in South East Asia - WHO

Environmental Health Relief Efforts after the

in South East Asia

© World Health Organization (2005)

Publications of the World Health Organization enjoy copyright protection in accordance with theprovisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction ortranslation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia,application should be made to the Regional Office for South-East Asia, World Health House,Indraprastha Estate, New Delhi 110002, India.

The designations employed and the presentation of material in this publication do not imply theexpression of any opinion whatsoever on the part of the Secretariat of the World Health Organizationconcerning the legal status of any country, territory, city or area or of its authorities, or concerning thedelimitation of its frontiers or boundaries.

Designed && PPrinted bby Macro Graphics Pvt. Ltd., www.macrographics.com

CHAPTER 1Tsunami: The Initial Impact 1

1. Loss of Infrastructure 32. Damage to Health Facilities 4

CHAPTER 2Challenges: No Calm after the Storm 7

1. Contaminated Water Sources 72. Sanitation 83. Risks from Hazardous Waste 94. Personal and General Hygiene 10

CHAPTER 3 Response 11

1. Disease Surveillance 112. Safe Water 123. Safe Food 174. Sanitation 205. Waste Management 216. Guidelines for Relief Work 24

CHAPTER 4 Rehabilitation and Reconstruction 27

1. Environmental Health Strategy 272. Resettling in a Healthier Environment 273. Strengthening Emergency Response Systems 294. Preparedness 29

CHAPTER 5 Lessons Learnt 31

1. Co-ordinating Responses 322. Post-disaster Needs Assesments 323. Effective Guidance in Disaster Response 334. Strengthening Capacity 335. Immediate Relief 346. Institutional Capacity and Coordination 367. Capacity Building and Emergency Preparedness 378. Conclusion 39

C o n t e n t s

T he tsunami that struckAsia on 26 December2004 was one of the

worst natural disasters in modernhistory. Although India, Indonesia,the Maldives, Sri Lanka andThailand bore the brunt of this catastrophe, several othercountries - including Myanmar,Somalia, Bangladesh, Kenya,Malaysia, Seychelles and Tanzania- were also affected.

Over 280,000 people are believed tohave died and 500,000 people wereinjured. A considerable numberneeded urgent medical or surgicaltreatment. Over one million peoplewere displaced from their homes.Overall, an estimated five millionpeople were directly or indirectlyaffected. Damage and destructionto infrastructure left hundreds ofthousands of people homeless andwithout adequate water/sanitationand healthcare facilities.

Indonesia - particularly theprovinces of Aceh and NorthSumatra - was the worst affected.With more than 130,000 peopledead and another 93,000 missing,and 514,000 people displaced in 18districts, Indonesia's devastationwas unprecedented. Twenty percentof the Acehnese population wasrendered homeless, and not a singlefamily in the region was untouchedby the disaster. Hundreds ofcommunities were totally washedaway.

Health facilities collapsed, as thetsunami painted a line ofdestruction across cities andvillages. A large number of healthworkers were also killed, injuredor otherwise affected. The peopleof Aceh and North Sumatra, in particular, were severelytraumatized by the scale of thetragedy. Rebuilding the regionrequires more than rebuilding

roads and bridges; it will entailreviving lives and livelihoods andresurrecting entire communities.

In India, more than 2,000kilometers of coastline along thesouthern states of Tamil Nadu,Andhra Pradesh and Kerala andthe Union Territory of Pondicherrywere damaged by the tsunami.The Andaman and Nicobar Islandswere severely hit, with more than215 aftershocks reported. Wavesas high as 3 to 10 meters sweptthe islands, sometimes as far as 3kilometers inland. Over 10,000people were killed and severalthousand were injured. More than3.6 million people were affected.

Although the number ofcasualties in the tiny islandnation of Maldives was lowcompared to the other affectedcountries, the impact wastremendous - one-third of the

1 Jan Speets, Environmental Health Advisor, WHO — October 2005

1

"Extreme situations demand extreme responses."1

TsunamiThe Initial Impact

Environmental Health Relief Efforts afterthe Tsunami in South East Asia2

population was affected. Thedeath toll reached 82, the highestin the history of Maldives in asingle disaster, with another 26people missing and 2,214 peopleinjured. Over 11,000 were lefthomeless, of which about 5,000had to be evacuated. The entire population of 13 islandshad to be shifted to other islands. Providing relief waslogistically difficult, consideringthe fact that the country's 200 inhabited islands stretch almost 900 kilometers across theIndian Ocean.

Sri Lanka, another island nation,was one of the worst affectedcountries. Around 550,000 people- a considerable percentage of the country's 20 millionpopulation - were displaced in 10districts. They moved into about1,000 camps for InternallyDisplaced Populations (IDPs)within a very short time. Around30,000 died. Almost all thedrinking water supplies andsanitation facilities in the coastal belt were affected. The total cost of therehabilitation and reconstruction

of water and sanitation facilitieswas estimated at about USD 220 million.

In Thailand, six provinces - includingpopular tourist destinations like

I was in Malé for official work on the day of the tsunami, and heard of it the same day. Thefishermen and walkie-talkies helped spread the news. Although I had heard that the damagewas extensive, nothing prepared me for what I actually saw. At first, I saw people crying. Then,as I went further into the island, I panicked and was very sad. As the chief of the island, I feltresponsible; it was very personal. After some time, we heard about the damage in the Maldivesand the support we could get elsewhere. We realised we could not survive on a small island likethis. So we took the decision to abandon the island and go to Burunee.

We left literally with what we stood in. Most of my family was in Malé. I wanted to be strongand show my people leadership. Two people died and 6 are still missing. Some people have goneback, but there is nothing for them.

Here we are overcrowded, which is difficult. There is no privacy. Also, the water is not good; ithas a bad smell. I am convinced that we will be here for a year and a half more. We want to stayhere in spite of all the difficulties. We realise that it is not feasible to go back to our island. Wedo appreciate what the government is doing for us.

Water supply is the priority, and then overcrowding. There are 2 extra units to be constructed,which should provide some relief from the overcrowding. The men are doing the same work asbefore, but for the women it is more difficult. The school has constructed 6 extra classrooms,which has helped enormously. This was good for the children. They have integrated very well intotheir new school.

