. Bremer R. Policy developmentin disasterpreparedness disasterin PapuaNew Guinea. Prehospitaldisaster Med and management: lessons learned from the January 2000:15:9-13.

JOI.]RNALOFMARINEMTDICINESOCIETY FORM NO IV (SECTION RULES 8) Statementabout ownership and other particulars about newspapers(Journal of Marine Medical Society) to be published in the first issue every year after last day of February. l. Placeof publication Instituteof Naval Medicine C/o INHSAsvini, Mumbai 400005. Z Periodicity of its Publication Half yearly 3. hinter's Name Surg Cdr R Chopra +. Whethercitizen of India Yes If foreigner, statethe country of origin Address C/o INHSAsvini, Mumbai 400 005. 5. Editor's Name: Surg Cdr IK Indrajit Whethercitizenof India Yes country of origin . Address Instituteof Naval Medicine C/o INHSAsvini, Mumbai 400 005. 6. Name andAddress of individuals Marine Medical Society who own the newspaperand partners Reg.No. F-3611 or shareholdersholding more than Instituteof Naval Medicine one percentof totalcapital Mumbai400005. I, Surg Cdr R Chopra, hereby declarethe particular given are true to the best of my knowledge and belief.

Date: l3th June,2005 sd/- SurgCdr R Chopra

Jour..MarineMedical Societv,2005, Vol.7, No. I 45 THE TSUNAMI EXPERIENCEAT A FORWARDMEDICAL AID CAMP IN PORTBLAIR - A REPORT

SUTgLtCdTSAMIRKAPOOR

ABSTRACT The tsunaml ol 26 Dec 04 ls now conslderedglobally as one of the worst natural dlsastersfaced by manklnd. As per the \{HO, the death toll due to the earthquake followed by the Tsunaml ls 300,000and the Indlan flgures are 10,749dead, 5640 mlsslng of whlch 5554 are from the Andaman and Nlcobar (A & N) Islands snd are feared to be dead.

The only posslble means of evrcuatlon of casualtlesfrom the remote lslands was by alrcraft, due to destruction of all clvll and Naval Jettles by the Tsunaml. Conscquentlally,a medlcal ald camp was set up 8t tbe Naval Alr Statlon, INS Utkrosh by 1200 hrs on 26 Dec 04. It commencedrecelpt of casualtlesfrom 1700 hrs on 26 Dec 04 till 06 Jan 04. The present study ls a dcscrlptlve report of the lssues faced In settlng up of the INS Utkrosh medlcal camp, triage and trestment ofcasualtles and'preventlonofoutbreak oflnfectlous dlseases.It also briefly descrlbes the types of casesencountered durlng the rellef operations. A few recommendstions,based on the experience, are made at the end of the report. KEY WORDS : Tsunaml Dlsaster,Dlsaster Geography,Medlcal aid camp

INTRODUCTION Since the after shocks of the earthquake were continuingand the situationwas unpredictablewith I disastermaybe defined as a destructiveevent /aresulting in an extensiveloss of life and prop- periodic warningsof a fresh Tsunami,it was impera- erty. There is an immediate requirement of a wide tive to evacuatethe injured and survivors at the range of emergency resourcesto assist and ensure earliestfrom theremote islands. All jetties werede- the survival of the stricken population []. As per stroyedas a result of the Tsunami;hence the only the WHO, the death toll due to the earthquakefol- possiblemeans of evacuationwas by aircraft, which lowed by theTsunami is 300,000 [2] and the Indian wereexclusively employed for evacuationin the first figures are 10,749dead, 5640 missingof which 5554 few days. are from the Andaman and Nicobar (A & N) Islands Geographically,a disasterregion is broadlyclas- and are feared to be dead [3]. The A & N Islands sified into an Impact area, a Filter area and a have been the worst affected Indian region in terms CommunityAid area.PortBlairin the aftermathof 26 of morbidity and mortality. Dec 2004, was a filter and a community aid area.As The Indian Armed forces have often been em- a resultof the air evacuation,the Naval Air Station ployed to aid civil authorities in case of such INS Utkrosh at Port Blair became the filter area, calamities.In this case,the Armed forcesestablish- through which all evacueesfrom the affected is- ments scatteredon many of the remote islandswere lands were evacuatedto Port Blair [Fig. l]. It also as badly affected as the rest of the population and becamean important part of the community aid area. the worst hit was the Air-force station at Carnicobar. In the first few days of the relief operations, most As a result of this, the serviceswhich could be ren- casualties were air evacuated to INS Utkrosh by dered by the Armed Forces locally, were severely AN-32, DornierLL-76,IL-78 and Chetak aircraftsof hindered. the Indian Navy, Indian Air-Force and the Coast

Graded Specialist - Aerospace Medicine, PMO INS Utkrosh, Port Blair, Andaman and Nicobar Islands.

46 Jour.Maine Medical Society,2AJ5, Vol.7, No. i utilizedto setup a medicalcamp and casualty relief ttpill centeralong with adequateequipment and stock of rml ; medicalsupplies.

'.lpill Selectionof Sitefor MedicalCamp 2005 Thefairly largespecialist vehicle hangar located ttptl I May closeto the runwaywas identified as the site for MedicalCamp and was prepared for the same[Fig cgrn/ 21.Communication lines were set up, augmented by May walkie-talkiesets. Followingconsiderations were takeninto ac- ttpilI rakeI countfor identifyingthe camp. The camp was : a) locatedon aroad head along line ofevacuation Fig I : Evacuationof StretcherPatient rgby to the referralhospitals and was not be too far ttp'.ll from the pointof deplaning. Guard. b) largeenough to receivethe maximumnumber A medical aid camp was setup at INS Utkrosh to years of casualtiesand was protected from weather. receivecasualties. It was the nodal point for recep- rews/ c) hadall the undermentionedfeatures : html tion ofall casualtiesin thefirstfew daysofthe relief operation.It played an important role in triaging and i) adequatelighting and ventilation port : filtering the casualtiesso that only thosein needof ii) toiletfacilities with adequatewater supply. gllenl urgent surgery / hospitalization were referred to the 2005 iii)communication facilities. hospitals. SOVoof the casualtieswere treated at the l next iv) parking medicalcamp itself. adequate spacefor ambulances. v) a spill-overhard area in theevent of having MATERIALAI\TDMETHODS to evacuatethe buildingin the eventof a This study is a descriptive report of the issues freshquake. ar faced in setting up of the INS Utkrosh medical camp, Themedical camp was set up by 1200hrs on 26 triage and treatment of casualtiesand prevention of Dec04. It receivedcasualties from 1700hrs on 26 outbreak of infectious diseases.It briefly describes Dec04 till 06Jan 04. It wasdisbanded thereafter and the types of casesencountered during the relief themedical set up shiftedback to theMI Room. operations.The report describesthe morbidity pat- Furtheqthe campwas set up so as to ensurea tern in the tsunami disaster. It outlines the requirementsin settingup medicalaid campsin the aftermath of marine disasters.A few recommenda- tions, based'onthe experience,are made at the end of the report.

Preparation The MI Room was informed of theTsunami and the catastrophic events at 1000 hrs on 26 Dec 04. Expectedly, all evacuatedcasualties in the next few dayswould be receivedat INS Utkrosh. It was also evident that the exact number of casualtiesand evacueesexpected could not be gauged immedi- .O ately sinceassessment of the situationwas only by aerialsurveys as all communicationlines weredis- rupted. Hence a reasonablylarge area had to be Fig 2 : Medical aid camp.

Vo.l Jour.Maine MedicalSociety, 2005, Vol.7, No. I 47 one-wayflow of casualtiesand was divided into: from26 Dec 04 to 06 Jan.On 29 and 30 Dec 04, one ma( a) EvacueeReceptiori : all evacueesdeplaning were more medicalofficer and one civilian medicalofficer mel first broughthere, stretcher patients were taken also attendedthe camp.A stretcher-bearerparty of bol directlyto thetriage area. Walking patients were 08 personnelwas employedto unloadcasualties. and askedto moveto the medicalreception area. All c) Medical comforts : Medical comforts in the don other evacueeswere immediatelyasked to board form of drinkingwater and a hot mealwere available wat vehiclesto be transportedto relief camps. for all patientsat all times.A freshset of clotheswas rou alsomade available. b) Medical Reception and Information: Walking takr patients were registered and records were The Task gier maintainedfor the information of relativesof star The primary taskwas to resusciiate/stabilizeand the casualties. ope treat as many casualtiesas possible,referring only c) Tliage area : Stretcherpatients were registered oft thosewho requiredurgent life/limb sa.vingsurgery/ and speedytriage was done allotting category afft specializedcare to INHS Dhanvantari/ GB Panthos- I, II, III or IV basedon mechanismof injury, pital. Treatedpatients could not be detainedfor anatomiccriteria, availablephysiological criteria 'wit longerthanthe arrival ofthe nextplaneload ofevacu- and co-morbidity factors. Triage tallies were ees since spaceand trained manpowerwas at a attachedand in caseofreferred patients(Cat I RE premium. and II), abridgedcase sheets were attachedin addition. Patientsrequiring surgery/hospitalization were (44 resuscitated/stabilizedand administeresinjectable wet O Resuscitation area : casualtiesrequiring analgesics/tetanus toxoid./ injectable anribiotics thar wel resuscitationwere immediatelyshifted here from the hospitalshad in adequatestock. Suturingof the triage areaand resuscitated. ofr lacerations,thorough cleaning, debridement and civ e) Tleatment and dressing area / Dispensary : dressingof woundsand splintingof fracturesand dressing of wounds, administrationof crushinjuries was done.They were then evacuated injectiblesand vaccineswas done here. to thereferral hospitals. All othercases were treated. 0 Holding area : stabilizedpatients who wereto given packetsof prescribedmedicines and moved be evacuatedto the hospitalsand patients out to the relief campsbefore the arrival of the next ) detained for observationwero kept here and planeload ofevacuees. monitored. The othertasks were to: C) Ambulance parking a. ensurethe health ofunit personneland prevent outbreakof any infectiousdisease. Equipmentand Medicalsupplies at MedicalCamp b. vaccinationof all personneland their families a) Overview : The MI Room is preparedfor the againstenteric fever. eventof an air disasterat all times,being an air sta- tion where civil airbus flights land. Besidesabove c. monitorquality of drinkingwater and food. medical suppliesand resuscitationequipment, lo- d. maintainthe highestpossible standards of cally designeddisaster kits, manufacturedat theunit sanitationin the medicalcamp, unit andaircraft level is availablesince Jun 04. Thesekits that con- usedin the evacuationprocess. tain plastic triage tallies and abridgedcase sheets, e. ensurehealth of aircrew and advise on were I successfullyused in the recent tsunamidisas- preventionof aircrew fatigue who were flying ter relief. Camp cots were usedfor detainedpatients. prolongedstressful sorties. Since stretcherswere not adequateand spinal il f. maintainthe morale of the personnel boardswere not available,hardback stretchers were and motivatethem to put in their best effort in the improvisedwith bambooand woodenboards. relief operationsdespite danger to themselves The (author) b) Team : One MO and08 medical andtheir families. assistantsmanned the medical camo24 hoursa dav Fit

Joi 48 Jour.Marine Medical Society, 2005. VoL7. No. I TABLE I :04,one Water pipelines were broken and fresh water was Age and sex - wise distributlon of cases rl officer made available to the unit and the medical camp by road head, all party of means of water bowsers. Being on Service Clvilian Total ralties. bowsers bringing water to the unit were inspected and testedfor free chlorine. Superchlorination was Male 50 174 1a A tsin the done and only after a holding period of one hour Female 4'l r49 196 vailable 12 yrs) 20 60 80 was the water allowed to be used [Fig 3]. Regular Children(< .heswas 1 rounds of the unit galley and unit premises were I Total 383 taken to maintain a strict vigil on standardsof hy- gieneand sanitation.Malaria chemoprophylaxiswas started since the troops were sleeping.out in the TABLE 2 lizeand open and malaria was a distinct threat.All personnel Daily breakdown of number cases ngonly of the unit and health personnel proceeding to the I Dsv Date Service Civilian ;urgery/ affected areas were vaccinated against enteric fe- 'anthos- ver. The medical camp was disinfected twice a day I 26 Dec 04 74 Nil 74 ned for -with the help of knapsack sprayers. 2 27 Dec 04 22 80 t02 fevacu- 3 28 Dec 04 26 106 132 /asat a RESULTS 4 29 Dec 04 l6 94 l l0 5 30 Dec 04 Nil ), 22 A total of 500 caseswere treated of which 224 6 3l Dec 04 02 20 22 )n were (44.87o)were males, 196 (39.2) were females. 80(16%o) 7 0l Jan05 Nil Nil Nil jectable (107o) were children as shown in Table l. 50 cases E 02 Jan 05 Nil 02 02 ticsthat were servicepersonnel, 70 (l4%o)were dependants 9 03 Jan 05 Nil 08 08 rring of of service personnel and the rest 380 (76Vo) were 10 04 Jan 05 Nil 08 08 ent and civilian personsincluding locaVtribal population. 11 05 Jan 05 Nil Nit Nit ruesand 12 06 Jan 05 Nit l2 t2 acuated 13 0? Jan 05 Nil Nil Nil treated, 14 08 Jan 05 Nil o2 o2 15 09 Jan 05 Nii. 06 06 moved thenext Total tt7 383 500

The daily distibution of cases is displayed in prevent Table2. A maximumnumber of 132(26.4Vo)casual- ties were treatedon 28 Dec M. No civilian casualties amilies were received on 26 Dec 04, whereas 74 service per- sonnel were treated.All service casualtieswere ood. evacuatedand treated by 31 Dec 04. ardsof The distribution of the types of casesis as shown aircraft in Table 3. Trauma casesaccounted for79.6Vo of the cases.Febrile illnesses and gastroenteritis formed the next major groupsof illnesses.06 women were in rseon various stages of pregnancy. One case of tetanus : flying was also received.Only one caseof snakebiteand two cases of near drowning were treated. Of the rel and casesofdehydration, one wasa boy who had stayed t in the + atop a coconut tree for l0 days and survived on a nselves bottle ofan aerateddrink [Fig 4]. Fig 3 : Superchlorinationofwater. Table 4 shows the injuries sustainedto various

Jour Maine Medical Societv,2005,VoI.7,No. I 49 7.No. l TABLE 3 TABLE 4 Distribution of cases treated InJurles sustslned to various body reglons Da: Diagnosls No. of Peicentage Reglon Ttpco?htury No of Ceses Cases of Total Melc Femsle Children un( Trauma 398 79.6% Chest Blunt injury 27 ll 02 wel Gastroenterltls 24 4.8% Abdomen Bluntinjury 12 05 03 me Splne Blunt injury 02 Dehydratlon 04 0.8% furt Fever undlagnosed 38 7.6% Fracture 06 03 mei Arthralgia 07 1.4% Head Closedhead injufoi 03 02 0l Near Drowning o2 0.4% Open head injury 0l a) Burns 0l 0.2% Upper Blunt Injury 20 13 07 Hypertenslvc emergency 0l o.2% Llmb Fracture 28 09 06 b) Bronchial rsthme 04 0.8% Others 72 35 l0 Prehepatlc coma 0l o.2% Lower Blunt Injury I 3 07 03 Meni ngoen cephal itls 0l o.2% Llmb Fracture 20 07 03 c) IHD with pulmonary oedema 03 o.6% Others 25 32 l0 Tetanus 0l 0.2Eo d) Low back ache 03 0.6% Total 124 45 Pregnancy 06 1.2% Snake blte 0l 0.2% Pain abdomen 05 r.0% the evacuationand the body was receivedat the e) medicalcamp. Total Of the500 cpsualties treated, l0 wereCategory I, 90 wereCategory II andthe restwere Category III andIV. Of the 100Cat I andII patients,20 service personnelwere referred.to INHS Dhanvantariand 80 patientsto GB PantHospital which includedall 8) orthopaediccases and all civilians.