There is no more counselling now. But I still feel there is a need for it. In 6 months time, I wouldlike to see jobs for my community members. For me personally, I want to see permanent housingas soon as possible. The food, drinking water etc. is ok.

People often ask us why there were so few deaths in the Maldives compared to other countriesaffected by the tsunami. I believe it is because we are taught to swim in the sea from a very earlyage. We have the instinct to survive even in water.

IIssmmaaiill SSaaiidd,,iissllaanndd cchhiieeff ffrroomm

GGeemmeennddhhoooo

Phuket, Ranong, Satun and Trang,Karbi and Phang Nga - were almostflattened by the giant waves. Thetsunami affected 660,000 people,and claimed over 5,300 lives.Around 3,000 people were reportedmissing and more than 17,000 wereinjured.

Unlike other countries in theregion, the tsunami had only amild impact in Myanmar. About5,000 people were estimated tohave been affected along thesouthern coast of the country.Sixty-one people were reportedkilled and another 43 injured.Damage to the public healthfacilities was minimal.

Loss of Infrastructure The unprecedented devastationthat the tsunami brought toinfrastructure in each one of the affected countries wasunimaginable. Though the tsunamiis not a new phenomenon, in manyparts of the affected areas, people

had never even heard the namebefore. Obviously, nobody - not

even the governments - wereprepared. Hundreds of thousands

Tsunami The Initial Impact 3

Everybody was devastated by the news of the tragedy - such an enormous impact on a scalewe have never seen before. Personally, I was overwhelmed by the pictures that we saw ontelevision. It was a day after Christmas; everybody was in a holiday mood. Immediately wecame to realize that we have a big role to play. We had no clue which way it would go. Wedidn't have any information on the actual size of the disaster. Also the pre-tsunami situationin Aceh was sketchy because of the ongoing internal struggle there. Lack of information wasan extra complication in designing any meaningful response. If you do not know thesituation, what can you do? It is no exaggeration; we were pretty much taken aback,overwhelmed.

We, however, felt a heavy responsibility on our shoulders. At the same time we were helpless. Weall sat together and discussed what we could do. Three persons from our office visited Aceh toset up a site office and decide on a possible course of action. The WHO office was also destroyed.Fortunately, no WHO staff was affected, because it was a holiday.

It became clear that it was a situation that we have never experienced before.

JJaann SSppeeeettss,,

WWHHOOEEnnvviirroonnmmeennttaallHHeeaalltthh AAddvviissoorr,,

JJaakkaarrttaa

of houses were razed to ground or made unfit for living. Hospitals, water supply andsanitation systems, roads andcommunication links and otheressential services were totallydestroyed in several affected areas.This led to the displacement of avery large number of people. Thetsunami also impacted the socialinfrastructure, affecting theavailability of local governmentworkers and trained professionals.

Almost all standing field crops diedwhere agricultural land wasflooded by seawater, shatteringthe economy of these areas. Butthe impact varied, depending onthe nature of damage caused tothe soil in various affectedcountries. In some areas of Aceh,for instance, there was reportedlysufficient rain to leach most of theimported salts and allow plantingof rice in the latter half of 2005.But in other areas, farmers willhave to wait for several seasonsbefore they are able to decide onthe fate of their land.

A year after the disaster, a largenumber of the affected people stillneed relief assistance. Theirgovernments, with support fromthe World Bank, the UN,international donors and theprivate sector, are rebuildingsettlements, basic services inwater and sanitation and healthcare structures. New healthfacilities will be made earthquake-and tsunami-proof, and will belocated in resettlement areas.

Substantial resources weremobilized in partnership with thegovernment health authorities,and in collaboration with other

UN agencies, the InternationalFederation of Red Cross (IFRC)and NGOs. Thus, the rebuildingand recovery process provided anopportunity for the health sector

in the affected countries, assistedby the World Health Organization,to strengthen their public healthsystems in the long-term.

Damage to HealthFacilities Damage to health facilities inIndonesia was particularly acutewith 53 of the 244 healthfacilities (22%) destroyed orseverely damaged. Fifty-seven ofthe 497 provincial health officestaff died, while 59 were reportedmissing - a loss of almost aquarter.

WHO's rapid assessment of SriLanka's affected areas, incollaboration with the Ministry ofHealth, highlighted substantiallosses and difficulties. Severalmajor hospitals were damaged, andmany smaller health units andMinistry of Health offices, close tothe coastline, were completely orpartially destroyed. Sri Lanka'shealth service was stretched by thescale of the emergency, withmedical and hospital supplies


"The aftermath of the tsunami presented a great public healthchallenge to WHO", said Dr Samlee Plianbangchang, Regional Director,WHO South-East Asia Region. "However, every disaster presentsopportunities to both the countries and the international agencies tostrengthen their capabilities and capacity."

reported to be very limited. TheRegional Medical SuppliesDivisions (RMSD) of Kalmune andMatara were damaged, disruptingdrug and vaccine distribution tothe affected areas. Storage ofvaccines became impossiblebecause of damaged refrigerators.One of the major setbacks faced bythe affected districts was lack ofmobility. Since almost all vehicleswere lost in the tsunami, it wasdifficult to reach out to those whowere in temporary sheltersscattered throughout the districts.Health teams, especially the field-level heath care workers, such asPublic Health Inspectors and PublicHealth Midwives, also faced thesame problem. Loss of vehicles alsomade it impossible for districthealth authorities to coordinate,monitor and supervise thedisrupted health services.

Lack of adequate health servicepersonnel was another majorobstacle in the initial stages of the

emergency. Volunteers and NGOsplayed a major role in supportingessential health services.

In the case of Maldives, thetsunami proved to be a huge blowto the country's public healthinfrastructure, damaging oneregional hospital, two atollhospitals, 14 health centers and 20

health posts. With 2,214 peopleconfirmed injured, prompt accessto adequate health facilities and treatment was logisticallydifficult, owing to the country'sgeographical makeup - 200inhabited islands stretching almost900 kilometers. Initial healthconcerns also focused on thecontamination of water and lack

Tsunami The Initial Impact 5

As for my personal experience of the disaster, visiting these camps was a tremendousexperience difficult to describe. All those who were working in the area were affected one wayor the other. It was such a devastating scene that it was difficult to comprehend. Everyone hadlost some one or the other. What can you say to them in a word of consolation? Here was alittle boy, who lost the entire family and possessions. You say 'hello' to him he does not respond,he just stares into nothingness. He doesn't know what his future would be! The affected peoplewere completely crushed, mentally. Therefore, programmes pertaining to Mental Health werevery important. I can say with confidence that all these issues were attended to and necessarysteps were taken.