DISCUSSION Day Tsunamisare giant seawaves which can be clas- \ sified undertelluric or teutonicnatural disasters. zatir They are formed as-a result of submarineearth- the quakes.The deathand destructionin the Indian ther sub-continenton26Dec 04 wasalmost solely due relie to the Tsunamithan to the earthquake.The high fres, numberof casualtiesthat were seen in this disaster a) Fig4: Youngboy stayed atop a coconuttree for 10 could be attributedto poor disasterpreparedness, days! absenceof any warning,feeble assessment of the gravityof thesituation, deficientcommunication and bodyregions including the type of injury.The maxi- mostof all a lack of knowledgeand ineffectual an- b) mum injurieswere to the limbs followed by chest ticipationdue to absenceof a pastexperience. The andabdominal injuries. Upperlimbs were more com- first to react were the Armed Forces,firstly due to monlyinvolved than lowerlimbs. The miscellaneous betlerpreparedness and resources to dealwith dis- c) gfoupofinjuries comprised contusions, sprains, lac- aster situationsand'secondly, due to better erationsetc. Adult malesformed the largestgroup comrnunicationfacilities. (57 d) of traumaticinjuries .5%of all traumacases). On theday of theTsunami, the first casualtywas ra Therewere no deathsin themedical camp; how- receivedat the camp at aroundI 700hrs. Only Armed everthere was one death on boardan aircraft during Forcescasualties were received that eveningmost

50 Jout Marine Medical Society, 2005, Vol.7, No. I Jour of who were dependantsor serious cases,Defense reported case of snakebite. personnelthemselves staying back to man and pro- One of the most challenging tasks, during the tect the defenseassets. From the next day,civilians entire relief operationwas triaging of the casualties. also started being received. The maximum number The task was difficult because of a) the periodic of civilian casualtiesreceived was on 28 Dec 04. The influx of a large number of casualtiesat short notice reasonfor this trend could be due to the fact that it and in one go ; b) varied patternsof diseasesen- took sometime for the civilians to realizethat evacu- countered apart from those due to injuries ; c) a ation by aircraft was being resortedto and thereafter limited appreciation of the triage process in such they had to,leach the airstrip wherever accessible. situations by the paramedical staff and d) a longer Almost 80% of the cases were due to injuries. time than would otherwise be necessary.wastaken This is in contrastto the casesseen in disasterdue since triage had to be thorough to assist referral to a flood whereinjuries constituted only l3.l07o of hospitalsthat could not be overloaded. the total numberof cases[4]. This is an indicatorof Patientswith apparently minor trauma to the ab- the force with which the Tsunamihad hit. Casesof domen and chest had to be thoroughly examined to febrile illnesses(7 .6Vo) and gastro-enteritis(4.8%) rule out intemal injury. Similarly, patientswith minor only increasedafter 72 hours but were not as many headtrauma had to be examinedin detail sincethey as expected.This could be due to the fact that cases did not needhospitalisation, yet neededto be ob- such as gastroenteritis were not being evacuated, served.Also, a numberof patientswho had beenin priority being given to more serious cases.This saline water for prolonged periods had to be thor- could be also be attributable to the efforts of the oughly examinedfor signsof dehydrationand ARDS. local population in maintaining adequatelyhygienic All the casualtieswith the exception of the tribal conditions and to the use of bottled water which population,showed anxiety, apprehension and ex- was suppliedin adequatequantities. haustion.Anxiety was most marked in pregnant Most injuries seenwere to the limbs, more to the womenand civilian populationnot belongingto the upper than lorver limbs followed by injuries to the islands.Most casualtiesand attendants.exhibited torso. Injuries were mostly due to the force of the "DisasterSyndrome" comprising of disorientation wavesalong with the impact of the debrisfloating in and apparentloss of purposeor direction.Pregnant the water. Spinal fractures were mostly due to fall women were mainly concernedabout foetal well- from heightsand trees.Minor injuries were also secn being.A properpsychiatric evaluation including an mostly to the torso and limbs when people tried to assessmentof post-traumaticstress disorder (PTSD) cling onto trees and various floating objects to stay could not be performed.Apart from reassuranceand afloat. Wounds in the first 24 hours did not show confidence building, no form of psychotherapy signsof grossinfection. Thereafter,all woundswith- could be administered. out exceptionwere infected. Some woundseven had maggots.One caseof tetanuswas also received. LESSONSLEARNT Minor injuries to the lower limbs such as abra- A few observationsare appended here which may sionsand lacerationswere mostly seenin the local/ help in planningfor future disasters. tribal population who had to trek through flooded a) There was an overwhelmingand disorganized ground and forests to reach the airfield. Most of convergenceof medical materialsand trained these wounds were severely infected. Without ex- medical manpower at the airfield in addition to ception,all casualties,of all age groups and both Non-GovernmentOrganisations and the Press. sexesshowed remarkable tolerance to paip and ex- These extraneous medlcal teams and material haustion.In the tsunamiof 26 Dec 2004, very few had many shortcomingslike : casesofARDS due to neardrowning(02) weretreated i. reachingPort Blair almost 72 hours after the as was also reportedfrom other medicalcamps [5]. ., incident, and another l2-24 hours to reach Also, astoundingly,in view of the fact that the Is- the affected areas,by which time, most of lands are infestedwith reptiles,there was just one the severelyinjured. and those requiring

Jour.Msrine Medical Saciety, 2005, Vol.7, No. i 5I urgent medical attention had already been Basedon the experienceofthis disasterit is sug- evacuatedto Port Blair gested that Regional Disaster Management ii. being transported to accessibleareas ofthe Committees with Medibal group should be consti- disaster,whereas the most of the casualties tuted region wise. Together, they should be requiring their assistancehad alreadybeen responsiblefor providing emergencyhealth care in evacuatedor were in areaswhich were not caseof natural/ man made disasters.They should easily accessible.What was required was work towards this end and should formulate a dis- ' the presence of an optimal number of aster managementplan basedon threat perception, surgicalteams in the right placesand public geographical location of the area, terrain and cli- health officials in. both accessibleand mate of the region and the health care delivery system inaccessible.affected areas. in place.Mathogratical models can be run with vary- ing inputsto simulatealternative disaster response iii. teams not self-sufficient and logistically strategies.One such approach has been presented dependenton the local reliefsuppliesmeant by FawcettW and Oliviera CS [ 10]. The plan should for the affected population, adding to the be rehearsedon a regular basis. burdenof the logistics teams. Eachregional committee should have a medical iv. public health officials did reach,but were ' command center to co-ordinate the activities of the working under severe constraints due to healthservices. The experienceof the medical teams insufficient manpower, equipment and during the Tsunamiin Thailand hasproved the value hygienechemicals. ofwritten and rehearseddisaster plans, capacity for v. inappropriate medical supplies sent by rapid mobilization,local coordinationof relief ac- various agencies; much needed dressing tivities, and activepublic healthsurveillance [8]. It materials,injectible antibioticsand hygiene is essentialthat the medical serviceswork asclosely- chemicalswere scarce[6]. knit and co-coordinatedmobile teams.Teams could (b) Most of the evacueesshowed extreme mental be formed for emergency and trauma care, public exhaustion and signs suggestive of the health, mental health support and technical support. "disaster syndrome". There was a complete In a pre-hospitalsetup, triage is the most impor- absenceoftrained psychiatric personnelto help tant tool in ensuringoptimal care to all categoriesof in performing psychiatric triage and providing patients.Triage rules should be well defined and psychotherapy.Psychiatric triage can identify basedon a combination of mechanismof injury, thosevictims most in needof early preventive anatomic,physiologic criteria and co-morbidity fac- therapeuticpsychiatric intervention In and [7]. tors I l]. In disasterssuch as the one described Thailand, following the Tsunami, six teams here,triage is different from conventionaltriage since providing mental health support were deployed the local healthsetup is disrupted,sources are lim- by the Ministry of Public Health, one each in ited. time to definitive careis uncertainand outside each of the affected provinces and community assistancecannot be expected for at least 48-72 mental health needswere rapidly assessedand hours.In suchscenarios, a dynamic triage method- addressed[8]. ology should be employed [12]. Since triage is 'experiencedependant training will go a long RECOMMENDATIONS [3], way in speedymanagement of casesand ensuring It would be optimistic to expectthat healthcare minimal morbidity and mortality due to enoneous would go plans in delivery accordingto a disaster. triaging. Psychiatrictriaging should also be done pairic There is bound to be some amount of [9]. alongside. However, to reduce the panic to a minimum, a plan should be in place where the role of each agency CONCLUSION should be specific and clearly laid down, thereby This study is a descriptivereport of the issues avoiding confusionand ambiguity. faced in settingup of the INS Utkrosh medical camp

52 Jour Marine Medicol Society,2405, VoL7, No. I for providing medicalrelief to the tsunamiaffected, 5. SapatnckarSM. .Tsunami- An Indian Perspective: during the relief operations.The report describes Tidal Wave Health Issuesfrom India [editorial]. JAPI 2005:53:91-92. practicalissues in disastermanagement such as set- 6. BremerR. Policy developmentin disasterpreparedness ting up medicalaid camps,triaging and analysis of and management:Lessons learned from the January morbidity patterns.The recenttsunami of De*2ffi4, 2001 earthquakein Gujarat,India. PrehospitalDisaster has focusedthe attention of many agenciesin af- Med. 2003 Oct-Dec; l8(4):372-84. fected countriesto "disastei medicine". This is 7. Rundell JR: Psychiatricissues in medical-surgical indeed,the need ofthe hour,especially in a country disister casualties:A consultation-liaisonapproach. Psychiatr 2000;7l(3):245-58. like India, to train personnelat'all levelsin theeffec- Q. tive planningand successfulexecution of disaster 8. Ccntersfor DiscaseControl and Prevention(CDC). Rapid healthresponse, assessment, and surveillance managementplans. after a tsunami -Thailand. 2004-2005.Morb Mortal Wkly Rep. 2005 Jan 28; 54(3): 6l-4. REFERENCES 9. Klein JS, Weigelt JA. Disastermanagemcnt.'Lcssons |. Lillibridge RS, Sharp TW. Public Health issues learned.Surg Clin North Am. l99l;71(2): 257-66. associatedwith disasters,In.: John M Last, Robcrt B ' 10.Fawcett Oliveira CS. Casualty treatment after Wallace, editors. Maxcy-Rosenau-LastPublic Hcalth W earthquakedisasters: development of a regional and PreventiveMedicine. Appleton and Lange. 1998; simulation model. Disasters2000; 24(3\: 271-87. rt69-13. Il. Hawkins ML, Treat 2. World HealthOrganisation : WHO sites> Healthaction RC, MansbergerAR Jr. Trauma victims: field triage guidelines. in crisesAilHO Conferenceon the Health Aspcctsof South Med J 1987; the TsunamiDisaster in Asia. 80(5):562-5. t2. BensonM, Koenig KL, SchultzCH. Disastertriage: 3. Governmentof India Ministry of Home Affairs. START,then SAVE -a new methodof dynamic triage Tsunami Impact (26th December 2004) in A &N for victims of a catastrophicearthquake. Prehospital Islands, UT of Pondicherry and other coastal States DisasterMed 1996; ll(2'l ll7-24. of Tamil Nadu, Andhra Pradeshand Kerala - Relief, Rehabilitationand other folloW up measures.Situation r3.Burkle FM Jr, Newland C, OrebaughS, Blood CG. Report35 - 1200hrs 18.01.200. Emergencymedicine in the PersianGulf War - Part 2. 4. CarriapaMP, KhanduriP, HealthEmergencies in Large Triage methodologyand lessonslearned. Ann Emerg Med 1994; 23(4): 748-54. Populations:The Orissa Expericncc,MJAFI 2003; 59(4): 286-89.

Jour MarineMedical Society,2005,Vol.7, No. I 53 STUDY OF INDIAN NAVAL MEDICAL RELIEFOPERATIONS FOR TSUNAMI VICTIMS DEC 04 - JAN 05 BY EASTERNNAVAL COMMAND

Surg Cdr GD BHANOT*, SurgCdr ABHARI)WAJ**, Surg Lt Cdr J SRIDIIAR{'**, Surg Cdr P GOKULKRISHNAN+

ABSTRACT Consequentto the esrthquake on 26 Dec 04 and the tsunsmi that followed, orders were receivedfrom IHQ, MOD (Navy) to undertake mass scale medical relief operations. Various ships and establishmentswere alerted and directed towards their mlsslonsfrom 26 Dec 04 onwards. The medicsl events during the preparatory phase, In the initial week and the period thereafter were a coordinatedand inlensive team effort of all Naval commands. This article reviews the medical rellef operationsconducted at ENC and provides proposalsand recommendations for modification of the existlng medical preperednessplais.

KEY WORDS : Medical Relief ; Tsunami ; Dlsastermanagement

INTRODUCTION provision of replenishmentof medical and other to the earthquakeon 26 Dec 04 and suppliesdue to lack of information. Considering /-lonsequent \-,the tsunami that followed, orderswere received available resourcesthe teams were geared up for from IHQ, MOD (Navy) to undertake mass scale the managementof about 1000casualties each, com- medical relief operations. Various ships and estab- prising of 100 P I (Fig. 2) ,200 P II and 700 P III lishments were alerted and directed towards their casualties. missions from 26 Dec 04 onwards. These medical The teamswere to be preparedto operateby air/ missions were able to contribute significantly to- boat.INS Nirupak would probablyhave to function wards the relief of affected populations wherever fully as a hospitlrl ship, but from an anchorage.This delegated. Notwithstanding the enorrnous efforts 1r- and achievementsof the medical teams there were numerouslessons leamt from their experiences.This article reviews the medical relief operationsand pro- vides proposals and recommendations for modification of the existing medical preparedness plans.

PREPARATION The scaleof disasterwas known to be massive and deathswere placed at approximately 30,000ini- tially at most of the destinations(Fig. l). As no direct briefing/ assessmentcould be made about the numberornature of casualtiesin the area,the number to be cateredfor by the teamsor the mechanismsfor Fig I : Birdseyeview of the damageNagapatnam Coast

*Classified Specialist (Marine Medicine), Base Medical Officer, INS Virbahu, Visakhapatnam **Asst Command Medical Officcr, Eastern Naval Command, Visakhapatnam, ***Graded Specialist (Dermatology), Visakhapatnam, INHS Kalyani, +Graded Specialist (Marine Medicine), Squadron Medical Officer, INS Virbahu, Visakhapatnam

54 Iour Marine Medical Society,2005, Vol.7, No. I containingreplenishment medical supplieswere pre- pared from all available medical stores keeping in view the scaleof disaster.Emergent indents for medi- cal stores were raised for supply to the deployed teams in anticipation to their needs for further re- plenishments. These were transported to INHS Kalyani/ INS Adyar from AFMSD Kandivali, Mumbai, by airl road. Large demands of medical storesfrom ships and INHS Dhanvantari were ca- tered for through urgent local purchasefrorn Vizag, Hyderabadand Chennai.The local purchases,com- pletedin recordtime, were particularly important for the conversionof INS Nirupak to hospital role in the Fig 2 : Intravenousfluid beinggiven to a tsunamito dev- light of the scaleof disaster. astatedlady in shock Medical relief work on ground: Initial week would entail that the ship would probably have set- All medical teams were able to reach and com- up an ashore medical camp after unloading relief mencemedical services rapidly, within few daysof supplies entirely by boat/ helo effort. This would the earthquakeand the following tsunami (Fig. 3). A also entail that all casesrequiring in-patient care/ Diary of events,date-wise, is displayedin Table 2. surgery would have to be air-evacuated. All medical personnelatMsakhapatnam were re- Medical relief issuesduring initial days called. All available personnel were kept standby . The main issuesfacing the teams during the ini- for immediate deployment as and when called for. tial days were The first deployment,consisting of 5 ships (INS a) day-to-day planning of medical operationsand Rajput, INS Ranvijay, INS Ranjit, INS Khanjar and accounting of stores was constrained due to INS Kirch) with one MO each and additional MAs lack of information on estimatednumber of could be effected the same evening of the earth- casualtiesand the likely duration of their quake,i.e.26DecM. deployment The medical storeof INHS Kalyani was activated b) growing concerns about the possibility of immediately after the earthquakestruck in anticipa- communicablediseases, the local hygieneand tion of orders for deployment for medical relief [Table l]. To this end the categoriesof emergency medical stores as under were mustered and loaded onto all available vehicles ready to be transported to ships/ establishmentson receipt of orders. TABLE I Activation of the Medical Store at INHS Kalvanl. Visakhapatnam

S. No Storc (Box) Boxes Rcadied

I Cas Evac Medical Stores 8 2 Casualty Clearing Station Stores (CCS) 3 3 MTSP Stores 8 Outstation Medical Stores 6

In addition to the above, additional packages Fig 3 : Dispensing medicines to the tsunami devastated people

Jour MarineMedical Society,20O5, Vol.7, No. I TABLE 2 Diary of events : ENC role in Tsunami dlsaster relief

Dste Key events

26 Dec 04 Following the massive earthquake on 26th Dec 04, messagesreceived that darnage to life and property are expected and massive relief operations may required to be undertaken , Medical team from INHS Kalyani mobilized immediately All the Medical Officers and Medical Assts of the station mustcred and specific job assigned so as to be able to . respond to any requirement that surfaced. Casevac Medical Stores and Outstation Medical Stores, already packed at INHS Kalyani, checked and kept ready to embark. Orders received to embark Medical Stores and additional medical staff on board 5 ships (INS Rajput, INS Ranvijiy, INS Ranjit, INS Khanjar & INS Kirch). INS Satavahana & INS Virbahu asked to establish Casualty Clearing Station. One team of Mobile Technical Support Platoon geared up to embark and establish Surgical unit on board a ship at short notice. 27 Dec O4 INS Jyoti & INS Magar deployed for relief operations. Medical Stores embarked for the same. . INS Ghorpad initiated for long duration deployment at Trincomalle. 03 Medical Officers and 07 Medical Assts along with l0 boxes of Casevac Medical Stores embarked on board. In addition a large amount of hygiene chgTicals (approximate weight of 3800 Kgs) embarked. . Medical team embarks INS Khukri, to sail from Chennai Signal received to procure and dispatch listed Medical Stores to INHS Dhanvantari by FAM. After HQENC approval l5 boxes of Medical Stores procured immediately through Local sources. packed by INHS Kalyani and sent to INS Dega for airlift to Chennai for onward despatch. Medical Officer of INS Sandhayak at Sri Lanka, deputed to Civil Hospital with Srilankan Medical Staff to render assistancein relief camps. Requirement to form medical relief teams considered essential. Medical Assts from Fleet and shore establishments asked to report INHS Kalyani and be stand by for deployment at short notice. 28 Dec 04 To meet the requirement of INHS Dhanvantari, One Dornier and One Islander leaves Chennai loaded with Medical Stores for onward dispatch. r One Hygiene qualified Medical Asst sent to Port Blair as per NHQ directives. 29 Dec 04 Medical Officers and Medical Assts of shore establishment of ENC deputed to INHS Kalyani for the composition of medical teams. INS Nirupak converted as hospital ship by EDC PM 30 Dec. Embarkation of Mobile Technical $upport Platoon medical stores commenced. Demand for Medical Stores received for units at Chennai despatched to NAS Ramnad by Air. 30 Dec 04 Mobile Technical Support Platoon (MTSP) consisting of 0l Surgeon, 0l Anaesthetist, 0l Medical Officer and 16 Medical Sailors along with MTSP stores embark INS Nirupak. The ship sails off in record time at 2355 hrs on 30 Dec after being converted into a 50 bedded hospital with facilities for major surgeries, X-Ray, Laboratory and blood bank. This entails embarkation of Naval and medical stores including OT,X-Ray, Oxygen cylinders, refrigerators erc A team of 04 Medical Officers, 0l SDM Officer, l8 Medical Assts and 03 Logistics/Domestic sailors sent to Chennai for setting up of Relief Camp under Administrative control of NOIC (TN). 3l Dec 04 Medical Stores air lifted by Dornier from AFMSD Mumbai to INS Rajali and sent to Chennai to be utilised by Medical teams. More medical stores including TAB vaccine air lifted from AFMSD Mumbai to Chennai. Balance of Medical Stores being dcspatched by Road. 24 Boxes of Medical Stores from Kalvani air lifted to Chennai to embark on board INS Khukhri for Oos Gambhir. o Medical Officers from all units recalled from leave. l-3 Jan 05 INS Kattabomman requested assistance to set up relief camp. One additional Medical Officer and three Medical Assistants from INS Rajali deputed. Apart from 198 packagesof relief material 48 packagesof medicine and

56 Jour Marine Medical Society,2N5, Vol.7, No. l Hygiene chemicals despatchedto INS Kattabomman. AFMSD stores received directly at Chennai by AN-32 utilised for INS Khukri and for use by medical teams sent from INHS Kalyani. INHS Kalyani medical team establish its camps under direct administrative control of NOIC.(TN). INS Jyoti with paramilitary personnel deployed from Port Blair to Campbell bay to assist in Mass burial at Trinket, Kamorta, Katchall and Nancowrie. 4-5 Jan 05 INHS Kalyani medical team apart from establishing medical camps also traveled from place to place in the ambulance provided to provide medical care. 75 Boxes of Medical stores received at INS Adyar from AFMSD despatched to INHS Dhanvantari by INS Sharabh. 6-7 Jan 05 Request received to provide maximum relief medical stores and hygiene chemicals for INS Nirdeshak at Chennai. 297 packages of medical stores despatched to Chennai on board INS Khanjar for the same. Hygiene chemicals locally procured and embarked onboard INS Nirdeshak by LPO(CH) 8-ll Jan05 Received list of medical stores for INS Jamuna. Stores procured by Kalyani and sent to Dega on l0 Jan for airlift. 40 packages of medical stores despatched to Chennai. Stores handed over by IR 140 to Reps of Jamuna at Trincomalee. 15 Jan05 INHS Kalyani Medical team returned back on deinduction of Medical camps at Tamil Nadu. 19 Jan05 CINCAN directs INS Nirupak to deinduct Medical team of Hospital ship and return Medical Officers and Sailors.

sanitationconditions, and the methodsof waste a) the post quake/ tsunami phase requiring disposal[1] emergencymedical aid was essentiallyover; c) apprehensionsabout safety and security of there was a significant decline in trauma and medical personnel deployed abroad emergencycare workload (to about l07o of the initial figures at the casualty),the presentfigures d) apprehensionsabout depletion/ shortage/lack being comparable with those prior to the of medicinesespecially for pediatric,skin and disaster in most places. psychiatric use b) the needsof the hour were for provision of e) attention on procurement and distribution of shelters,rehabilitation, sanitation, safe drinkin g about food and shelterof personnel water, public health servicesincluding 0 communicationwith affected patientsdue to vaccinations (especially for Tetanus), non-availabil ity of interpreters containment/isolation facilities for patientswith g) guidelinesfor chain ofpatient evacuation communicablediseases (especially in case The teams were able to contribute emergency diseaseslike measles,cholera, typhoid, dengue, medical services,especially trauma care,in the first meningitis and tuberculosisare encountered) few days ofdeployment. They were adequatelypre- l2l andtimely replenishmentof medicalstores pared for this role and faced no difficulties during (under the systematic supervision/ this period. coordination). c) therewas adequatemedical aid at hand and no Medical relief work on ground: Subsequentweeks scopefor additional trauma related services, All the teams could establish, quickly, effective especiallyfor surgicalteams in the area(perhaps liaison with the local health and administrative au- this was the time to start scaling down the thorities. By the second week of operation the surgical facilities in the area to make way for situation was vastly improved. Numerous NGOs other agenciesto begin operations). had anived with men and material creating at times d) the roles of NGOs towards return of normal surplusesof relief. A strong need was felt for coor- livelihood of the affectedpopulation in the region dination of the relief processes. was paramount, requiring long term By the third week,based on the consensusopin- commitmentsof service,perhaps for the next 6 ions ofall representativesofvarious areaspresent, months, from the various organizationswho the following generalconclusions were derived: would eventually have to take over from the

Jour Maine MedicalSociety, 2a05, Vol.7, No. I 57 medicalaid agencies. information. e) the issueof cost of servicesprovided would The contingencyplans of the commandwere have to be considered,at some stagein the availableand well rehearsedwhich lead to fastrno- progressof rehabilitationand control of health bilizationof the teamsand the medicalstores. The ' relatedmatters, perhaps with concessions/ exhaustiveSOPs of INHSKalyani forhandling mass subsidiesinitially followed by appropriate casualtieswere available as a guidefor readyrefer- chargesfor specificservices till the complete ence.Though the casualtiesdid not come to returnto self sufficiencyof the staterun health Kalyani,the samecould be usedas a guideline. services. Themotivation of thepersonnel was high. Thus D the main aim of the relief organizationsat this recallwas effected and no problemswere encoun- point of time would haveto be changedfrom teredin deploymentof the teams.The personnel emergency health care provision to couldwork tirelessly,often going without rest and establishmentof safeand habitable conditions food,facing hardships like sweepingon theground/ that would encouragethe earliestpossible return on spreadnewspapers and without shelter. of displacedpeople to their homesand work. Achlevementsand shortcomingsin MedicalRelief In view of the aforementionedand the rapidre- turnto normalcyof medicalfacilities in theaffected The specificpositives/ achievements that sur- areasa decisionwas made to scaledown the Indian facedfrom the operationwere Navalmissions at the deployedlocations by thethird a) the largely successfulvalidation of existing weekpost tsunami. SOPson disastermanagement Finalorders forde-induction all themedical relief b) thetimely largescale mobilization of menand operationswere issued between l0 to 20 Jan05. A materialto the affectedareas in the available totalof approximatelyL4,27?patients were seen by timeunder overwhelming circumstances the variousmedical teams from the EasternNaval c) effective provision of appropriate and Commandduring the tsunami relief operations. comprehensivemedical services to the affected populations(Fig. 4), includingemergency/ DetailedAnalysis traumarelated services, containment of public The entirerelief operationfollowing the earth- health,immunizations, limited psychiatric care, quakeon 26Dec 04 andtsunami disasters thereafter schoolhealth etc. wasconducted with exceptionalalabrity and preci- sion. The disasterwas the largestever known in living memoryin termsof devastationto manand property.The enormousscale of the disasterwas matchedby the extraordinaryinitiatives and hard work put in by thoseinvolved with the taskof pro- viding timely medicalrelief. The effortswere often at the costofpersonal needs and rest, and at times beyondtheir trainingor call ofduty. Following the massiveearthquake and the tsu- nami,despite a knowledgeof extensivedamage, the actualextent of the devastationwas not known. The teamswere mobilizedin anticipationof expected damage.Even in thefuture, in suddenimpact disas- ters.the detailsof the scaleof devastationwill not be availablewith the relief providersat tle onsetof Fig 4 : A queueof localpopulation seeking medical re- relief efforts.Inescapably, the teams in futuredisas- lief and medical care in the aftermathof the terstoo, will probablybe dispatchedwith minimal tsunami

58 JounMarinc Medical Society,2005, Vol. 7, No.I d) successful conversion of INS Nirupak to availabilityofsupplies in the scaleneeded from hospital ship in record time and thereafter,for AFMSDs, necessitatingurgent local purchases, the first time in Indian naval history, successful a process fraught with protracted procedural deployment in a hospital role for a prestigious requirements and uncertainty overseasmission k) lack of coordination between various e) the promptness, devotion to duty, team-work Government and Non Governmental and motivational aspectof all involved with the organisationsfor relief operations, perhaps medicalrelief missions symbolizing the scale and magnitude of the D The conductof the camps,in general,saw no disaster. untoward incident, security threat or Recommendations misunderstanding.The affected populations appeared genial, cordial and hospitable. The The largest known tsunami disaster in recent patientsas well as authoritiesexpressed their times,has left in its trail, a variety of expEriences, sincere gratitude to the medical teams for all and importantlessons in disastermanagement that their efforts at the time of their de-induction. needto be placedon record,In considerationof the valuable inputs from the various medical teamsde- The specific negatives/ shortcomings that were ployed, the following recommendationsare exposedduring the operationare listed herein:- suggestedfor implementationin future SOPsof dis- a) shortagesof pediatric, skin and psychiatric astermanagement. medicinesin the casevac/ out stationmedical a) The presentscales of casevacmedical stores stores cater only for war casualties.These scalesdo b) shortagesof hygienechemicals, anti malarials, not cater for family and child health. As mosquito nets/ repellants observedduring thesereliefoperations, a good c) much neededservices of a stressmanagement percentageof the people affected belonged to team./counsellors in the devastatedareas was thesegroups. Keeping in view the demandsfor absent medical stores received from operating teams d) all teams worked in an information void that in relief camps,a revisedscale of medical stores constrainedtheir planning of strategy and for disaster relief has been prepared. These resources storeswill be required to be packed and kept readyat all timesat INHS Kalyani.The sameis e) inadequateknowledge oflocal languageswas to be changedand repackedevery threemonths. an impediment towards patient communication b) In a natural calamity, it is not feasible for the in-patient care of female patients on board D medical campsto carry all hygiene chemicals hospital ships was not catered for during and instruments required for their application planning in such vast areasas were recently affected by g) acute shortage of professionalnurses in the the Tsunami.However. it is recommendedthat devastatedareas was projected by most local preparedpackets of the following should be authorities,no relief was planned readilyavailable with MO(V) for supplyto the h) public health issues of hygiene, sanitation, relief teamsat shortnotice. waste disposal, vaccinations etc were i. Baytex granulesfor antilarval measures.It inadequatelycatered for does not require spraying machines or i) provision of self contained facility for running diluents.The granulesare to be sprinkled medical camp in field areas was needed, over non-potablewater collections. including accommodation and ration for staff, ii. Bleaching powder usedas a disinfectant and to enableround the clock services for purifying potable water (4gms of ) immense difficulties were faced in acquisition bleachingpowder in 500liters of water will of medicalstores in the given time due to non- give lppm offree chlorine)

Jour.Marine Medical Society, 2N5, Vol.7,No. I 59 iii. Mosquito repellant like DMP oil/ Odomos/ authorities leading the relief operations are Autin liquid for personalprotection against required to preparethemselves for the same. mosqitoes/bed bugs. The problem of languagebarrier will persist, c) Mental health assistanceto the populations especially when teamsare deployed abroad. In affected by the Tsunami: Basic social and mental most places, volunteer interpreters will be health interventions - on which there is broad available. However,the glossaryof somewords consensus- shouldbe implementedbefore more translating into local language will be made specializedinterventions are considered.In the availableto the team whenever.possible. acute relief phase,it is advisableto conduct c) Nurseswill haveto form an importantpart of a few actions that therewill social/medical so be medical relief operation [4] . It was observedin little interferencewith responsesto vital needs the recent relief operations that the Armed such as food, shelter and control of Forces of some developed countries had communicable diseases[3] . The following included voluntary NGOs as pa4 of the team guidelines are to be followed for determining for nursing. Thus they could cater for an appropriateresponses: adequatenursing staff. Similarly, the possibility i. to provide uncomplicated and accessible of including MNS officers/ NGOs to work with information on location of corpses; our medical teamsshould be explored. ii. to discourage unceremoniousdisposal of h) As per WHO guidelines on environmental corpses; health, following natural disasters,particular iii. to provide family tracing for unaccompanied attention should be paid to : minors, the elderly and other vulnerable i. Structural or functional damage to water people; to encouragemembers of held teams supplies. to actively participatein grieving; ii. Size and location of populations with an iv. to encouragerecreational activities for adequatewater supply to identify groups at children; ' increasedrisk of communicabledisease; and v. to widely disseminateuncomplicated, iii. Actual or potentially contaminated water reassuring,empathic information on normal sources,and populations exposedto such stress/traumareaction to the community at sources. large (religious leaders, teachersand other In determining the state of sanitation the social leadersshould be involved actively); following should be examined: vi. during any medical assessmentto enquire i. Structural integrity of sewage treatment about n'eed for maintenance of . systems; anticonvulsant treatment for people with u. Signs of functional damage (such as epi'lepsyor antipsychotic medication for overflowing of septic pits); and those who were previously receiving such medication. iii. Presenceof vectors. 'hand-book d) In sudden impact disasters,it is proposedto A on prevention of an outbreak of sendadvance teams, with I MO + 2 MAs and I diseases'is being prepared. Copies of this Cas Evac store each, to gather information booklet, will be given to each team proceeding about the extent of devastationand provide for disasterrelief operations. 'disaster initial medicalrelief. Revisedscales of relief medical stores', e) If and when the teams are to be deployed for has been prepared based on the recent inpatient care (eg. Hospital Ship) unlike war experience,and should cater for medical relief situations where there are only male patients,a operationswhenever required in the future. good percentageoffemale patientsand children Thus local purchaserequiring urgent approvals will have to be cateredfor. The administrative and sanctionswill have to be resorted to onlv

60 Jour MarineMedical Society, 2a05, Vol.7, No. I in exceptionalcircumstances. From the lessonslearnt in the conduct of the recent k) The state and regional level disaster tsunami operations, few changeshave been incor- . managementbodies are required to meetevery porated into the existing SOPs for disaster relief, altemateyear to discussthe rggionaldisaster particularly towardsrevision of medical store scales managementpolicy and redefinethe roles of and sequencesof mobilization of men and material defensevis-a-vis other bodies. Each body can as part of relief camps. It is undoubtedly clear, that presenftheir capabilities and role. The NOi/Cs with induction of these valuable inputs, the Indian of the respectiveregions may constitutea Naval disasterrelief teams will be able to perform 'disastermanagement cell'which may work in their roles better in any future disaster. unisonwith the regionaldisaster management REFERENCES policy. |. WaringSC, Brown BJ. The thrert of communicable diseasesfollowing naturaldisasters: a public health STJMMARY& CONCLUSION response.D isaster Manag Response 2005;3(2):41-7 . Reactingto the tsunamidisaster, the IndianNa- 2, BalaramanK, SabesanS, JambulingamB Gunasekaran val missionswere able to successfullycontribute K, Boopathi Doss PS. Risk of outbreakof vector- men,material, expertise and energy towards provid- borne diseasesin the tsunamihit areasof southern ing relief and succourto the affectedpeople, lndia. LancetInfect Dis 2005 ;5(3):134 simultaneouslvalone coastalIndia and southeast 3. Silove D, Zwi AB. Translatingcompassion into psychosocial aid after the tsunami. Lancet Asiancountries. The provisionof medicaland lo- 2005;365(9456\:269 -7 r. gistic relief was basedon the existinghealth care 4. Nursesneed advanced skills in disasterhealth care.Br andlogistics organization at the affectedlocations. J Nurs2005 Feb 24-Mar 9;14(4):190.