But it is not possible to meet each and every demand, and naturally, in some areas supply fellshort of demand. Looking back now, I am still worried about what needs to be done. Some timeago, the UN Coordinator, the highest official coordinating the post-tsunami relief andrehabilitation operations, said, "the progress has been too slow". It does not pertain only to WHO,but all agencies. Nine months after the disaster, people are still living in squalid camp conditionsin many affected areas. Money was not a problem. In fact, there was too much money.

JJaann SSppeeeettss,,

WWHHOOEEnnvviirroonnmmeennttaallHHeeaalltthh AAddvviissoorr,,

JJaakkaarrttaa..

““AA TTrraauummaattiiccEExxppeerriieennccee””

of adequate sanitation facilities,posing the threat of diarrheal

diseases. There was also concernabout vector-borne diseases.

In India, fortunately, the majorityof health facilities were eitherintact or services could beextended to the affected areaswithout much delay, except inAndaman and Nicobar Islands.

Although seriously overstretchedinitially, in India and Thailand,government resources and,especially medical staff andprofessionals from other sectorscould be mobilized to providesupport in restoring basicservices.


T he impact on theaffected countries wasvaried. In Aceh and the

Andaman and Nicobar islands thedamage was such that it tookweeks to make a properassessment, while South India, SriLanka, Thailand and Maldivesmanaged to quickly assessdamage and rapidly mobilizeassistance. Waste management -i.e. safe disposal of human waste,solid waste and hospital waste -was a particular concern due tothe volume and the absence of functioning landfill sites inmany affected areas. Householdand community wells werecontaminated with salt water anddirt. Debris also posed a risk ofinjury and the threat of vector-borne disease. Some industrialfacilities and a nuclear researchplant, in Tamil Nadu, requiredcertification of risk.

The tsunami led to a plethora ofquestions on the environmentalhealth risks emanating fromdisasters of this magnitude.Environmental health status in any

situation depends on several factorsincluding quality and quantity ofwater, waste disposal facilities,food safety, health surveillance,sanitation and general hygiene.

Contaminated WaterSources The tsunami caused majordamage to the drinking watersources and supplies in theaffected areas, contaminatinghand-dug wells and production

wells, breaking up piped watersupplies and making surfacewater unfit as a water source.

Indonesia Contamination of ground waterreservoirs by saline intrusion wasthe most evident consequence ofthe tsunami. Water supply andsanitation infrastructures includingtreatment plants and theirdistribution network were seriouslydamaged.

2 ChallengesNo calm after the storm

The main challenge facinginternational agencies and aidworkers was dealing with increasedsalinity along the coastal areas ofAceh. Some water sources had tobe abandoned creating the need torapidly find other sources, such aswells on higher land, deepboreholes, or springs. In Aceh,using protected springs in the hillswas problematic due to the on-going internal conflict.

Sri LLankaAs in Indonesia, drinking watersources were unusable due toexcessive salinity. About 12,000wells were damaged, particularlyin the remote areas. Another50,000 wells were abandoned.Distribution pipes along thecoastal area were severelydisrupted or totally washed away.Major bridge crossings were alsoshattered, taking along with themthe trunk lines laid across them.Approximately 60,000 householdlatrines were destroyed

MaldivesThe hydrogeology of the Maldivesposes a particular difficultyregarding access to safe drinkingwater, as they comprise smallislands surrounded by largeexpanses of seawater. Thefreshwater aquifer lying beneaththe islands is a shallow lens, no more than a few meters thick. This aquifer is normallyexposed to pollution from poorwastewater practices as well asfrom badly constructed septictanks.

The problem became worse afterthe tsunami, as ground waterexperienced high levels of salinity.Most wells were completely flooded

with seawater. After the tsunamimost affected islands had to rely onrainwater and desalinated water fordrinking purposes.

India In the southern Indian state ofTamil Nadu, the tsunami broughtup titanium from the sea bed. It isnot clear whether this will cause longer term environmentaldegeneration or water qualityproblems. The tsunami also had adetrimental impact on groundwater

quality and sanitation, especiallydue to poorly-maintained septictanks, which continue to pollutegroundwater widely.

Sanitation The sanitation challenge posed bythe tsunami was much higher thanwater supply. In most of the affectedareas, sanitation facilities weredestroyed or rendered unusable.

Proper disposal of human excretafrom emergency and reconstructedlocations of habitation is essentialfor protecting human health andthe environment. Human faecesmay contain a range of disease-causing organisms, including


viruses, bacteria and eggs or larvaeof parasites. These microorganismsmay enter the body throughcontaminated food, water, cookingutensils or by contact withcontaminated objects. Variouskinds of diarrhea are spread in thisway and can be major causes ofsickness and death in disasters and emergencies. When previouslyendemic in the affectedpopulations, cholera and typhoidmight also pose serious publichealth risks.

Intestinal worm infections aretransmitted through contact withsoil contaminated with faeces andmay spread rapidly where opendefecation occurs and people are barefoot. These infectionscontribute to anaemia andmalnutrition, and therefore canrender people more susceptible toother diseases. Children areespecially vulnerable to all theabove infections, particularly whenthey are under the stress of disasterrelocation, high-density-campliving and malnutrition. Whilespecific measures can be taken toprevent the spread of infectionthrough human faeces (e.g.chlorinating the water supply,promoting hand-washing withsoap), the first priority is to isolateand contain faeces.

Risks from hazardouswaste The tsunami posed a hugechallenge to waste management.This was largely due to the vastgeographical area affected and

the extent of the damage. Aidorganizations and governmentagencies found that the approachthey had used in other large-scaleemergencies had to be modifiedto deal with these circumstances.