Jour MarineMedical Society, 2005, Vol.7, No. I 61 TSUNAMT}OO4:ROLE OF SOUTHERNNAVAL COMMAND IN NAVAL MEDICAL RELIEFMEASURES

SurgCmde VK SAXENAvsu*, SurgCapt A BANERJEEsc**

INTRODUCTION Day I (26 Dec 20M) -l-h" Indian coastline experienced the most The eventsthat were immediatelyinitiated after I devastatingtsunami in recordedhistory on 26th the tsunamistruck included the following : - December 2004. Triggered by an earthquake of , a) dispatchofonemedicalteamcomprising0lMO magnitude 9.0 on the Richter scale,off the coast of and 02 MA with a brick of Medical Stores Sumatrain the IndonesianArchepelago at 06:29 hrs (600kgs) by Dornier to Sri Lanka IST (00:59hrs GMT), thetsunamistruckmany coastal b) embarking of two medical teams of similar countries of south east Asia, characterizedby a composition in INS Shardafor Sri Lanka sequenceof "timed" destructivewaves. c) embarkingof three medical teamsin INS Sutlej Overview d) deploymentofone medicalteam ofOl MO and The Dec 2004 Tsunami was a disasterof unprec- 04 MA at Kayamkulam / Chertalaat the request edentedproportions. The tsunamiwaves, originating of Kerala StateGovernment, to supportrescued at a singlepoint in the Indian Oceanbed, sequentially marooned people and ongoing diving struck coastalregions of many countries,causing operationsand underwater search in the destructionand devastation along its wake.Playing channel. a responsibleand regional role, the Indian Navy e) Musteringand dispatch of sevenmedical teams launched multiple simultaneousrelief operations and sevenbricks of meCicalstores locally as well as in the neighboringcountries, in the vicinity of the littoral waters. Day 3 (28 Dec2004) The Indian Nayy put all its resourcesin its three With the launchof the initial seriesof relief meas- Naval Commandsfor undertakingextensive disas- ures,the next setof medicalpreparations comprised ter relief operations,deploying ships,aircrafts and of thefollowing :- personnel.The relief missionswere deployed under a) Two medical teams with necessarymedical OperationMadad (along east coast of India), Op- storeskept standbyat INHS Sanjivani. erationSeawave (Andamans), Operation Rainbow b) Medical supplies to deal with infectious (Sri Lanka), OperationCastor (Maldives) and Op- diseaseskept ready, in view of growing erationGambhir (Indonesia). concernsof spread of infectious diseasesin Medical Relief from Southern Naval Command the affected areas. As a part of this mammoth peacetime disaster c) Medical suppliesto deal with pediatricspatients reliefefforts, the reliefand rescueoperations were kept ready. launchedby the SouthernNaval Command,to the d) Watersterilization tablets procurement initiated. tsunami-hitregions. The following "diary of events" e) Each medical teamsissued with four kilograms recountsthe extensive disaster medical reliefopera- of bleachingpowder for water sterilizationas tionscarried out from SouthernNaval Command.

*Executive Officerl Senior Advisor (Medicine and Neurology), INHS Asvini, Colaba, Mumbai 400 005.

62 Joun Marine Medical Scciem. 2N5. Vol.7. No. l an interim measure Day l0 (04 Jan 2004) At this period in time, the focus of relief was Day 4 (29 Dec 2004) shifting gradually from local shores to the Children By the fourth day,the relief measures,were well neighboringcountries. under way, on ground, at Indian coastal areasas a) Two medicalteams returned with INS Sharda 02 well as in neighboringcountries. A seriesoffurther 03 measureswas inductedswiftly, to consolidateand b) One medical teamreturned from Chertala further augmentthe effective delivery of the relief Day 13 (07 Jan 2005) measures.These comprised the undermentioned:- 0l A steady"supply" chainofessential medical and a) Deputationof Oi/c StationHealth Organization, logisticsitems was created to sustainthe relief meas- 07 to Port Blair for SHO cover at A &N Islands 06 uresactively by thefollowing :- b) Embarkementof two medical teamson board IO a) Medical Storesrequirement for threeweeks kept INS Sarveshak. 03, ready at INHS Sanjivani for embarking INS 03 c) Conversionof INS Jamunato HospitalShip with Sutlej,Sarveshak, Sharda and Jamuna l0 an EDC of two days b) Two Bricks were airlifted to Sri Lanka for Sutlej 45 d) Large requirementfor bleachingpowder and and Sarveshak watersterilization tablets for personnelon relief ops and local population. Day 19 (13Jan 2005) rd at the e) Augmentationof manpoweratINHSSanjivani, Relief measureswere now focusedtowards the with supportfrom NHQ andCABS aftermathof the destructivetsunami at Sri Lanka. rtegoryI, Embarkmentof Mobile Surgical Unit with a) Medical Storesfor Baticaloa,Sri Lanka as per D ' egoryIII personnelequipment and stores aboard INS indentwere dispatched by Dornier aircraft 0 service Jamuna(Hospital Ship) by 30 Dec 2004 b) Medicalrelief wasprogressing on groundat Sri ntari and g) Demandingand getting emergentmaterial form Lanka(Fig.I and2) :ludedall AFMSD Mumbai forINHS Sanjivani c) Medical Stores requested through High Commissionwas embarked aboard CGS Samar Day 6 (31 Dec 2004) for Sri Lanka Well into the sixth day,there was a growingreali- n beclas- zationofthe unprecedentedscale and magnitudeof Day 23 (17Jan 2005) disasters. the disaster,across the globe. This promptedfur- a) O i/C SHO (K) returnedEx-SHO (PB), away for ne earth- ther actions to consolidateand sustainthe initial aboutthree weeks. re Indian relief measuresthat were launchedearlier. The setof olelydue b) Medical stores for Tarangini (two bricks) fresh measuresincluded :- The high embarked. s disaster a) Medical teamswith storesaboard INS Jamuna Day 29 (23 Jan 2005) aredness, and Sharveshaksailed for Sri Lanka. INS )nt of the Jamunawas capableof admitting 45 patients, Nearly a month later,the measureslaunched by :ationand with an exclusiveICU facility of 4 beds IndianNavy, in providingmedical and logistic relief :ctualan- b) Two Medical teams(Ex-Army), eachcomprising were completedsuccessfully. :nce.The one MO and six NA embarkedeach of the two a) All medical teamsand personnelreturned by tly dueto ships. dav 29 with dis- c) TAB andTT vaccinerequirements procured and c) A total of one surgical team for the hospital io better dispatched ship and anotherten medical teams were d) Cholera vaccinecould not send due to non deployedEx- Sanjivani ualtywas availability, in view of their not being d) Approximately 18350 Kg of Medical stores rlyArmed manufacturedin India suppliedEx- Sanjivanifor the disasterrelief ling most

/ol.7,No. l Jour.Maine MedicalSociety,2005, Vol.7, No. I 63 a) Medical Appreciation: The Ops order/ appreciation needs to be communicated to enable a medical appreciation and tasking of medical units and assets/ resources. The logistics of medical manpowerand materialcan be plannedmore effectively. b) Coordination: A Medical person should constitute a part ofthe coordinating team at the apex,middle and field/ ground level. c) Communication : Communication must be made availableas: - i Administrative : For administrativepurposes through local command and control ii. Technical: For guidance of field medical personnel, specialist consultation, telemedicine and such like uses. d) Logistics for medical teams i Accommodation, food, transport, water and other administrative support was adequate as the teams were operating as extension of the base support unit. However, where the teams are to operate independently,they need to be instructed /prepared suitably to face any eventuality.They needto be briefed on the resourcesavailable to them for the task. They also need to have ration for survival, tinned food, water sterilizing chemicals,filters, booklet of instructions to enable resources,protective clothing / equipment and immunization, and insect repellant and such like items. ii. The medical team should not be left independently with out support. The non - Figs. I and2 : Medicalrelief at Sri Lanka. medical component should cater for items like torches, stationary, generators,pumps, operations (Operation Rainbow West) pick axe,drums, communication,earth work e) A seminar was held on 16 Jan 05 to discuss equipment / material, bicycle /mechanical preparednessfor Medical Ops in Peaceand War. transport,stores, tentage and such like items LessonsLearnt dependingon the role for which deployed. The Indian Navy undertook its biggest peace- iii. Somepermanent items to enableexamination time military operation to take relief to the / care of patient should constitute a separate tsunami-affectedin the coastal areaslocally as well pack for individual teamswhen deployed. as at neighboring countries. During the preparation iv. Water sterilizing tablets / chemicals / and induction of relief measuresfrom the Southern bleaching powder should constitute a part Naval Command, the following significant issues of the brick of consumables. emergedimportant.

64 Jour MarineMedical Society, 2005, Vol.7, No. I order/ rtedto v. Vaccines-TT, TAB, ARV etc should form part III. Advising on disposal of dead, and ing of of the brick. prevention of diseaseg. s. The vi. Add on bricks need to be created for drugs IV. Nutrition ial can and water requirements. keepingin mind peculiaritiesthat may obtain, V. Medical intelligenceif available e.g. chronic diseases like diabetes. should be communicatedto the relief teams. ihould psychiatric drugs, tranquilisors,sedatives, n at the pediatrics,and obstetricdrugs. CONCLUSION e) PreventiveMedicines The Indian coastline experiencedthe most dev_ e made i. Groups of medical teamsshould have at least astating tsunami in recorded history, on 26th one person with a preventive medicine December2004. The Indian Navy undertookits big_ lrposes background for: - gest peacetime military operation to take relief to the tsunami-affected I. Advising on hygiene and sanitation in the coastal areas locallv as redical requirements. well as at neighboring countries. This article ad_ ;ation,. dressedthe key issues during the preparation and II. Construction of DTL/STL/water and induction of relief measuresfrom the SouthernNa_ sewagedisposal. .diary val Command,recounted from the of events". iterand lequate sionof ere the y, they ably to briefed for the ion for ilizing tionsto thing / . insect be left 3non- ,r items pumps, th work hanical :eitems rloyed. rination eparate toyed. ricals/ l a part

.7,No.I Jour Marine Medical Society,2a05, Vot.7, No.I 65 MEDICAL RELIEFOPERATIONS OF RAINBOWWEST - (Southern NavalCommand)

SurgLt Cdr G PARTHASARATHY.,Surg Cdr N CHAWLA", SurgCdr R RAY.'., SurgCdr R KOSHI., SurgCdr KK MISHRA*, SurgLt Cdr R SMSANKAR'**, SurgCdr R PANICKER', SurgLt CdrS CHATTERII#, SurgLt STAI\EIA##$

ABSTRACT

INHS Sanjivani, the nodal hospital at Kochi, was an integr:tl part of the Medical Relief conducted by Southern Naval Command, in the aftermath of tsunami of 26 Dec 2004, As a part of the disaster relief team of the command, this article describes the medical events and issues that dominated the disaster relief, on ground at Sri Lanka. Thc role of relief teams at three district areas within Sri Lanka, namely Hambanthota, Galle and Trincomallee is highlighted, In all, nearly 20 Medical Officers and 25 MAs were directly involved in the rclief operations as a part of Operation Rainbow (West) from SNC.

KEY WORDS : Tsunami. Disaster.Relief

INTRODUCTION On 28 Dec 2004,a teamcomprised of one MO 26 Dec 2004, the earth shook and changed and02 MAs embarkedINS Sarvekshakwith 600 kg /ln lr.-,/foreverthe lives of many millions on the south of medicinesand set sail to Colombo.INS Jamuna east Asia. It was a day, when coastlinesof south was designatedas a hospitalship on 29 Dec 04 and eastAsia was hit severelyby nature,making it go taskedto sail for Srilankaon 30 Dec 04 to provide down in history as the single largestnatural catas- immediateSurgical/ Medical relief to the tsunami trophe sincethe eruption of Krakatoa.By noon on affectedareas. 26Dec 2004, lndia steppedin to provide relief and A MobileTechnical Support Platoon (MTSP) pre- succourto the coastalareas within local shores.as viouslycalled the MSU (MobileSurgical Unit) from well as neighbouringcountries. INHS Sanjivaniwas embarked on 29 Dec 2004.In additiona psychiatrist,with two MAs had already PREPARATIONS embarkedon theprevious day. This wasin addition At about1230 hours, INHS Sanjivani,as the clos- to theShips MO andMA. The MTSP comprisedof estand the largestService hospital, was taskedwith one surgeonand anesthetist,three ORTs, one radi- the formation and dispatchof Medical relief teams ographer,laboratory technician,BTA each. They at the earliest.At 1430hours, the first of many such carriedwith them6000 kg of medicinesand equip- teams,comprised of oneMO and02 MAs proceeded ment. to Colomboby IN Dornier carrying600 kg of medi- The districtwise details of the operationsare as cines.Shortly after,at 1530hours. two moreteams, below.Table I providesan overview of thedisaster with two MOs and 04 MAs embarkedINS Sharda reliefcarriedout. with 1200kg of medicinesfor the first ship borne missionto Colombo.At 1630hours, a MobileSurgi- HambanthotaDistrict caiTeam,along with 06 MAs embarkedINS Sutlej At 1730hrs on 26 Dec 2004.the first IN Dornier with 1800kg of medicinesto proceedto Colombo. arrivedat Ratmalanaairbase (SLAD at 1940hrs. On

-Graded Specialist(Pathology); "Classified Specialist(Pathology): "'Graded Specialist(Dermatology); -Classified Specralist (Surgery)t ClassifiedSpecialist (Psychiatry): '*'Graded Specialist(Radiology); rClassified Specialist (Obs & Gyn)l *'Gradcd Specialist (Surgery); "'Medical Officer: INHS Sanjivani, Kochi 682 004

66 Jour Marine Medical Societv.2005, Vol.7. No.I TABLE I Distribution of relief teams

District Tearn Date from Date to Approx no. of patients

Hambanthota IMO+03MAs 27 Dec 2005 04 Jan 2005 500 lI*, Galle I MO+ 04 MOs + l0 MAs 28 Dec 2004 04 Jan 2005 I 100 Galle IMO+02MOs+15MAs 04 Jan 2005 12 Jan 2005 r 800 Ampara / Batticaloa I MO + 02 MOs andl0 MAs 07 Jan2005 16 Jan2005 3750 Trincomalle I Surgeon+ MTSP 08 Jan 2005 25 Jan2005 4500

27 Dec 2004, the team received ordersto proceedto the army personneland volunteer workers at the ihern f the Hambanthotadistrict to provide medical aid. The Hambanthotaarmy campsite.Provision of safedrink- nd at. team was airlifted by a SLAF Y-12 aircraft to ing water was ensured. ) and Weerawilaairbase in thedistrict along with themedi- relief The type of of casesencountered during the re- cal supplies.The teamarrived at HambanthotaBase lief effort at this district comprisedof : a) Effectsof Hospitaland liaisedwith the SrilankanSchool of blunt & penetratingtrauma like headinjuries. CLWs (SLSME), Military Engineering who requestedthe etc;b) Drowningand post-drowning pneumonitis : team to provide guidanceregarding the safe and c) Upper and Lower Respiratorytract infections. hygienic disposalof the dead bodiesbeing recov- Acute Gastritisand Gastroenteritis due to poorqual- rMO, eredin largenumbers. ity of the water available; d) Chronic Diseases )0 kg The SL Army extricatedand massburied more including Bronchial Asthma, Hypertension,IHD. TIUNA than2500 bodies over thenext 03 days.The medical These patientshad lost accessto their medicines 4 and teamthen startedvisiting variousdisplaced persons sinceall thepharmacies were closed and the district rvide camps(DP camps)for medicalaid activities.There hospital was quite distant from the camps and e) Lnami were 37 DP campsestablished in the district. The PostTraumatic Stress Disorder, manifesting as hys- Indian Naval Relief Team was the sole foreign aid teric spells,catatonia and extremedepression (Fig. ) pre- ,i, teamin the entiredistrict till 30 Dec 2004. s). from I The team visited Kandamaharaelementary 14.In Galle District schoolcamp, (nearTangalle), approx. 30 km from ready Hambanthota.The team liaised with the SL Red On arrivalof INS Shardaand INS Sutlej,an aerial Cition Crossand obtainedpediatric syiups and medicines sortie for videographyand damage assessment ;edof for disbursementto patients.The team also visited launchedat about 1630hrs from INS Sharda.Dam- radi- Tissemaharama,Beliath and Kirinde areas.All camps age was mainly limited to about 500 mts from the They had adequatemedical facilities. On return to coast.Liaison was establishedwith SL Naval au- quip- Hambanthota,the team was reinforced-with sup- thoritiesand key affectedareas were identified on plies including medicines,masks, rubber gloves, 27 Dec2004.Medical stores were disembarked in SL areas goggles, aprons, water purification tablets, Naval Camp,Boossa. saster chlorinometer, a portable fogging apparatusand Both medicalteams started visits to variousmedi- sprayingeqpt for hygienechemicals. The teampro- cal centersin areasof requirementof medicalrelief. ceededto the Sooriyawewa camp. Two casesof Medical campswere conductedin the Hikkaduwa chicken pox and one caseof mun"pswere detected and Balapetiya.A liaisonwas establishedwith the )rnler and isolated. Districthealth authorities at the Balapetiyadistrict 's.On The teamthen joined up with 4021 Fd Amb from hospitaland inputs received regarding requirements the IndianArmy on 3l Dec 2004,which hadby then and locationsof refugeecamps in various areasin orderto plan further movement. :cial i st arrivedat Hambanthota.It caried out mobile vacci- lraded nation campswhere more than 600 volunteersand Communicationswere severely hindered due to servicepersonnel were ino:ulated. The teamtreated breakdownof telephonelines. Hence most of the

Jour.Marine Medical Sociery, 2005, h|.7, No.I 67 locationshad to be visited in person,until personal then set sail for Trincomalle port and arrived there liaisonwith civil doctorswas obtained later for vari- on 05 Jan2005. The medicalteam was divided into ous inputs.The teamsvisited the BatapolaRural two groups.The surgeonand anesthetistvisited 2 Hospital and Batapolacollege relief camp, which TrincomalleGeneral Hospital and met the medical tl wasthe largestrelief camp in theregion with almost superintendentto assessthe situation and to offer S 3000refugees. About 400 patientswere treated here the servicesof the team.The Medical Superintend- sl Liaisonwas established with localpharmaceuticals ent requestedthe servicesof a psychiatrist. ('r andhospitals which werewilling to donatemedical The secondteam comprising of the psychiatrist L suppliesand addto IN medicalsupplies. and ship'sMO visited an inaccessiblearea at 2l On 30 Dec 04, a base camp was set up at Kuchchiveliby ship'shelicopter. They visitedthe GlosenbergHotel, Galle.About 100- I l0 patients affectedarea along with naval authoritiesof SLNS weretreated here daily. Help of an NGO (SewaLanka) Wellagambaand studiedthe suitabilityof estab- b wastaken to conducta campat theOld Dutchcolony, lishing a medical camp in an isolatedremote area (t Galle.Teams were sentout to Unuthwanaand Matara which hadbeen cut off from Trincomallefollowing where about 250 - 300 more patientswere treated. damageto the road and bridge. They located the On 3l Dec2004, a mobilemedical team comprised of Kuchchivellihospital which was located100 mts 2 Mos and04 MAs visiteda seriesof relief campsat from the seashore and had borne the burnt of the the Kogalla temple, Veeduwa monasteryand tsunami.The medical and para-medicalstaff had Bodregamatemple rendering treatment to about100 abandonedthe hospitalfollowing the tsunamiand patients. no medicalhelp had reachedthe areaeven 10 days On 0l Jan2005, I MO andanArmy teamconsist- after the calamity. Assessingthe situation,it was ing of 02 MOs and l5 MAs joined the remainderof decidedto setup an IndianNaval ReliefCamp in the theteam. From 0l Jan2005 to 05 Jan2005, the team hospitaland makeit functional. provided medical relief Lo the abovementioned The Kuchchivelihospital staff comprising of one camps as well as other nearby relief campsand medicalofficer, one RMO, onemidwife, dresser, am- treatedaround 1800 patientsin all, in addition to bulancedriver and watchmanhad abandonedit providinghygiene and sanitation related assistance followingthe tsunami. The hospitalwas without elec- to the camps. tricity, water supply,medicines or communication The team from INS Sutlej was then de-inducted links. from Galle district andrelocated toAmpara district, On 07 Jan the Indian Naval Relief Team of INS anotherhigh casualtyarea to the eastof Galle dis- Jamunacomprisingof medicaland para-medical staff, trict. The teamcarried out relief operationsatAmpara engineeringand electrical personnel with logistics district and Kalmunai sectorof Batticaloadistrict supportestablished a full fledgedrelief camp at the from 07 Janto l6 Jan2005 andtreated around 3800 rural hospital Kuchchiveli. OPD servicesre-com- patientsin this sector. mencedon 08 Jan05 afterhaving informed the local In all, around l6 different medical campswere Gramsevaksof the surroundingvillages. In addition mobile medicalteams were also despatched daily in organizedin this sector in various displacedper- t sonscamps and public institutionslike templesand rotationto theperipheral villages and refugee camp. The hospitalservices were provided around the ; schools.The team from INS Sarvekshakcontinued I at Galle till 12 Jan 2005. The profile of the cases clock and acute caseswere admitted/ detainedat treatedwas essentiallythe sameas in Hambanthota the hospital for expert management.The hospital and cther districts. functionedfor l8 daysfrom 08 Janto 25 Jan05 and finally officially handedover to the directorof pro- TrincomalleDistrict vincial healthTrincomalle district. The assistance The Mobile TechnicalSupport Platoon on board renderedto the distraughtcommunity was well ap- INS Jamunaaugmented the efforts of the teamson preciatedby thelocal public, the healthauthorities INS Shardaand INS Sutlejtill04 Jan2005. The ship and SrilarikanNaval authorities. F

68 Jour Marine Medical Socie\, 2005,Vol.7, No.I -17

Final Tally edthere TABLE 2 dedinto In the final tally, nearly20 Medical Officersand Distribution of medical relief supplies visited 25 MAs weredirectly involved in the reliefopera_ Date Quantity Conveyed by medical tions as a part of OperationRainbow (West) from to offer SNC. 18,350kg of medicalsupplies were carried by 26 Dec 20O4 600 kg Dornier rintend- ships or airlifted towards this massiverelief effort 26 Dec 2004 1200kg INS Sharda (Table2). 26 Dec 2004 1800kg INS Surlej 27 Dec 2004 600 kg Dornier ,t,iuoi., Lessonslearnt on Disaster relief : 26 Tsunami 21 Dec 2004 600 kg INS Krishna areaat 2004 28 Dec 2004 600 kg INS Jamuna iredrhe 28 Dec 2004 600 kg INS Sarvekshak A few salient points regardingdisaster relief f SLNS 29 Dec 2O04 6000 kg INS Jamuna(MTSP) emerged,as a result of this operation.These were, 30 Dec 2004 750 kg f estab- - Dornier briefly: 0l Jan2005 600 Otearea kg Dornier (a) The composition 02 Jan2005 600 kg Dornier llowing of relief medicalteams should take into 03 Jan2005 605 kg INS Sutlej rted account the nature of disasteras in the 03 Jan2005 600 kg INS Sarvekshak the presentcase. Most of the deathswere 100mts 06 Jan2005 650 kg 4027 Fd Amb immediateand very few casesrequiring surgical rt of the 07 Jan 2005 450 kg 4027 Fd Amb interventionwere encountered taff had afterthe first 4g l2 Jan2005 300 kg 4027 Fd Amb hours. Most lmi and of the patientswere wornenand 14Jan 2005 1200kg INS Taragiri childrenwith thecommon l0 days ailmentslisted earlicr. r,it was rp in the g ofone rser,am- lonedit rutelec- 'l' nication r of INS calstafl ogistics rpat the re-com- helocal rddition dailyin ecamp. ,rndthe rinedat rospital r05 and ' of pro-

;istance t vellap- horities Fig 1.2. -l and 4: Medical Relief in the afrermathof thc Tsunamiat distrids of Sri Lanka !

Jour Murine Medical Sociery, 2005, 7.No. I Vtt.7, No. I (0 Communicationsfailure, which is inevitable. during suchcatastrophes, should be taken into considerationand all medicalteams going into I a disasterarea should be adequatelyprovided for with mobilephones or otherequipment to l'' keepin touchwith higherauthorities. G) Generatorset should be provided,in eventof a needfor OperationTheater to be setup.in areas

y Tr*t withoutelectricity. i htcction3 (h) Provisionof digital cameras,portable notebook lSlin tla6asci or laptop computerswith even intermittent internetconnectivity could be includedfor ease llPosl Traumatic Str!t3 CI!ordet of datacompilation and transmission. Fig. aAcid.Pcptic Dricrsc 1a 0) Prefabricatedbody bags for disposalof large Fig. 5 : Casesencountered during relief work of numberof casualtiescould be considered HarnbantlrotaDist. towards a more aestheticdisposal of the deceased. (b) The needfor a surgicalteam is in the immediate (k) The 24 to 48 hours of the disaster and the team teamsmay be made more self reliant and selfcontained provision should be dispatchedat the earliestas after by of logisticsupport in the form of rations. this period most of the acutecases would have tentageand additional personnel, beenalready dealt with by theavailable medical support similarto themodel of Army Medical FieldAmbulances. resourcesor succumbeddue to lack of it. Corps 6. (c) The rnedicinescarried by theteams were mainly CONCLUSIONS for emergenciesand not for pediatric, INHS Sanjivani,the nodal hospital at Kochi,was gynecologicaland chronic disease requirements an integralpart of theMedical Relief conducted by which form the majorityof thepatients after the SouthernNaval Command,in the aftermathof tsu- first 48 - 72 hours. nami of 26 Dec 2004.As a part of the disasterrelief 1. (d) If possiblethe apex medical authority of the teamof thecommand, this article describes the medi- affectedcountry should be contactedas early cal eventsand issuesthat dominatedthe disaster as possible to determine which areasrequire relief,on groundat Sri Lanka.specifically at three immediatemedical/ surgical assistance in order areaswithin Sri Lanka,namely Hambanthota, Galle to avoidduplication of effortsin placeswhich andTrincomallee. In all, nearly20 MedicalOfficers alreadyhave good rnedicalcoverage. and25 MAs weredirectly involved in thereliet op- (e) Suitablekits for cleaning& testingof wellsand erationsas a partof OperationRainbow (West) fronr other water sourcesis a must before the water SNC. A successfuloperation of this scalewould canbe declaredportable. Guidelines should be surelynot havebeen possible without excellent co- given by PSM specialist,during time of relief ordinationand support from thenodal hospital, INHS initiation,to guide thefield MOs to treat,test & Sanjivani,Kochi, particularlyMedical Storeswhich declarethe water sourcesfit for consumption. providedprompt logistic supportand timely dis- patch of medicalstores to distant shores.

cor 1 pas dest

70 Jour Marine Medical Socien. 2005. Vil.7. No. I Jour ---

MEDICAL RELIEF FROM WESTERNNAVAL COMMAND IN AID OF TSUNAMI VICTIMSAT EASTERNPROVINCE. SRI LANKAZT Dec04 -23 Jan05

Surg LCdr SK SAHU*,Sqn Ldr YK KIRAN**, Maj ANIJRAGSHAIUVA'r**

ABSTRACT A massiveearthquake in the oceaniccoast of Indonesiaoff Sumatra, on 26 Dec 04, resulted in massiveland displacementunder sea leading to giant tsunamisdevastating the various costal areas of South.EastAsia. A multidisciplinary team comprising of six medical officers and twelve medical assistants,assembled at short notice on 26 Dec 2004, proceededto Male and Sri Lanka. This article reviews the salient features of the disaster and medical relief activities carried out during the period after the tsunami. KEY WORDS : Tsunami: Disasterand Medical Relief: PreventiveHealth

INTRODUCTION checkedtheir storesonce again and preparedthem- selvesfor the task ahead.The team was airlifted to 1/ln 26 Dec 04, a massiveearthquake in the oce lr.,rfanic coastof Indonesiaoff Sumatra,resulted in BatticaloaAir forcebase on 02 Jan2005 and further massiveland displacementunder sea leading to gi- to the 233 Bde HQ by road around 1230Hrs. The ant tsunami's devastatingthe various costal areas BrigadeHQ would providethe teamwith accommo- of South-EastAsia within a shortperiod of time. dation, logisticsand administrativesupport during theperiod.Immediately on arrival the Bde HQ briefed Preparation the team regardingthe extent of damage,the ex- A multidisciplinaryteam comprising of six medi- pectedreliefrequirements and the securityconcerns cal officers and twelve medical assistantswere in the area. assembledat shortnotice on 26Dec2W. After brief- Planning and Execution ing, the teamembarked INS Aditya, and proceeded to Maldiveson27 Dec at 0800hrs,along with a large As per the briefing the areato be covered was quantityof relief items and medicines. approximately 250 Sq Km with a death tol'l of 2,254 and around 1000 persons still reported On arrival Male at l800hrs on 29 Dec 04, situa- missing. Roughly 95,000families were displacedwith over tion was reassessedand afterreplenishing the other 2,00,000people housed in difficult living shipsin the region,the ship setcourse for Colombo conditions in 94 campsaltogether (lnternally Displaced in view of extensivedamage to Sri Lanka, requiring Person or IDP Camps).An estimated40,000 houseswere additionalsupport. The ship enteredColombo har- completely damaged.The local authoritieshad bour at l800hrs on 3 I Dec 2004. The medical teams startedthe relief camps in the available schools, along with their supplieswere disembarkedon 0l churches& mosques,however there was acute Jan 2005. The medical team was briefed about the shortageof medical & paramedicalstaff, with generaltopography, demographic profile, present two district hospitalscompletely damaged and road situation,the task aheadand also the securitycon- the networkonly partly operational. cemsdue to the ethnic war in Sri Lanka. The teamco-ordinated with the District Medical After obtainingthe requisiteclearance from the Officer,the Medical Officer Health- Batticaloadis- Ministry of Health, Sri Lanka, the teamproceeded to trict, the SpecialTask Force and the Bde HQ. Batticaloa,joining the relief activitiesas per the re- An elaborateassessment of the situationwas donewith quirement projected by the ministry. The teams respectto availableresources in the form of medi-

xMedical Officer, INS Viraat, **Dept of Pediatrics. !t**Dept of Surgery, INHS Asvini, Mumbai 400 005

Jour. Marine Medical Societu 2@5, Vol.7, No. I 7I - \:

cines,vehicles & manpower. and alsoconducted lectures (Fig. 3), that were pre- The team startedits work from Kattankudy where paredin local dialect(Tamil) with the help of all existing medicalfacilities were completely interpreters. paralyzeddue to the disaster.The town which is Achievements one of the most denselypopulated areas of South The main achievementof teamwas to help the EastAsiawith approximately50,000 people living in localauthorities in settingup of Districthospital by total areaof onesquare mile. At thetime of arrivalof helpingthem to identifythe suitablelocation, ple- the team the local healthauthorities with l8 IDP paringof thearea, suggesting the lay-outof hospital campsneeded augmentation, as the local district and in providingprofessional advice as asked.We hospitalwas completely awash, with no supportfrom werealso managing the entireburden of IDP camps any outsidemedical resources. as well as the OPD at temporary District hospital The team.in coordinationwith Medical Officer beingrun at a schoolso the local authoritiescould health,District MedicalOfficer, HQ 233 Bde & civil devotethemselves in working up towards the set- administrationadopted the completeIDP campsof ting up of District Hospital that was completely Batticaloadistrict by undertakingvaried tasks like destroyedin Tsunami disaster.The team also do- l. Healthcamps nateda part of their medical storesto the hospital 2. HealthEducation which wasbeing built from scratch. 3. Hygieneand sanitationactivities The teamhad aimed to practiceholistic medicine 4. Settingup District Hospitalto nearnormalcy in and worked hard on preventiveaspects to prevent coordinationwith District Medical Officer breakdownof anyepidemic. The work put in by the 5. Liaisonwith: teamwas fruitful ason retrospectiveanalysis ol'ac- a. UNHCR, IRC, Medicine SansFrontiers, tivities conducted,the effective health management HandicappedInternational, ROHUT and various other Sri Lankan and International Agencies. b. Othermedical teams - America.Greece. UK. France,Fiji and others. c. Local doctors d. Campsupervisors e. Local leaders& Religiousheads In addition the team conductedvarious otner campsin thearea extending over 256 sq km i.e.from Kodaikallarto Kallady,some parts of which werein- accessibleby road,hence forcing the teamto carry the medicalsupplies by, cycle, and at times by lift- ing on man-packbasis. In additionthe movementof the team was restrictedto certain areasin view of security concerns. During the Healthcamps the teamattended to all medical needs of the people including providing medicines,dressings, minor field surgicalprocedures (Fig. l), andreferrals to the generalhospital for ma- jor illnesses(Fig. 2). Medicaldocuments for chronic patientslike hypertensiveand Diabetics who had lost all their previousdocuments during the disas- ter,were also prepared. The teamalso carried out hygieneand sanitation Fig. 2 : Total Attendanceat Various Camps at Eastern province,Sri Lanka activitieslike chlorinationof water.sanitarv landfill

72 Jour.Maritrc Medical Socieo, 2005, VoL7,No. l a-€

providedby the teamis clearly broughtout, asthere undergoingtreatment under the team and chronrc wereno epidemicsof Notifiable/ communicableill- patientswere advised to reportto the District hos- nessesand also there was progressivedecline in pital for furtherfollow-up. the numberof personsseeking medical help. The team embarkedon INS Sutlej at Colonrbo The comprehensiveefforts put in by the Indian port on l9 Jan2005 and reached Cochin on 20 Jan Medicalteam, as highlighted in Table l, werehighly 2m5. appreciatedby local healthauthorities and people. Advantageousstrengths of the DisasterRelief it was appreciatedby the district As a matterof fact, team healthauthorities that. the Indianteam was not only l. Composition- Multidisciplinary team, different thefirst foreignmedical team to arrivein thedistrict, from theroutine with mix of variousspecialties but was also the largestforeign medicalcontingent (Surgery,Medicine, Pediatrics)as part of the working in the district.Further, the team was able to teamthus helping to ensurepromising results. achievea high level of satisfactionas well as ac- 2. Mobility - Hired vehiclesprovided at the ceptancefrom localcommunities. disposalof team enabledcoverage of large TABLEI areaswith comparativeease with independent Disaster relief from Western Naval Command in aid of Tsunami victims at Eastern province, Sri Lanka mobilitv 3. Communication- Provision of telephoneswith Medical Relief Activity Post Tsunami Numbers all facilitieshelped th,: team to becontinuously Disaster in touchwith Indian High Cornmission,local