Even in normal situations,accumulation of waste, especially inurban areas, creates public healthrisks through the proliferation ofinsect and rodent vectors ofdiseases. The debris left behind bythe tsunami posed a threat on amuch larger scale. Besidesfacilitating the breeding of vectors,inadequate waste managementcauses pollution of surface andgroundwater, compromising thesafety of drinking water.

The destruction caused by tsunamidisplaced hundreds of thousands ofpeople who were then forced tolive in temporary shelters. As thenumbers were high, it waslogistically difficult to maintainproper environmental health in the

camps or shelters. Constructingtoilets for such large numbers ofpeople was a major challenge,considering their culture, traditionsand practices.

In the first few days after thetsunami, the disposal of deadbodies posed a problem for thegovernments. Internationalagencies and NGOs assisted thelocal authorities in disposing of thebodies as quickly as possible. Thetask was not easy, as the need forproper identification of the deadperson and local customs andpeople's sensitivities had to betaken into account before any bodycould be buried or cremated. Onthe other hand, people's fear ofoutbreaks of diseases, due todecaying bodies, had to be takeninto account. The widespread beliefthat corpses pose a risk ofcommunicable disease is wrong.Especially if death resulted fromtrauma, bodies are unlikely tocause outbreaks of disease such as

ChallengesNo calm after the storm 9

typhoid, cholera, or plague.However, corpses may transmitgastroenteritis to survivors if theycontaminate streams, wells, orother water sources.

Since normal sanitationstructures were damaged ordestroyed in affected areas,disposal of human faeces wasone of the main problems. It was important to preventoutbreaks of waterbornediseases, particularly among thedisplaced populations.

Disposal of hazardous waste,including clinical waste andchemical waste from factories or other sources, was anotherarea that needed attention.Fortunately, in most affectedareas, except in Aceh, chemicalwaste did not pose any seriousthreat. Disposal of clinical wastesposed a greater challenge thanany other waste.

Personal and GeneralHygiene An important issue following thetsunami was personal and generalhygiene, especially in the IDPcamps. The large numbers ofpeople displaced from theirhomes, and thus living intemporary community shelters orcamps, had little resources toaddress sanitation problems ormaintain hygiene standards.

The aim of any water and sanitationprogramme is to promote goodpersonal and environmentalhygiene in order to protect health.Hygiene promotion is defined in theSPHERE2 guidelines as a mixture ofthe people's knowledge, practiceand resources along with agencyknowledge and resources.

Effective hygiene promotion relieson an exchange of informationbetween the agency and theaffected community. This can helpidentify key hygiene problems andenable the community to design,implement and monitor aprogramme to promote hygienepractices. Furthermore, it canencourage the optimal use offacilities to ensure the greatestimpact on public health.

Proper washing of hands and theavailability of soap is one of themost effective ways of preventingthe spread of diarrhoeal diseases.Throughout the emergency stageand reconstruction activities,hygiene promotion had to beintegrated into water supply andsanitation activities.


2 The Sphere Project, Humanitarian Charter and Minimum Standards in Disaster response, 2004 edition (WWW.sphereproject.org)

Even experienced disastermanagement experts acrossthe world were

overwhelmed by the magnitude ofthe tsunami disaster. Never beforehad a natural disaster struckseveral countries across South andSoutheast Asia and affected evenareas in Africa. The world - bothgovernments and people -responded with unprecedentedgenerosity and solidarity to theaffected communities and localand national authorities.

The first priority was to provideimmediate relief to ease thesufferings of those who survivedthe disaster and restore theirbasic needs.

Disease SurveillanceThe large number of displacedpersons, crowded conditions,flooding and a vulnerablepopulation posed an increasedrisk of communicable diseasesfollowing the tsunami. Thus, theimmediate health concern wasthe identification and controlof potentially widespread

outbreaks of disease that couldsweep across the region.Reacting without any loss oftime, SEARO set up anOperations Room in New Delhiand sent out both general andtechnical guidelines togovernments and regional andlocal civic authorities to dealwith all aspects of the healthsector, including information ondisease surveillance, provision ofsafe water and food andsanitation facilities.

WHO staff, including the GlobalOutbreak Alert and ResponseNetwork (GOARN) were deployedto Aceh Province in Indonesia, SriLanka and Maldives to assist theministries of health (MoH) withthe establishment of supplementalsurveillance, early warning alertand response systems (EWARN).The principal objective of thesesurveillance systems was to detectepidemic-prone diseases occurringin the population, based onsymptomatic diagnosis followed

3 Response

by laboratory confirmation, and toinstitute necessary interventionsto contain further spread ofdisease and limit morbidity andmortality in affected populations.

No doubt the timely re-establishment of diseasesurveillance systems with assistancefrom WHO, helped prevent anymajor outbreak. These systems ofepidemiological surveillance andoutbreak response will now be usedas part of the routine integrateddisease surveillance.

Safe Water Safe and adequate water supply isone of the pre-conditions forreducing environmental healthrisks and promoting good hygienepractices.

Emergency Water Supply: Themost important immediateenvironmental health measurethat must be implemented, afteran emergency, is the provision ofsafe water for drinking andcooking along with facilities forexcreta disposal. WHO, working inassociation with relief agenciesduring the emergency phase ofthe disaster, focused on ensuringthat the population had access toall possible safe water sources.Activities included monitoringwater quality, repairing damagedinfrastructure and providingtechnical advice to relief agenciesand government officials.

In water supply and sanitation,UNICEF is the lead-agency in

the UN-family. WHO supportsUNICEF in planning andcoordination, and in waterquality management. WHOwater experts were able to startrapid assessments in theMaldives and Sri Lanka at theend of the first week, while inAceh, WHO water and sanitationexpertise was provided to the Inter-Agency Rapid HealthAssessment Team operatingfrom the USS Abraham Lincoln.Initially, WHO staff physicallysat with UNICEF in Sri Lankaand Aceh, and thus contributedsubstantially to a coordinatedeffort by government, UN-agencies and NGOs. All affectedcountries have subsequentlymaintained a permanent WHOwater and sanitation presenceduring 2005, with additionalstaff being assigned to Aceh,due to the complicated natureof the restoration of water andsanitation facilities.