Team conducted total number of camps 33 healthauthorities and Bde HQ. Total number of patients seen over 10,000 4. Liaisonwith undermentionedagencies was very Paediatricpatients 5684 helpful as problems encounteredwere Total number of minor surgeries/dressings 4300 addressedimmediately by them. Preparationof lost documentsof chronic I 000 a. IndianHigh Commission patients b. Localhealth authorities Identifying and starting treatmentfor fresh 440 chronic cases c. Districthealth Officer Emergencies d. 233Brigade Field surgeries 2l e. DistrictMedical Officer Referrals(to zonal hospital) 5 t) f. Voluntary Health organizations & Admissions 8l InternationalHealth asencies 5. High levelof motivationand commitment of the During the stay the logistic support was well team. takencare by the Bde HQ. The heavyworkload re- 6. Desireto practiceholistic medicine,hence not sultedin rapid reductionof medicinesby the end of only to cure the disease,but also to prevent first week. Medicines were replenishedby second any major epidemics by educating the shipmentwith effective and timely interventionby community. the Indian High Commissionenabling the team to Limitations of the team work unhindered. L Absenceof anyexperienced member in theteam Closing Up of Operationsand moving back who has attendedto any natural disaster At the end of two weeksthe IndianMedical con- before.However in retrospectit was overcome tingentscarrying out their operationsin Sri Lanka with motivationand hardwork. were instructedto be ready to move back as the Z Languagewas the most important handicap acutephase following the tsunamiwas over and Sri initially as there was no member who could Lankan healthsystem was gearedup to take up the speak Tamil or Sinhalese.However under work load.On receivingthe intimationof de-induc- directionof Teamleader it wasdecided to learn tion. the team visitedall the IDP campswith the workableTamil. The team learnedTamil with District medicalofficer for follow up of the patients the help of local people and interpreters.The JounMarine Medical Society, 2005, Vol.7, No. I 73 : --...-

successof the teamcould be assessedwith the up high level of trust among various fact that by the end of first week team was communities(Sinhalese, Muslims, Tamils & conductinglectures in Thmil. Christians).It helpedin buildingup of solidarity 3. Securityconcerns due to ongoingethnic conflict amongpopulation affected (Fig. 5). hadrestricted the mobility of the team.The work 6. High standardsof medical care provided with done by the team spreadby mouth and people minimal resources,by effective coordination. from adjoining districts who were in need of planning,execution and a high level of medical help had approachedthe team for motivationand commitment (Fig. 6). conductingcamp in their areas. 7. The team helpedin settingup of district hospital 4. Restricted mobility as most of roads were that was destroyedduring Tsunami at makeshift damageddue to tsunamiand some of thecamps placeby the end of secondweek thus helpedin were totally cutoff from the rest of the world. re-establishingthe health care to nearnormalcy. The teamdidn't let this to work as limitation Recommendations and team carried out medical camps at all locationsfollowing a fixed schedule,by carrying l. Team should have at least one member medicalsupplies by cycle or by lifting on man- experiencedin disastermanagement as the pack basisas warrantedby situation. requirementsin managingan arearavaged with disasterare different from normal requirements. SpecialAchievements of Medical Team An experiencedteam member will be an assetto l. Focuson Hygiene and Sanitationactivities: A the team and team can be better preparedto rangeof Hygiene and Sanitationactivities like dealwith eventualities. Digging Pits, water chlorination, spraying of Z Teamshould have at least02members fluent in bleachingpowder, Waste disposal management, the local dialect facilitating better maintenanceof cleanlatrines was carried out at communication. many places,in the aftermath of the tsunami 3. Pediatricianto be part of the team. as large (Fie.3). quantumattended were ofpediatric agegroup. 2. . Health educationconducted at local areasto 4. In caseof point epidemic as Tsunamidisaster prevent gastrointestinalailments, skin and earthquakespreventive medicine plays a infections, respiratory infections and various significant role in preventing outbreaksof othercommunicable diseases (Fig. 4). epidemicswhich arisedue to people living in 3. Achieved nil breakthroushsof communicable temporary camps which have problems like diseases. unsafedrinking water and hygiene arrd 4. Meticulousdocumentation of all cases. sanitationproblems due to inappropriate waste 5. Over a period of time the medicalteam had built

Fig. 4 : A lectureat a missionschool , Batticaloato teach Fig. 3 : Cleaning the camp site and disposalof waste proper disposalof rvaste

74 Jour.Maine Medical Sociery.2005, VoL7.No. I Y

vitable. ien into inginto rovided mentto rentof a in areas otebook rmittent for ease

Fig.5 : Explainingof dosagesof medicinesto tsunami Fig.6 : Distributionof medicinesduring conduct of ntedi ot large affectedpopulation. Over a periodof time the cal canrpat IDP curnp.Universe School rsidered nredicrltearn had built up a highlevel of tLu.t. BatticaloaRailway Station goodwill I of the facilitatingspread of disposal.A PSM / public healthspecialist in the liantand teamwill be an addedasset in suchconditions. ; support 5. Medical teams should be sent by the fastest Jditional meansto the site of the disasteras the team of Army could haveaverted the delav if wereair lifted to the disastersite. 6. Laptop and digital cameras can assist. integratingthe all round activitieslike in ochi,was documentation,maintaining statistics and luctedby forwarding accurate feedbacks to various th of tsu- headquarters. lterrelief 7. Medical storesto be carriedshould depend on themedi- the type of disasterand as per analysisof Fig.7 : Loadingof medicinesin vehicles- Beginningof : disaster previous missions who have worked in such anotherday y at three conditions before. severenatural disasters till date,in living memory. ota,Galle 8. Augmentationof the stores/ manpowershould The disasterrelief providedby IndianNaval Mis- lOfficers be by the fastestmeans so as to continue the sion was swift, comprehensive.including both reliefop- work unhindered,(Fig. 7) asthe teamwas able curativeand preventive components, and facilitated /est)frorn to work without waiting for suppliesat any time the spreadof goodwill in localcoastal areas. as well rlewould unlike someother foreign teamswho were not as distant shoresof neighboringcountries. On ellentco- ableto work continuouslyfor want of supplies. ground,the objectivesof Disasterrelief, were truly ital,lNHS 9. The practiceof preventivemedicine in form of realized,in the trail of the tsunamidevastation with reswhich effective hygieneand sanitationmeasures and relief effortsprovided by the Indian Medical teams melydis- provisionfor adequatesafe drinking waterwas appreciatedand acceptedby one and all. instrumental in prevention of any major Acknowledgements communicablediseases. The authorswish to expresstheir gratitudeto HQ (WNC). CONCLUSIONS lndian High Commission,109 HelicopterUnit of Indran Air Force, HQ 233 Bde of Sri Lanka Army, DefenceAdvisor The recentTsunami in Dec 20M was of unsur- to Indian High Commission.Colombo and Commanding passedmagnitude and scale. The sweep of Oflicer. INHS Asvini, Mumbai for having been the guiding destructioncaused by it, made it one of the most force behind the team at every step. thus successfully accomplishingthe mission.

Vol.7.No. 1 Jour.Marine Medical Society, 2005, VoL7, No. I /) PECULIARITIES OF MEDICAL CARE DURING LIQUIDATION BY NATURAL DISASTERSAND CATASTROPHIES_ THE INDIAN NAVAL TSUNAMI RELIEF EXPERIENCEAT ACEH PROVINCE. INDONESIA

SurgCdr A DUTTA', SurgCdr G VISHWANATTI*, SurgCapt YPMONGA#'Surg CdrA BIIARDWAJ*, SuTgLtCdTSHALOOGARG*

ABSTRACT

The recent earthquake and tsunami disaster called for unprecedented and unusual efforts by the military medical fraternity. An Indian Naval hospital ship had the opportunity to work with numerous international military missions/ non-government organizations at Aceh, Indonesia. Their efforts were fruitful and yet many lessons could be learnt. The importance of cooperation and coordination between international militaries in optimizing health care delivery came to light. This article reviews the efforts made during preparation, the planning of the mission against a background of information void, that was filled up by a steep rise in numbers. The article furthermore. studies the situation on ground. the medical needs in initial days as well as weeks. analyses the disaster relief experience at Aceh province, Indonesia, and examines the achievements and the lessons learnt.

KEY WORDS: Military Medicine, Disaster Relief, Hospital Ship

INTRODUCTION complishedlargely by the militariesof Indonesia n 26'hDecember. 2004, South-East Asi a suffered andneighboring countries. The scalesof mobiliza- fi \-,/one of the largest earthquakesin recent his- tion.of bothmen and material, were large and needed tory, which was followed by an even more urgentsupplementation much beyondthe planned devastatingtsunami. An IndianNaval Hospital Ship contingencies.The timelyactions of militarymedi- wasdeployed at the westcoast ofAceh, Indonesia, cal missionshelped mitigate the initial impact of the wherethe naturaldisaster had destroyedvirtually healthdisaster. The militariescould successfully play every village and town in the affectedcoastal zones leadingroles in casualtyaccess and evacuation, re- lying below l0 m elevationand extending3-5 km suscitation,trauma care and related emergency inland.Following the disaster,damaged roads, dev- medicalservices, as well asresponsible for reaching astatedphysical and human infrastructuresand much neededmedical and otherrelief suppliesto limitedair assetsposed huge challenges to earlyaid the area,and for setting up temporaryshelters for efforts. displacedpopulations.

OVER\TEW PREPARATION

The recent earthquakeand tsunami disasterat An InformationVoid Aceh. Indonesia,was so devastatingthat unfore- The devastatingtsunami that slammedSouth seenscales of internationalmedical relief had to be EastAsia happenedwith little warning.The Indian initiated.During the initial 2-3 weeksthis was ac-

'Classified Specialist(Anaesthesiology), INHS Kalyani, Visakhapatnam- 530005,* ClassifiedSpecialist (Surgery & ReconstructiveSurgery), INHS Asvini, Colaba, Mumbai - 400005, ' Commanding Officer & Senior Advisor (Surgery & ReconstructiveSurgery), INHS Kalyani, Visakhapatnam- -530005," AssistantCommand Medical Officer, Headquarters. Eastern Naval Command. Visakhapatnam- 530014. ** Graded Specialist (Anaesthesiology).INHS Kalyani, Visakhapatnam- 53 00{)5 "

76 Jour Maritte MedicctlSocietv, 2005, Vol.7. No. I Naval medicalmission had to rely on minimalinputs cal equipmentwithin thosecenters. Equally irnpor- from local and internationalgovernments, press re- tant was AL the mobilizationor training of new staff to leasesfor planningtheir operationIl]. No reliable replacethe many healthworkers who had died. Even- A informationwas availableon the numberor type of tuallythe temporary health clinics, which werebeing casualties.the specifichealth needs or the statusof staffedby internationaland local volunteersat in- theirhealth care infrastructure. The exactnumber of termittenthours, needed to cedethis role to others: deadtill evena month laterremained unknown. Of- eitherlarge NGOs who could provide serviceson a ficialestimatesrill l9 Jan05 indicatedthat 166,000 longer-termbasis, consistent with the expressed people,or l7.3Voof anoriginal population of 961,000, needsof the population:or a gradualtransfer of had perished[]. Internallydisplaced populations theseresponsibilities back to local healthauthori- (IDPs)within thedistrict wereestimated at 125.000. ties.This effort was expected to takeabout 3-4 weeks. and thesecontinued to be mobile [2]. This madeit difficult for the authoritiesor agenciesto accurately THE SITUATIONON GROUND li ta11-' tional' count and target the population. The province of No masterlist existedthat detailedthe overall man] Acehthus received medical aid in a chaoticmanner. medicalsupplies available for provisionto interim ies in healthposts. This hasresulted in shortagesof ma- n. the Planning the Mission terialslike wound nbcrs. dressingkits, plaster-ofparis. The t,eek s. missionplanning was basedon the follow- stethoscopes,BP recorders,oxygen, delivery kits rd the ing key assessments[3,4,5]: a) confirmationof the for safebirth andother common supplies. Oral rehy- emergency;(b) detailsof thetype, impact and pos- drationfluids, amoxycillinand paracetamolwere sibleevolution of the disaster;(c) measuresof it's availablein largequantities. One common complaint presentand potential health impact; (d) adequacy was that NGO groupsbrought only enoughsup- of existing responsecapacity and immediateaddi- plies to treatclients but did not leavebehind any tional needsand (e) recommendedpriority Incsla actions suppliesor medicaltools when they left, rendering for immediateresponse. riliza- the community health care centersunable to treat patients. eeded The missionrelied essentially on standardoper- Other than medical equipment,non-food itemssuch lnneo ating proceduresfor disasterrelief. The resources as hygieneproducts, disinfectants and even mcdi- mobilized were from pre-packedreserve medical body soapshave were not delivered in suffi- cientquantity. of the storesfor disasterrelief. However,the scaleof the vplay presentdisaster was aboveand beyondany known Sanitationwas a significantconcern, particularly In, fe- in living memory. There was a need, thereforeto becausethe impendingrainy seasonwould con- urgentlysupplement the Iency medicalsupplies. without tinuefor two monthsand virtually no viablewaste ching delayingdispatch of the medicalrelief teams.These disposalsystems existed throughout the region. This lesto additional medical storeswere procuredbased on had becomeone of the most pressinghealth con- rs for only assumptionson their need.A systemfor re- cerns.The Indian Naval Medical missioncreated plenishmentof suppliesafter 2 weekswas worked and demonstratedthe method of waste disposal out. throughsanitary landfills in the Meulabohgeneral hospital(Figs I &2). Cleanwater was available. PerceivedRoles but notin thequantities needed by thepopulation. How- The aimsof themedical missionwere ascertained ever,since there were multiple water systems being iouth to be: a) to provide emergencymedical services to used,such as wells, rivers, bottle water, trucked warer tdian the affectedpopulation ; b) by settingup temporary andtanks, there existed the possibility of increasing comprehensivehealth clinics;c) to provideexper- watersupplies to within acceptabletimits in a short tise and medical relief suppliesto the government periodof time. Much of the drinking water being :rv & authorities/NGOs. The ultimate '..,,' objectiveof themis- collectedfrom wells and other sourceswere con- sion was perceivedto be to assistin timely trters. taminated.and did not meetaccepted standards for rehabilitationof local lam - communityhealth centers, with drinkingwater quality. Very little of this warerwas a demand-based logisticssystem fordrugs and medi- beingdisinfected, although most people reportedly

Jour.Morine Medical Socierv.2005. Vol.7. No. I 77 Oo:

rev Int onl tl des .{ ofp '-i Fig l: Sanitarylandfill, 6 feet deep,readied f ;..biomedi- prel cal waste disposalat the Meulabohgeneral .L hyc hospitalby IndianNaval volunteers. des boiled their drinking water prior to consumption, int which may help explain the lack of dianheal disease DII outbreaks[2]. Fig.2 : Demonstratingthe use of a sanitarylandfill to I . ' More troubling was the devastatedroad network IndonesianMedical Coordinators,at the diar and bridges, which would require both consider- Meulabohgeneral hospital set able time and manpower for reconstruction. These a) roads were necessary alternatives to the current community shelterssuch as schools,mosques and medical aid airlifts and crucial to an unobstructed other public buildings.Another significantportion flow of supplies to the devastatedareas. were living in makeshift shelter fashioned out of scavengedmaterials. Amuch smallernumberare liv- Due to the timely, significant response by the ing in tents.Conditions were crowded in many of militaries of a number of countries (both on and off the shelters,with some schoolcompounds hosting shore),basic food staples,particularly rice and noo- over 2000 persons. dles, had been delivered by helicopter to most locations along Aceh's West Coast. In most loca- Personsaffected by the earthquakesand tsuna- tions, however,food suppliesdid not include protein, mis following 26'h December2004 were exposedto oil, sugar or vegetables.Micronutrient supplements exfeme stressors(personal danger, loss ofkin, etc.). were also lacking. For obvious reasons,no nutri- Thesestressors did representrisks for mental health 't tional assessmentof the affected population had problems. Also, most people impacted by this dis- been conducted. No serious targeting offood relief asterlived in resource-poorconditions and this fact .1 had occurred, nor any special effort done to get made the task of providing assistancemore diffi- food to the most vulnerable populations (primarily cult. .<-. children under 5, elderly, and pregnant or lactating In particular,while mostgeneralhealth needs were women). No acute cases of rnalnutrition were ob- being addressed,there remaineda significant dearth served.Nevertheless, the riutritional statusof IDPs of providers for maternal and child health care. could not be sustainedon the rations that were cur- Throughoutthe assessmentarea, women who had rently being distributed. Distribution of food was delivered babieswithin two weeksafter the tsunami largely coordinated by the TNI ('Tentara Nasional had to dependon either untrainedfamily members Indonesia'or the IndonesianArmed Forces),or in or traditional birth attendants.This was an unac- collaboration with civil administrators rvhere they ceptableincreased risk to the reproductive health of survived. Quantities received by IDPs varied ac- women[,2]. cording to available stocks, and the agency TIIE INDIAN NAVALDPERIENCE responsiblefor distribution [,2]. Survival of the fit- test was the reality. The hospital ship was able to reach and com- mencemedical services rapidly, within few daysof Displaced personswere being housedin various the earthquakeand following tsunami. The mission types of shelters. Significant portions of the IDPs ' - was able to contribute emergencymedical services, areliving with host families in communitiesthat were *':l Fig. especially trauma care, in the first few days of de- not affected by the tsunami. Others were living in ,,t, 78 Jour MarineMedical Society, 2405, Vol.7, No. I Jout ployrrent. They were adequatelyprepared for this servicesincluding vaccinations(especially for role and facedno major difficulties during this pe- Tetanus),containment/ isolation facilities for riod. patients with communicable diseases (especiallymeasles, cholera, typhoid, dengue, Medical Needsin Initial days rneningitis and tuberculosis) and timely The main issues facing the medical relief team replenishment of medical stores (under the during the initial days were systematicsupervision/ coordination) a) day to day planning ofmedical operations 'accounting and c) therewas adequatemedical aid at hand and no of storesconstrained due to lack of scope for additional trauma related services. accessto information on estimatednumber of especiallyfor surgicalteams in the area(perhaps casualties and the Iikely durationsof their this was the time to start scaling down the deployment surgicalfacilities in the areato make way for b) concerns about communicable diseases. other agenciesto begin operations) hygiene, sanitation,waste disposal d) the roles of NGOs towards return of normal c) safety and security of medical personnel livelihood in the regionwas paramount, requiring deployed long term commitmentsof service,perhaps for d) a depletion/shortage/lackof medicines the next 6 months, from the various especiallyfor pediatric, maternalhealth, skin organizationswho would eventually have to and psychiatricuse takeover from the medicalaid agencies e) food and shelter needsof personnelinvolved e) at somestage in the progressof rehabilitation in relief and control of health relatedmatters the issue of cost of servicesprovided would have to be f) communicationwith affected patientsdue to considered,perhaps with concessions/ non-availability of interpreters subsidiesinitially followed by appropriate g) guidelines for accessto and chain of patient chargesfor specific servicestill the complete evacuation returnto self sufficiencyof the staterun health The teamcould establish,quickly, effectiveliai- services son with the local health and administrative D the mainaim of therelief organizations at this authorities. By the second week of operationthe point of time would have to be changedfrom situation was vastly improved. NumerousNGOs emergency health care provision to hadarrived with men and materialcreating at times establishmentof safeand habitableconditions surpluses of relief. A strongneed was felt for coor- thatwould encouragethe earliest possible rerum dination of the relief processesand resources. of displacedpeople to their homesand work.