Water Supply Reconstruction: Thefocus of the reconstructionactivities was on ensuring theprovision of sufficient safe waterbased on guidelines establishedby WHO, in conjunction with international, bilateral, andspecialized agencies (i.e.Guidelines for Drinking WaterQuality, Environmental Health inEmergencies and Disasters, etc.)Throughout the reconstructionphase, measures were taken toensure, not only the provision ofan adequate quantity of safewater in the short-term, but also

that the water supply systemwould not be vulnerable topossible future disasters.

Wherever possible, WHOemphasized the principles outlinedin Water Safety Plans (WSPs), as recommenced by the WHOGuidelines on Drinking-waterQuality. These plans provide apreventive 'quality assuranceframework' for a cost-effectiveand systematic means of ensuringan acceptable supply of safedrinking water. WSPs are alsobased on a 'Catchment toConsumer' approach for managingwater safety from source toconsumption by assessing hazards,identifying control measures,monitoring and verification; andby developing management plansfor normal and disaster conditions.

Although a significant proportionof activities focused on workingwith communities and otherpartners in the reconstruction of


household and community basedwater systems, another majoraspect of WHO work was onensuring that hospitals, clinicsand schools had access to safe water. These activities were directly funded by WHO, and involved assessing localmedical and education facilities,determining priorities, andproviding the necessary resourcesto ensure access to safe water.

IndiaIn India, WHO initiated rigorouswater quality monitoring andsanitation projects in the reliefshelters in the worst affecteddistrict in Tamil Nadu. Assistancewas provided for monitoringmicrobial contamination of water and laboratory surveillanceof Shigella spp and cholera spp.WHO supplied 1,000 chloroscopesto monitor the quality of drinkingwater in the affected areas. In collaboration with theGandhigram Rural Institute, WHO also provided technicalassistance to district authoritiesto strengthen the monitoring of drinking water quality, hygiene education, and wastemanagement in Nagapattinam,Kanyakumari and Karaikal.

In addition, a long term project tomonitor the changes in groundwater quality, following thedisaster, was initiated in all thecoastal districts of Tamil Nadu. Aproposal is being developed withthe Tamil Nadu Water andDrainage Board to assess changesin drinking water quality in thecoastal areas after the tsunami.

IndonesiaWHO worked closely with theprovincial health authorities,providing technical advice and support in assessing water quality in the affectedareas. Assessments focused on evaluating the damage and resource requirementsnecessary to protect health.Short/medium and long-termneeds were assessed. These

included procurement of suppliesand equipment for monitoring andtesting, development of guidelinesand promotion of good hygienepractices. These activities werecomplemented by practical waterquality monitoring workshopsorganized in collaboration withUNICEF and MOH. WHO trained21 agencies and NGOS in watermonitoring and testing.

WHO further provided water and sanitation supplies andequipment (tankers, sludgepumps, and consumables, etc.)and assisted in emergency repairsto water treatment plants byproviding supplies and equipment(silica bed and filter beds).

WHO guidelines were adapted to the Aceh conditions andtranslated into Indonesian. Theseincluded a water quality testmanual, technical notes foremergencies and sanitaryinspection forms.

In collaboration with the UNICEFand Australian emergency healthexperts, assessments of the water,sanitation and health situation incamps for internally displacedpopulations (IDPs) were carried

Response 13

out in Banda Aceh. Theseassessments suggested that thecapacity for providing waterthrough water tankers wasinsufficient and recommendedthat more tankers be supplied.

Though the transition fromemergency to routine surveillanceis now complete in Indonesia,there is still a need for moretraining and resources tostrengthen the system. Waterquality testing of some watertankers in Aceh continues toreveal serious problems. WHO isworking with various stakeholdersto improve water qualitysurveillance at critical points.

Sri LLankaIn Sri Lanka, WHO was able tomake an initial assessment fairlyquickly. The priorities were toprovide clean water to reliefcamps and to health facilities, to ensure that water quality was systematically tested, toprovide sanitation facilities inareas where communities were

returning to their homes, and to ensure that all activities were complemented by hygieneeducation programs, particularlyin relief camps.

As a large number of shallowwells in the coastal areas wereseverely contaminated there wasan urgent need to empty the wellsof water and chlorinate therecharged water. This was themain source of drinking water forthe affected population.

As supplies in the interior of SriLanka were often still functioning,water tankers were extensivelyused to supply IDP camps.

At the request of the National Water Supply andDrainage Board, WHOdeveloped a one-page good practicesheet for agencieswho transported thewater to the IDPcamps to ensure thatadequate residualchlorine remained inthe water at thedelivery point.

This and other interventionsensured that WHO had good andregular communication with allwater and sanitation sector actors.

WHO also provided chlorinetesting equipment (Chloroscopes),dewatering pumps, chlorinetablets and water storage tanks tothe health department. Laboratory

equipment was purchased to strengthen water testinglaboratories in affected areas forthe water board and the provincialhealth department.

These activities werecomplemented by hygienepromotion campaigns. Trainingprogrammes were organized atnational, regional and districtlevel, including practicaldemonstrations of water testing,hand hygiene and water qualitysurveillance. Sanitation kits wereprovided to relief camps to enablecamp management to keep thepublic latrines serviceable.

Local water authorities confirmedthat the water testing kitsprovided by WHO were veryuseful for spot testing.


WHO also supported thepromotion of solar disinfection ofwater in its training courses tohealth staff and NGOs, usinglocally available promotionmaterials (SODIS).

MaldivesIn Maldives, WHO assisted thegovernment by procuringmaterials and equipment forwater quality testing andmonitoring, by assisting the Maldives Water andSanitation Authority (MWSA) indeveloping guidelines on watersafety risk management i.e.Water Safety Plans (WSPS), andby providing training tocommunity health workers insetting up a surveillance systemfor water quality testing andreporting. Other agencies suchas UNICEF provided testingequipment, rainwater harvestingtanks and materials anddesalination plants.

The Public Health Laboratory(PHL), Regional Hospitals andatoll hospitals were providedwith equipment to test water forchemical and microbiologicalcontaminants. Workshops onwater quality testing andmonitoring were organized forFamily Health Workers andCommunity Health Workers ontsunami affected islands. These workshops consisted oflectures and practical classes.Demonstrations covered the useof chlorine residual comparators,portable battery operated pH

metres and the Oxfam-DelAguaWater Testing Kit.

A surveillance programme wasdesigned with input from theisland communities. Healthworkers were trained in datacollection, data analysis, datainterpretation and reporting to the central authority i.eMWSA. Participants were alsotrained in the design andimplementation of Water Safety Plans (WSP). As stated previously these planshelp identify parameters andprocesses to be monitored

systematically, e.g. chemicalcontaminants, maintenance ofpipes and storage tanks etc.WHO also helped design a“model” Water Safety Plan(WSP) for rainwater harvestingsystems tailored for theMaldives.

To address long term sustainabilityof potable water supplies in Maldives, a geohydrologist,contracted by WHO, carried outdetailed assessments ofgroundwater resources andexisting water supply on selectedislands. Assessments included

Response 15

Response 17

resistivity surveys, topographicalsurveys, household surveys andwater quality surveys. MaldivesWater Supply and SanitationAuthority (MWSA) staff wastrained in geophysical surveyingincluding topographic surveying.The objective of this activity is toarrive at an ecologically soundmanagement of water resourcesavailable to island communitiesthrough improved harvesting ofrainwater, protection of groundwater by improving sanitation, and

by developing appropriatesolutions for waste water andwaste management.

Water and sanitation issues haveseen significant improvements,albeit by temporary measures,such as the provision ofdesalinated water in the islands,while long-term solutions for asustainable water supply arebeing sought. The timelyavailability of technical experts inaffected areas helped greatly inplanning the recovery efforts.

Safe FoodIn disaster situations, food safetyis crucial because contaminatedfood in affected areas can lead tothe risk of outbreaks of food-borne diseases such as dysentery,cholera, hepatitis-A and typhoidfever. Poor sanitation, including

lack of safe water and toiletfacilities and the lack of suitableconditions to prepare food, haveled to outbreaks of food bornediseases in disaster areas in thepast. The people suffering fromthe direct effects of a disaster mayalready be at increased riskbecause of malnutrition, exposure,shock and other traumas. It is,therefore, essential that the foodthey consume is safe. This isparticularly important for infants,pregnant women and the elderly.

Following the tsunami, WHO wasquick to send food safety experts tocountries that requested supportand issued guidelines for reliefworkers and officials in ensuringfood safety at all stages-fromprocurement to transportation,storage, production, distributionand consumption.

The need for strengthening Food safety communication was well recognized at the 1998Regional Consultation on Food Safety in New Delhi.

A10-Point Regional Strategy for Food Safety was formulated. One of the priority actions was the"development of advocacy materials for policy makers, training resource materials forimplementers as well as education and training materials for producers, industry, trade, foodhandlers and the public [ are necessary"].

The Food Safety Units in WHO have since created materials for educating consumers on FOSrisks and about safe food handling behaviours that can help minimize those risks. The FOS "FiveKeys to Safer Food" Poster has made consumers become more aware and learn safe foodhandling habits.

Recently, SEARO translated the "5 keys" food safety poster in 18 languages and produced anaccompanying guidance booklet for use by small and medium scale food and restaurantbusiness owners/food vendors/ food & sanitary inspectors/ hospitality business students/consumer organizations/ schoolteachers, etc.

The booklet: "Bringing FFood SSafety HHome: FFirst, SSay iit RRight!", gives advice on how to adapt thefood safety messages to local needs.

CCoonnssuummeerreedduuccaattiioonn::

BBrriinnggiinngg FFooooddSSaaffeettyy HHoommee


The "Five keys to safer food"3

which are simple rules topromote safe food handling andpreparation practices werereinforced in the local languagefor guiding public healthofficials / volunteers and donoragencies. This information wasalso used to educate food

handlers and consumers abouttheir responsibilities towardsfood safety.

MaldivesMost of the affected countrieswere able to provide reliefsupplies without much difficulty,except in the Maldives. Pre-

tsunami Maldives was alreadydependent on the import of mostfood items, as agricultureaccounts for only 20 percent ofthe GDP. The tsunami resulted inthe destruction of hundreds offishing boats, fishing equipmentand the insulated storagefacilities belonging to fishermen,crippling Maldives' fish andseafood industry. After thetsunami, fruits and agriculturalcrops were swept away and mostparts of the agricultural landcovered with salty mud leaving itunusable for agricultural purposesin the immediate future.

Given this situation, WHO carriedout an assessment of food safety, inthe aftermath of the tsunami inJanuary 2005. Recommendations interms of immediate measures, shortterm measures and long-termmeasures were made to theGovernment for improving the foodsafety situation in the country.

Following this assessment, WHOassigned experts from the regionaloffice to assist the MaldivesMinistry of Health in implementingkey measures to facilitate thecapacity building in food safety inpost-tsunami Maldives.

WHO began its task by assisting theDepartment of Public Health (DPH)in the identification of suitable foodsafety monitoring tools4. Training

3 Keep Clean, Separate Raw and Cooked, Cook Thoroughly, Keep Food at Safe Temperatures, Use Safe Water and Raw Materials4 non-contact food thermometers, food probe thermometers, disposable swabs, thermolabels, chlorine concentration indicator strips

and cold chain monitoring data loggers

Response 19

of food inspectors was carried outin monitoring and compliance and auditing of food processingunits, resorts, hotels and food establishments. Food safetyadvocacy sessions were alsoconducted for officials from various Ministries and statutoryorganizations as well as for foodimporters.

WHO also supported the Ministryof Health in upgrading the PublicHealth Laboratory for effectivesurveillance of foods. Suitableequipment for monitoringchemical and microbiologicalcontaminants was identified andprocured. Staff received trainingon using this equipment.

The country's food safetyguidelines for monitoring foodprocessing units, resorts/hotelsand food imports were reviewedand comprehensive food safetydraft guidelines were developed.Guidelines were also developedfor safe handling of fish at sea,fish market, storage and transportof food. The application of thefood safety draft guidelines wasalso demonstrated during thefield visits by personnel fromDepartment of Public Health(DPH), Public Health Laboratory(PHL) and Water and SanitationAuthority (MWSA).