MedicalNeeds in third week ANALYSISOF MEDICAL DISASTERRELIEF By the third week it was generallyconcluded in EXPERIENCEATACEHPROVINCE. INDONESIA most areasthat Achievements a) the post quake/ tsunami phase requiring The key intervention that helped these devas- emergencymedical aid was essentiallyover; tatedpopulations escape a secondarydisaster was therewas a significant decline in trauma and the timely deploymentof military assers.These as- emergencycare workload (to about l0%oof the sets were made availableto the Indonesian initial figuresat the casualty),the presentfigures govemmentand internationalaid agenciesearly on being comparablewith those prior to the in the crisis.They provided disaster medicalcare and casu- alty evacuation,airlifted water,rice and other food b) in most places 2] the needs [, of the hour were stocks to isolatedpopulations, initiated aerial re- for provision of shelters,rehabilitation, connaissanceof roads and facilitated operational sanitation,safe drinking water, public health agenciesin getting to remote sites.These assets Jour.Marine Medical Society, 2005, VoI.7, No. I TABLE I Patient categories seen by the Indian Naval medical relief camp till l7 Jan 05 (Major trauma related surgery showed a significant decli ne)

PAII€iTS SEEN Af MEULABOH

?50 a P3ycha.kE Cas€s 200 I Oth.r lh6ssar Fig.3: IndianNaval medical relief camp ran from dawn r50 O Gf hircbn 100 E Re3pfetory hloction to duskpost tsunami till 17Jan 2005. 5 km 50 I Minor Suroefy inlandat Meuluboh. lndonesia. I M.io. Surg.ry werevital in conveyingto the internationalaid com- munityinformation on prevailingconditions. and in bringingsupplies to thosewho neededthem most comnrunityh.rl,h.";;^ ('puskesrnas')- the back- desperately[,21. boneof the public healthsystem - were severelv ln responseto the acute nature of the disaster, impactedby thetsunami: the Government estimated many nations deployed teamswith tertiary health that 4l of the province'shealth centers were de- skills to addressthe severewounds of the injured. stroyed[2]. At leasthalf of thesewere on the West This had resulted in an oversupply of temporary Coast.In addition,many sub-health centers ('pustu') tertiarycare facilities and medicalstaff (including, weredestroyed. Exact numbers were not known. atone point in time,twenty surgeons in Meulaboh). Despitethe continuedabsence of a systematic Most temporaryfield hospitalshad noteda signifi- responseto the multipleneeds of this population. cantdecrease in averagepatient load betweenweek- I there were some good achievements.Instances of post-tsunami.from 120 patientsa day to a week-4 malaria.measles, and watery diarrhea were signifi- daily caseloadof 30-45patients [2]. Acute-carehos- cantly lower then expected.Food stocks.though pital bed capacity in westernAceh Province limited in proteinand calorie density. were reaching appearedto be adequatefor the immediatereferrals. most largepopulation groups via civil authoritres The IndianNaval medicalcamp (Fig. 3) contin- andthe Indonesian military. Schools were ready to ued to see an averageof 160 patients a day, but re-openin a few areasand local foods had begunto traumarelated cases decreased significantly by the re-appearin local markets. endof thefirst week,with a risein infections,nutri- LessonsLearnt tionaldeficiencies and psychiatriccases (Table l). The Indian missionalso contributed by settingup With mostcommon citizens carrying cell phones, thefirst bloodbank, post tsunami. within theexist- in countrieswhere many peoplewere individually ing facilityat thegeneral hospital at Meulaboh. The accessiblevia affordabletechnology, perhaps a sin- missioninitiated biomedical waste disposal by sani- gleemergency message might havebeen broadcast tary landfill at the hospital(Fig. I & 2). Expertiseof to every personcarrying a phone,telling them to the plasticsurgeon and anesthesiologiston board getto higherground. and fast. [4-7]. wereoften solicitedby thehospital, as were requests Despitetheir bestintentions, local and interna- for medicalstores such as injectableantibiotics, life tionalNGOs, largely operating on an ad hoc basis. savingdrugs, plaster-of-paris, X-ray films,etc. The neededto better coordinateso that their eftbrts ship's workshopwas being usedto refabricate could bolsterthe primary healthcare systemand splintsfor traumapatients from availablematerial. other essentialsectors. IVIore sustainable civilian The temporaryfield hospitalshad met manyof logisticsand transport systems needed to be estab- the acuteneeds of the populationbut did not suf- lishedas soon as possible. The IndianNaval mission tlce in themedium- or long-term.Most medicalneeds ashorewas dependent on roadtransport as well as of the affectedpopulation related to the restoration reliable landing crafts from local resourcesdue to of primaryhealth care and preventive services. The devastationof berthingfacilities and jetties.Tlre

80 Jour.Marine Medical Socierv,2005.U,I.7, No. I - r" --'

Fig.4a : A patientwith sepsis& gasgangrene ofthe right Fig.4b:At IndianNaval Hospital Ship Nirupak a patient foot. wasevacuated by helicopteron boardto underwenta life savingamputation on 08 Jan theIndian Naval Hospital Ship Nirupak. 2005

seahad, in fact, moved in-land. Being primarily a The convergingmilitary medicalrelief carriedout hospitalship, the facility was constrainedtowards by all internationalcountries would havebeen bet- optimal utilization. Only helicopter evacuationof ter servedthrough cooperation and coordinationof casualtieswas possible.Nevertheless, this facility efforts and pooling of resources.This would have was usedwhenever required for emergencymajor optimizedthe collective effort so asto benefitmaxi- surgeries,being the only sterileoperating room avail- mum patient populations and facilitated an early ableduring the first few daysat Meulaboh(Fig.4 a recovery of the local health infrastructuresand &b). smooth transitionof health administrationto gov- The rolesand responsibilitiesof the healthagen- ernmentagencies/ NGOs. cies on the ground neededto be clearly defined by Recommendations the sectorcoordination groups. In some areas,as manyas 22 NGOs were working in thehealth sector a) Impmvecnordinationandleadershipwithinthe along with the military and Ministry of Health health sector : Immediate improvementsare (MOH). Coordination was also neededbetween necessaryin planning regional health agenciesthat worked on issuesthat closelyaffected coordination within the affected regions to population health in order to optimize the health ensurethe most productive use of resources impact.These issues included better food distribu- and to ensure that the health needs of the tion, properresettlement of IDPs, accessto suitable populationare being adequatelyaddressed. shelter,the restorationof livelihoods,and ensuring Many military units, NGOs, and other local accessto non-food items. organizationsare invariably available for healtlr servicesthroughout affected areas. A detailed In order to guaranteea safe supply of drinking review of sectorwide needs(field and desk water to IDPs and affected populations a greater studies pulling together the numerous emphasisneeded to be placedon disinfectingdrink- assessmentsreports) should be completed ing water suppliesas well as the safe storageof within onemonth, analyzing gaps and looking drinking water in the homes.Further as most fami- at longerterm recoveryplans [2]. lies lackedadequate water storagecontainers these could have been distributed as soon as possible. b) Addressing logistical needs : The response Maternal,child and mental healthconcerns should thus far had facedsignificant obstacles related havecomplemented humanitarian work in the first to the effects of the tsunami.This was due to daysof the aftermathwithout unduly burdeningre- the great distancesthat neededto be covered liefoperations. in the disaster area: the extended lines of

JounMarine Medical Societv, 2N5, Vol.7,No. l 81 supply;broken lines of communicationand the to IDP settlements,people who remained at severedestruction of roads, bridges,and home in damagedcommunities, as well as to telecommunications.UN agenciesare well hostcommunities. It will alsobe necessaryto equipped with addressingthese issues [2,3]. initially operatemobile clinics to meetthe needs Agencies should look i'o support theseefforts. of isolatedcommunities that have limited access Promptand simultaneousefforts towards these to care. issueswill help medical relief organizations D Health Sector Development : A strategy and immenselyin their activities. policy for the healthsector development needs c) Tlansition : There is a needto increasethe role to be accomplished.It is critical that health cf local/ provincial civilian authorities in agenciesresponding to the disasterrebuild and planning and implementingevery healthaspects strengthen local health systems in a of the medical relief and recovery efforts. Long- coordinatedand complementaryway. Theseare term strategiesto rebuildpublic health,clinical, opportunities to revitalize and improve andpreventive services should be initiatedwith organization structuresand management morecoordination and consultation. Local staff systemsto deliver servicesto standardsbetter should man this processalong with additional thanbefore the disaster (tsunami). There is good staff secondedfrom other provinces/districts. capacity within Indonesia,and neighboring Upgradingand developmentof capacity(skills countries in South Asia, to support such and management)at all levels in the health capacitybuilding within the health sector sector should be implementedusing a dual through technical inputs and for scholarship- mode method.Firstly, on-the-jobtraining should funded training. 'accredited' be provided by internationalaid g) Sector specific assessmentsand Action Plan agencies/NGOs in the workplace. Secondly, for Health : All health relatedsectors should short-term training for multi-skilled village have a focused assessmentto further midwives,health center staff anddistrict public characterize the needs of their service healthstaffis needed[2]. populations.This informationand all datafrom o Health information systems : A regular previous assessmentsby agenciesshould be epidemiological report and operational report evaluatedand incorporatedinto a "Health including interpretationofthe dataand general ActionPlan" within 7 days[2]. situationshould be publishedand sharedwith h) Mental health assistance: Basic social and all relevantagencies, decision-makers on a mentalhealth interventions - on which thereis regular basis.Health agenciesshould bring broad consensus- should be implemented appropriateinformation technology,personnel, before more specialized interventions are and training to the field to support these considered.In the acute relief phase, it is activities12,4,51. advisableto conductfew social/medicalactions e) Proper targeting of health delivery programs : so that there will be little interference with Expandedclinical services,including trauma responsesto vital needssuch as food, shelter care, initially given higher priority during the and control of communicablediseases. first month(after the tsunami), should then give The following guidelinesshould be usefulin de- way to an emphasison primary care,maternal- terminingappropriate responses [2] : child health and preventiveservices, (i.e. o to provide uncomplicatedand accessible immunization,health promotion). It will be more informationon locationof corpses; effective to provide resourcesto community 'puskesmas'), health centers,(i.e. so they can r to discourageunceremonious disposal of startworking againor copewith the extraload corpses; rather than deploy advancedtemporary field o to providefamily tracingfor minors,the elderly hospitals[2]. Servicesshould be madeavailable and other vulnerablepeople;

82 Jour.Maine Medical Societv.2005. Vol.7. No. l - I

o to encouragemembers of field teamsto actively be betterserved by local governmentagencies/ participate in grieving; NGOs. o recreationalactivities for children; to encourage REFERENCES . to widely disseminate uncomplicated, l. Reuters press release as on 19 Jan 05 :Available at reassuring, empathic information on normal http ://www.tsunami-info.org.us.rd.yahoo.com/ stress/traumareaction to the community at large dailynews/rss/asiatsunami ; Accessed on 16 May 2005 2. World Health Organization website : Available at http:/ o during any medical assessmentto enquireabout /www.who.int/hac/crises/international/crisis-tsunami/ need for maintenanceof anticonvulsant final-report ; Accessed on l6 May 2005 'Rapid treatment for people with epilepsy or 3. World Health Organization publicationtitled antipsychotic medication for those who were Health Assessment Protocols for Emergencies', previouslyreceiving such medication. Geneva. Switzerland . 1999 4. Carter, W Nick. Disaster Management: A Disaster CONCLUSION Manager's Handbook. Asian Development Bank. Manila, Phillipines, l99l The tsunami disasterrelief carried out by Indian (Eds.), Navy, recently has validated the role of military lo- 5. Mishra, Girish K. and GC. Mathur 1993. Natural Disaster Reduction. Reliance Publishing House, New gistic support and military medicine in global Delhi, India disaster management.The role of military in con- 6. Dudley, W.C., and Lee, M. Tsunami!. University of certed International medical relief, particularly in a Hawaii Press,l998 'l global disastersetting, is significantly beneficial by . Brian F. Atwater, Marco Cisternas V., Joanne Bourgeors, provision of much neededemergency medical serv- Walter C. Dudley, James W. Hendley II, and Peter H. ices, reviving locally destroyed public health Stauffer. Surviving a Tsunami-Lessons from Chile, Hawaii, and Japan. U.S. Geological Survey Circular medical systemsand replenishmentof stores.Com- I 187.1999 mitments for long term health care delivery would

Jour.Maine Medical Sociery,2005, Vol.7, No. I 83 RE-ORGANIZINGOURSELVES FOR DISASTER RELIEF : LESSONS FROMINDONESIA

SuTgCdTGVISHWANATH*

ABSTRACT

The Indian Navy responded spontaneously to the devastating tsunami that occurred on 26 December 2004, by providing logistics and medical relief. The aims of the mission included a) to hand over relief supplies to the local Indonesian government authorities; b) to provide services of the ship in hospital role and c) to act as ambassadors of goodwill, in the course of providing medical relief. The swift response which was multidirectional and multidimensional, gave an opportunity at all levels within, to assessthe efficacy of delivery of such services after a large scale natural disaster. At the end. the Indian team won much appreciation both from the Indonesians and from other agencies in the region for its participative, positive and problem solving approach. its empathy and alacrity to action.