As part of the promotion of foodsafety measures among thepopulation in general, effortswere also made to include schoolsand promote food safety as one

more component of the `HealthySchool Initiatives' launched bythe Government, with supportfrom WHO and UNICEF.

WHO also helped the Maldivesgovernment to consider aNational Food Safety Strategy.This strategy is primarily based on`Risk Analysis' approach alongwith emphasis on self-regulationby the industry, consumerparticipation and selectiveenforcement by the government.The WHO recommendationsemphasize the constitution of aNational Food Safety Committee(NFSC) so as to provide a strongcoordinating mechanism foruniform implementation of foodsafety activities and effectiveimplementation of a Risk Analysisapproach.

IndonesiaThe earthquake and tsunami had asevere impact on food safety-related programs in the publichealth sector in Aceh and otherareas, destroying or damaginglocal (district), provincial, andnational offices. Many commercialestablishments including markets,food and water processing

facilities, and restaurants werealso disrupted. In addition, IDP camps and resettlementcentres created new challengesfor maintaining food safety during storage, preparation anddistribution.

The most pressing problems werepresent to a large extent before thetsunami. Food hygiene awareness,in general, was limited, andknowledge or concern about foodsafety was poor among the generalpopulation.

Most food safety-related activitiesin Aceh province, including foodservice and other inspections andmost importantly education offood handlers and food processors,were carried out at the district ormunicipal level. While there weresome dedicated public healthworkers with training in foodsafety and environmental health,their numbers were small, andtsunami-related staff shortagesmade things worse.

A mission to Aceh was undertakenby a WHO consultant together withan environmental health specialistfrom the Indonesian Ministry ofHealth and another from theUniversity of Indonesia. Thesespecialists worked with Provincialand district authorities to identifyneeds and develop plans of action inthe affected districts. While theimplementation part was carriedout primarily by district levelenvironmental health officers, WHOsupported the technical aspects.


Appropriate infant and young child feeding was promoted.Responding to concerns about thelarge quantities of milk powderbeing sent into the region, WHOand UNICEF issued a jointstatement on appropriate infantand young child feeding,cautioning caretakers and healthstaff about unnecessary use ofmilk powder and the need formonitoring the distribution of thisproduct.

Sanitation The provision of appropriatefacilities for defecation is one of anumber of emergency responsesessential for people's dignity,safety, health and well-being.

The focus of the sanitationreconstruction activities was on ensuring the safe disposal of excreta, so that it did not contaminate theenvironment, water, food orhands. In addition, sanitationreconstruction attempted toprevent the proliferation ofvectors. Certain species of fliesand mosquitoes lay their eggs,breed, or feed on exposedmaterial and can carry infectionto people and domestic animals.Rodents and other vermin canalso spread disease.

Measures were taken to ensuredisplaced people had a sufficientnumber of toilets, close to theirshelters to allow them safe andacceptable access at all times ofthe day and night.

Indonesia In some IDP camps thetemporary facilities initiallyprovided were inadequate orunsuitable. Sanitation needswere assessed for the campsassuming one toilet unit (with 2cabins; one each for male andfemale users) per 50 people.However, sharing toilets byvarious social groups in society created major problemsfor the authorities. Inadequateknowledge of proper use oftoilets, especially among thefishing community, and their

unwillingness to use toilets, were major challenges. However,construction of separate urinalunits helped reduce occupancyrate during peak hours in camps.

India In India, WHO supported theGandhigram Rural Institute incarrying out a post-tsunamipublic health project to extendbasic facilities for water,sanitation and hygiene promotionin some of the affected areas.After an assessment of theenvironmental problems in the

Response 21

IDP camps, a campaign wasdesigned to reach the affectedpeople with tools to maintainappropriate sanitation andhygiene habits.

Target specific Information,Education and Communicationprogrammes were prepared topromote better hygiene practices,and to encourage the communityto use the sanitation facilitiesprovided in the camps and avoiddefecation in the open. Tofacilitate proper hygiene, locallyspecific toilets were constructed.Group discussions, publicmeetings, cultural programmesand rallies were organized tocreate awareness. Local volunteersand community members weretrained in conducting culturalprogrammes on environmentalhealth to effectively disseminateinformation to their owncommunity members.

WHO also provided the affecteddistricts in Tamil Nadu withinsecticide-treated bed nets toprevent an outbreak of malariaand technical support for sprayingand fogging to prevent vector-borne diseases.

Sri LLankaAlthough Sri Lanka has quite asatisfactory sanitation coverage,this is low in the coastal areas,especially in fishing communities.Naturally, the problem becameworse with the temporarysettlement of affected communitiesin rehabilitation camps. Latrineswere provided to IDP camps by aidagencies and NGOs. However, as inIndonesia, the people for whomthese were intended did not usethem or maintain them properly.Poor hygiene habits posed a healthrisk and WHO had to addressthis problem.

WHO enhanced local capacity by "training of trainers", practical demonstrations, personaldiscussions, by motivatingcommunities and by providingsanitation kits. Much technicalliterature including fact sheets,guiding notes, books and relatedarticles were freely distributed.

WHO also agreed to support, twonational level, 12 district level and45 divisional level workshops forpromotion of hygiene behaviourand practices, in tsunami affectedareas. These programmes wereconducted through the HealthEducation Bureau of the Health Ministry. A national levelconsultative workshop and reviewwas held in Colombo in October2005. The workshop was attendedby 49 participants, mostly healtheducation officers, from all thedistricts of the country. Fact sheetsand reading material, developed by

WHO, and a set of seven postersdeveloped by UNICEF, weredistributed to the participants.

Waste Management The impact of the tsunami resultedin three fundamental challengesregarding the management ofsolid waste:

The need to immediatelyremove and dispose of largeamounts of rubble fromblocked roads and fromdamaged buildings

The total disruption andpartial destruction of wastemanagement systems anddisposal sites, especially inhealth care facilities

"Hot spots", where possiblemixing of hazardous andnon-hazardous materialshad occurred, increasinghuman exposure to toxicsubstances.


WHO's focus in working with reliefand reconstruction agencies, wasto ensure that all solid wasterecycling, removal and disposaloperations were done in a safe andenvironmentally sound manner.