KEY WORDS : Medical Relief: Disaster: Tsunami of 26th December 2004

INTRODUCTION severalstorage spaces. The composition of the MTSP was one surgeon,one anesthetist,one 1-tonsequent to the earthquakeand tsunamithat lr,.-,occunedon 26 Dec 04, oneMTSP (Mobile Tech- GDMO, l4 Medical assistantsof varioustrades and nical Support Platoon) was embarkedon a survey 3 domesticbranch sailors. ship convertedto hospitalrole for disasterrelief at Consideringavailable resources, the MTSP car- Indonesia.The deploymentof this hospitalship in ried equipmentand storesfor the managementof Indonesiafor medical and relief aid after the Tsu- 100Pl casualties.200 P2 casualtiesand 700 walking nami providedan opportunityto assessthe efficacy wounded. Urgent local purchaseof supplies and ofdelivery ofsuch servicesafter a largescale natu- equipmentwere resortedto. ral disaster.This paper attemptsto make a critical The Hospitalship sailedfrom Visakhapatnamon appraisalof the same. 30 December04, reachedIndonesian waters on 02 An overviewof mission January05, wasassigned an areaof operationon 05 January05. and provided medical relief aid at The aimsof themission included a) to handover Meulabohin theAceh provincefrom 06 Jan05 to l7 relief suppliesto the local Indonesiangovernment Jan05. authorities ; b) to provide servicesof the ship in hospitalrole and c) to act as ambassadorsofgood- Meulaboh,a town on the westerncoast of will, in thecourse of providing medicalrelief Sumatrawas badly affectedby the Tsunami.Large scaledevastation had resulted(Figs. l. 2, 3) and Preparations thoughno official figureswere available at the time, INS Nirupak,redesignated as a HospitalShip, for deathsplus missing personswere placed at l/3 of the Medical Relief missionwas orderedto the task thepopulation. The healthcaredelivery system was and one MTSP embarkedfrom INHS Kalyani. The also devastated. ship in thehospital role containedan operationthea- The salientachievements are given herein: tre, two wards, an isolation ward, a blood bank, a a) The handing over of relief stores(grain, laboratory,an x-ray and dark room, a mortuaryand noodles,biscuits, blankets, packaged drinking

*ClassifiedSpecialist (Surgery & ReconstructiveSurgery), INHS Asvini, Mumbai 400 005. u4 Joun Marine Medical Socierv. 2005. Vol.7. No. I -

c) Participationat daily briefing and planning sessionsheld for all medicalteams at the local GovemmentHospital at Meulaboh. This led to bettersituational awareness and communication amongall concerned.The pooling ofresources resultedin a highlevel of synergyand optimal enhancedhealth care delivery. d) Provisionof criticallyrequired medical supplies to the hospitalsuch as IV fluids. antibiotics, life-savingdrugs, Plaster of Paris,anaesthetic drugs,surgical cotton, X-ray film, etc. e) hovision of surgical,plastic surgical, anesthetic opinionsand advice as required at the hospital. Casesrequiring surgery (sourced at the dispensaryor refenedby the hospitalstaff to usduring morning rounds at thehospital) were operatedon boardthe hospitalship. c) The settingup and operationof the much neededblood bankat the hospital. h) The settingup and operationof a sanitary landfill for biomedicalwaste at thehospital. During the courseof this operation,the team observedcertain shortcomings and deficiencies in its structure,composition and functioning. Based on this someobservations are made and a few rec- ommendationshazarded. a) A naturaldisaster such as the Tsunami poses a large scaleemergency where speedis of essenceto the relief team.Under these circumstancesit is imperativeforthe reliefteam to movequickly into positionand begin operationto be ableto salvagemaximum life. Thisteam sailed on 30 December04, reached Indonesianwaters on 2 January05 but could commenceoperations only on 6 January05, i.e. tendays after the disaster. The delay was owing to problems of communication and coordination.In suchdeployments in thefuture Fig 1,2and 3: Largescale devastation by theTsunami at it would be importantto guardagainst such Meulahoh.Indonesia a town on the western coast delays. of Sumatra b) It is importantto realizethat ten daysafter the water, fresh vegetables, etc) to Indonesian disasterthe natureof relief requiredwould authorities. changefrom providingrescue, resuscitation b) The setting up of a dispensary ashore with a and emergencyservices to providing minor OT where a total of 1.712patients were rehabilitation,public health, care of displaced attended to. personsetc. The compositionof the team

Jour.Marine Medical Society, 2005, Vol.7, No. I 85 -

requiredshould changeaccordingly. e) The MTSP consideredsetting up a field hospital c) Disastermanagement is muchmore than a large ashore.Owing to the securitysituation existing scalesurgical exercise. Indeed, surgical cases in theAceh province,the TNI (lndonesianarmy) were in minority in the work load facedby the authorities advised that all material and MTSP (this experienceis also sharedby other personnelbe recoveredon board every day by teamsdeployed elsewhere in Tsunamireliefl. dusk. This precluded setting up of the field The case load composedlargely of gastro- hospital.The relief teammust be self sufficient intestinaland waterborne diseases, respiratory for its securityneeds. illnessesand other illnesses related to exposure, D All in-patientmanagement had to be performed skin infectionsrelating to overcrowding in relief on board at anchorage.The environment on camps and post traumatic stressdisorder and board was not very woman/ child friendly as otherpsychiatric disorders. I I ] All in all, illnesses the medical team had no female members.Over seen were those of the dispossessed,the half the casesseen were women and children. displacedand the bereaved.It is stronglyfelt Femalerelatives / volunteershad to be carried that the servicesof the psychiatristand of the by helo to the ship and messedon board to specialistin PreventiveMedicine are invaluable serve as lady attendants.Future relief teams in such a scenarioand that thesespecialists must carry female members. must be on the strengthof the tearr in all such g) The Indian team had the opportunity to work deploymentsin the future. closely with and observethe structureand d) When the hospitalship setout on its mission, functioning of other relief agenciesin the region it was envisagedthat a berth alongsidewould suchas the SingaporeArmed Forces,Medecin be available.It was plannedthat a shoreMI SansFrontieres, ESCRIM ('Element Securite room would be setup to serveprimary healthcare Civile Rapide d'Intervention Medicale'), etc. needsand only those casualtiesrequiring in- Conceptsfrom the organizationalstructure of patient observation,investigation or surgery theseteams may meritconsiderationif we decide would be brought on board. On arrival at to overhaulour structure[2] .One such Meulaboh it was seen that no jetty had been structureis laid out schematicallyin Fig 4. spared by the Tsunami. The medical team h) The ME scale of equipmentfor the MTSP therefore had to operate from the ship at requiresto be upgradedto include therapeutic anchorage.All personnel,material and casualty and diagnostic equipment sufficient for the movementhad to be by helo (Chetak:I lying/3 setting up of a modern field hospital ashore sitting casualties)or by Gemini boats.Further, where required.The ESCRIM model of fietd the relief material carried to the area was hospital appearsbest. The key components of obviously of no use without the meansof deliveringit. The missionhad to dependon the host nation and other agencies for motor transportand boats. It is suggestedthat in future all suchrelief missionsbe providedwith all weatherday/night capablehelicopters, air cargo net, motor transport,landing craft and boats(even amphibious craft if necessary)and not proceedwith the assumptionof receivinga berthingfacility. It is felt that the relief team 'stand must have alone' capability and not require to borrow from the beleaguered resourcesof the hostnation to be ableto deliver aid. Fig 4 : Suggestedorganization of a disasterrelief team

86 Jour Marine Medicttl Society.2005. Uol.7. No. I =

this model are: attendanceis not possible.The result is better i. thehospital is entirelyset up within synthetic situational awarenessand communication tents among all concerned.At these sessions,the situationand resources available are reviewed, ii. the water supply cin be from the sea action plans formulated and tasks shared by through own desalinationplant various agencies. This forum can be iii. the staff consistsof doctors. nursesand instrumentalin producing the liaison and paramedics. synergybetween various agencies in the region iv. the staff resides within separate tents and leadto optimal functioning [3]. adjacentto the hospital SUMMARYAND CONCLUSION v. the 30 bedsare rigged up as male and female wards,with scopefor expansionas required The devastatingtsunami that occurred on 26 Dec 04, necessitateda global convergenceof humani- vi. the hospital is equipped with all modern tarian efforts ofan unprecedentedkind. The Indian medicaleqpt for the conductof emergency Naval mission respondedby providing spontane- health care in the situation including a ouslogistics and medical relief. The swift response, casualty, a sterile operation theater,CSSD, which was multidirectionaland multidimensional, radiology with a C-arm and ultrasonography, gave an opportunity at all levels within, to assess laboratory, intensive care unit and the efficacy of delivery of such servicesafter a large gynecology department scalenatural disaster.At the end. the Indian team vii. the hospital can mn a dedicated section won much appreciationboth from the Indonesians for a vaccination campaign. and from other agenciesin the region for its viii. all documentation is electronic right from participative,positive and problem solving ap- the reception/ registration, including proach,its empathyand alacrity to action. electronic photography Acknowledgement ir the hospitalis fully air conditioned The author expresseshis gratitude to Surg Cdr A Dutta. x the sewagedisposal is by chemicalclosets Classified Specialist (Anaesthesia),INHS Kalyani, Visakhapatnamand Surg Cdr ZA Shameem,Medical Offlcer, xi the hospital is capable of being set-up or Dockyard Dispensary, Naval Dockyard, Visakhapatnam, dismantledin 24h asrequired and canbe air for their valuable inputs, in preparationof this article. lifted REFERENCES xii.the hospital is provided with medical and l. McDermott BM, Lee EM, Judd M, Gibbon P. other suppliesto run non-stopfor l0 days Posttraumatic stress disorder and general till replenished psychopathologyin children and adolescentsfollowing a wifdfire disaster.Ca4 J Psychiatry2005150(3):137- In all disastersituations, early communication +J. and liaison must be establishedwith all 2. Engineering expertise sought. Health Estare 2OO5l agenciessimilarly deployedin the region and 59(2):39-40 regularbriefing sessions(more frequently than 3. VanRooyenM, Leaning J. After the tsunami--facing daily if required) should be held. Wreless or the public health challenges. N Engl J Med 20O5 other communicationmay be usedif physlcal 3;352(5 ):435- 8.

Jour.Marine Medical Socieu, 2005, Vol.7, No. I 87 - I

PATHOLOGYQUTZ

SurgLt Cdr RAMESH RAO*, Lt ColA MALIK**, SurgCapt RN MISRA*. SurgCdr IK INDRA"IIT ' SurgCdrAS NAIDU*** andSurg CaptJDSOUZA*'&*'*

A 38 yearsold ladypresented with painin abdo tomy specimenwas sentfor histopathological -{a.men andmass right flank of 0l yearduration. examination.Acut surface is displayed. CT andMRI Scanshown below was suggestive of Whatis yourdiagnosis? granulomatous !a . chronic pyelonephritis.The nephrec- . ,O:, 22 ...... , i. l)tp|ttridra ol Prd$lot! eho U,'oL.- t\f,S.t$iri

Fig. I : CT and MRI scanof patient

Fig.2 : Cut surfaceof rightkidney

*Graded Specialist (Pathology), **Classified Specialist (Pathology) & Oncoplthologist, 'Senior Advisor (Pathology & Microbiology), Classified Specialist (Radiology and CT/MRI), ***Classified Specialist (Radiology), *+*Senior Advisor (Radiology and InterventionRadiology), INHS Asvini

88 Jour.Marine Meclical Societv, 2405, Vol.7, No. I ANSWERTO QUIZ: MALAKOPLAKIA KIDNEY

DISCUSSION Histopathologicalexamination of kidneyshowed distortionof renal parenchymawith featuresof xanthogranulomatousinf'lammation and presence of the Michaelis-Gutmannbody in histiocytes. Malakoplakiais an inflarnmatorycondition pre- sentingas a plaqueor a nodulethat usually affects the genitourinarytract but may rarely involve the skin [2,3].Malakoplakia was first describedin the early 1900sas yellow soft plaquesthat were seen on themucosa of theurinary bladder []. Malakoplakiais believedto resultfrom theinad- Fig. 3 : Photomicrograph showing presenceuriac equatekilling of bacteriaby macrophagesor (Michaelis Gutnrann ) bodiesinhistiocl'tesiH& monocytesthat exhibit defectivephagolysosomal E 400x) activity.Partially digested bacteriaaccumulate in for CD68 . lysosomes,and a-chymotrypsin. monocytesor macrophagesand lead to the deposi- Immunostainingwith polyclonalanti-Mycobacte- tion of calcium and iron on residualbacterial riunr bovisantibody may demonstrateorganisrns in glycolipid.The presenceof theresulting basophilic patientswith malakoplakia[81. inclusionstructure, the Michaelis-Gutmannbody, is consideredpathognomonic for malakoplakia[4,5]. REFERENCES Studieshave suggestedthat a decreasedintrac- l. Douglas-JonesAG. Rodd C, James EM, Mills RG. Prediagnosticmalakoplakia presenting as a clrrorric guanosinemonophosphate (cGMP) ellular cyclic inflammatory mass in the soft tissuesof the neck. -/ levelmay interferewith adequatemicrotubular func- Laryngol Otol 1992 Feb: 106(2): 173-7. tion andlysosomal activity, leading to an incomplete 2. FeldmannR, Breier F. DuschetP. ct al. Cutaneous eliminationof bacteriafrom macrophagesand nralakoplakia on the forehea<1.Derntatolog.r' 1997: 194(4):358-60. monocytes [5,6]. 3. Font RL, Bersani TA, Eagle RC Jr. Malakoplakia of Although E coli is the mostcommon gram-nega- the eyelid.Clinical. histopathologic.and ultrastructural tive bacteriaisolated, other enteric bacteria may be characteristics.Ophtlrulntologv 1988 Jan: 95(l): 6l- 8. found on culture.Staphylococcus oureus and Pseu- 4. KogulanPK, Smith M. SeidmunJ, z,ra/. Malakoplakia dontonasaeruginosa may be cultured [4]. involving the abdonrinalwall, urinary bladder.vagina. Sheetsof ovoid histiocyteswith fine eosinophilic and vulva: casereport and discussionof ntalakoplakra- associated bacteria. Int J Gytrccol Purhol 2O0l Oct: cytoplasmicgranules (von Hansemanncells) are 20(4): 403-6. seenon routinestaining. Histiocytes with 5- to l5- 5. Lewin KJ, Fair WR, SteigbigclRT, at rrl. Clinical and mm basophilicinclusions with concentric laboratory studies into the pathogenesls ()l laminations(Michaelis-Gutmann bodies) are diag- nralacoplakia.J Clin Putlrcl 1976 Apr: 29(4\: 351- 363. nostic.Michaelis-Gutmann bodies demonstrate 6. SencerO, SencerH, Uluoglu O, cr al. Malakoplakiaof positiveresults using periodic acid-Schiff stain and the skin. Ultrastructureand quantitative x-r'ay are diastaseresistant. They stain with von Kossa microanalysisof Michaelis-Gutmannbodics. Ar

Jour.Marirrc Medical Socierv. 2N5, Vol.7,No. I 89 -l

RADIOLOGICAL QUTZ

SurgCaptJ D'SOUZA*,Surg Cdr IK INDRAJIT**, SurgLt CdrSN SINGH.

A 32 yearsfemale presented to MI room with of chestis shown at Fig l .{-lsudden onsetchest pain, dysphagia, and What is your diagnosis? odynophagiafollowing a meal.A plainradiograph

Fig. l: Plain radiograph of patient presentingwith odynophagia

*Senior Advisor & HOD (Radiodiagnosis)," Classified Specialist(Radiodiagnosis), *PG Trainee (Radiodiagnosis),INHS Asvini, Mumbai.

90 Jour Marine Medical Sociery,2005, Vol.7, No. I Answer: Pneumomediastinum b) Continuousdiaphragm sign denotingpresence The plain radiographsof this patient [Fig. l] of gasbetween the pericardiumand diaphragm, revealevidence of left sidedpneumomediastinum. resultingin cleardelineation of centralparts of G+ I diaphragm. -1 In this case,free gaswas observedtracking vertically -d on the left side of the heart,the arch of aorta& the c) Lucent ring aroundthe right pulmonary artery ry I descendingaorta. Besides,radiographic evidence on a lateralchest radiograph. t pneumothorax r of & continuousdiaphragm sign were d) In infantswith pneumomediastinum,the thymic I present. t Howeverthere was no hydropneumothorax, lobes are shifted upwardsresembling a full t. hydrothorax,consolidation. The eponymously 'V' spinnaker[2]. described sign of Naclerio was not appreciated 'V' e) signof Nacleriowhich describes in in this case. air the left cardiovertebral angle of the diaphragm. DISCUSSION D Delayed mediastinalwidening representing Cfillto Chestradiograph in typical casesof pneumome- presenceof mediastinitis[][3]. ai the diastinum often demonstratesthe undermentioned Clinicalexamination of a caseof pneumornedi- setof findingsin variouscombinations: astinummay revealany of the following: a) :s and a) Linear radiolucentareas vertically trackingthe subcutaneousair; b) Hammansign denotingpre- ortion left sideofthe heart,retrosternally, precardiac, cordial systolic crepitationsassociated with or surroundingthe trachea Besidesthis diminutionof heartsounds and c) pneumothorax. out of []. ----- rueliv- hydropneumothoraxor hydrothoraxmay also tlil4t. , anyof be present. A Barium swallow performed subst{iciirl c.r osting her areshown as Fig2 & 3 respectively.The barium tsuna- rsedto r,etc.). health risdis- I risfact ..l- : diffi- ls were dearth I Care. ho had ;unami :mbers unac- alrhof

I com- laysof rission '1" rvices, Fig. 2 : Barium swallow shows filling defect due to an Fig. 3 : Bariumswallow shows epidence of perforation. of de- i impactedforeign study with contrastspill into mediastinum .tiJr 7,No.l Jour Maitte Medical Society,2005, Vol.7, No. I 9t --

swallow reveals an impacted foreign body in the REFERENCES mid esophagus,which perforated the esophagus. l. Brooks AB Martyn C. Pneumomediastinum. Br Metl J 1999Jan l3; l(6156): 125. Thoracotomy & immediate repair of esophagus 2. Briassoulis was performed. Patient has recovered completely GC. Venkataraman ST, Vasilopoulos AG. Air leaks from the respiratory tract in mechanically and is currently asymptomatic at follow up. ventilated children with severe respiratory disease. Pediatr Pulmonol 2000: 29(2): 127-34. FINALDIAGNOSIS 3. Albaugh G, Kann B, Whalen TV. Spontaneous II Pneumomediastinumdue to oesophagealperfo- pneumomediastinumin a shallow-water-divingchild. ration by a foreign body. Pediatr Emerg Care 2O0l: l7(4):262-3. fi. 4. Ryan J, Banerjee A, Bong A. Pneumomediastinum in association with ingestion. J Energ Med 20Ol: 20(3\: 305-6.

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