Hazardous WWasteBeyond the havoc left in affectedhealth care facilities, the tsunamialso resulted in localized releases oftoxic and hazardous materials toterrestrial and marine environments.Emergency response activities such as uncontrolled disposal ofinfectious wastes from medical carefacilities, significant donations ofoutdated pharmaceuticals, largeamounts of plastic wrappingmaterials, and an accumulation ofempty pesticide containers used forvector control, aggravated theproblems of hazardous wastedisposal. Far-reaching and long-term effects on the environmenthad to be assessed.

HHeeaalltthh CCaarree WWaasstteeSpecial care had to be taken withrefuse from any health care facility.The main categories of waste thatcan be produced in these settingsare: infectious waste; pathologicalwaste; sharps; pharmaceuticalwaste; genotoxic waste; chemicalwaste; waste with high heavy metalcontent; pressurized containers;radioactive waste and hazardouswaste waters. Each type of wasterequires specific "cradle to grave" management measurefrom the site of generation,throughout segregation, handling,storage, collection, recycling and

final destruction. In emergencysituations on-site burial may beappropriate, following segregation.In extreme situations, where largefacilities produce significantquantities of infectious waste,incineration may also be considereda solution. Plastics should not beburned as their fumes may containextremely toxic substances (dioxins).This waste should be separated anddisinfected, if possible, for recyclingpurposes. Alternatively plasticsshould be buried properly. When health facilities operatediagnostic laboratory services,radiological diagnosis and treatmentfacilities, pharmacies, etc., wastemanagement is a specialized activityrequiring trained and well-equippedstaff.

WHO was requested to advise andsupport affected countries in thearea of health care wastemanagement. Expert consulting wasshared with all the SEAR countriesand substantial efforts on theground were undertaken inIndonesia (Banda Aceh and Sumatra

Provinces) and in the Maldives,through concrete projects.

IndonesiaPrior to the tsunami disaster,health care waste management inthe affected areas was not wellorganized. The main problem waslow awareness and knowledgeamong all health care personnel.This resulted in weak infectioncontrol practices and poor overallperformance of the few treatment

Response 23

systems. After the tsunami, mostpublic health facilities becamenon-functional and many of thetemporary health facilities did not have proper guidance orequipment to manage health carewaste adequately.

There is no environmentally soundwaste disposal capacity in Aceh.Disposal practices, where waste iscollected, is to open dumps,where burning is the normalpractice. In many areas, includingmost Tempoary Living Camps(TLCs) and IDP camps at present,waste is dumped in piles andburned on-site. Fly dumping iscommon throughout the province.

The only engineered landfill in theprovince was the Banda AcehGampong Jawa landfill, whichwas actually run as an opendump. It was heavily impacted bythe tsunami and then wascovered with tsunami waste.Reconstruction of a decentlandfill at the site is essential toassure basic waste disposalcapacity for Banda Aceh and theTLCs and IDP camps.

WHO staff assisted in developingthe plan for construction of theGampong Jawa landfill. They alsoassisted in the clinical wasteassessment and provided technicaloversight for disposal of 78 m3 oftsunami damaged medical waste atZ. Abidin hospital, which was

becoming a public health concerndue to scavengers.

At the request of the provincial health authorities,WHO Indonesia initiated a HealthCare Waste Management projectin the Nanggroe Aceh DarussalamProvince across the 13 tsunamiaffected districts5. After assessingthe extent of the problem,training was organized on wastemanagement. Materials andguidance were developed for over500 health personnel, clinicalwaste managers and disposalworkers.

Training included "training oftrainers" to create a resource basein all tsunami affected districts.Training manuals and tools weredeveloped on segregation of waste,storage, disposal and universalprecautions. A committee wasformed to effectively manageunwanted pharmaceuticals andexpired drugs.

Equipment was supplied to 30health care facilities to protectboth health care workers andpatients. This equipment includedfoot operated colour codedplastic bins for segregation at source, plastic liners, gloves, protective devices, needlecutters, bleaching powder fordisinfection, and waste sharpcontainers for containment.District hospitals received

autoclaves for disinfection beforedisposal, plastic shredders, andtrolleys for safe transportation ofwaste. Some district hospitalsreceived incinerators for finaltreatment of waste.

It is hoped that these efforts willhelp the government develop aNational Training Plan andagenda for health care wastemanagement.

Maldives Early on after the tsunami struck,WHO carried out a nationalassessment of health care waste management practices. The assessment found that therewas a general lack of awareness about inherent hazards caused by improper management ofhazardous waste. Information on existing management andtechnology options formanagement of waste was alsoinsufficient, and the country lackeda national policy, regulatory toolsand operational guidelines toensure sound management ofmedical wastes. Priority areasincluded the systematicintroduction of basic wastesegregation practices in all healthcare facilities, standardized sharpsmanagement in all health carefacilities, waste reduction at sourceand specific capacity building.

In close collaboration with the regional hospitals, simple

5 With substantial support from the European Commission


guidelines were developed onhealth care waste management,including a check list to help staffon a daily basis. Guidelines werealso developed on the managementof hazardous liquid wastes andmanagement of mercury in thehealth care setting. Equipment andmaterials, to enable all hospitals to implement their waste action plans, were identified. Theseinclude two high performanceincinerators, autoclaves, waste bins,autoclavable bags, cleaning carts,disinfectants, sharps' containers,laboratory equipment and personalprotective equipment.

As regards the purchase of theincinerators, a compromise wasmade between what waseconomically affordable andecologically sound. Health carewaste cannot be land filled on theislands or placed in a deep burialpit because of the possibility ofleachate entering the aquifer.Transport capacity in the atolls islimited and frequent transport byboat is not a realistic option

because of the costs of fuel,labour and equipment.

Capacity building in health carewaste management wasorganized for over 50 health careworkers from the regional andatoll hospitals, the Public HealthLaboratory, MWSA and theMinistry of Environment, Energyand Water (MEEW). All traineestook a 10-day training course atthe MS Ramaiah Medical College,Bangalore, India, in May, July andSeptember 2005.

WHO also supported the countryin determining the functionsof a health care wastemanagement coordinator totake the lead in developing astrategy for the country and inensuring that regular training isorganized for staff at allregional and atoll hospitals.

Guidelines for Relief WorkA significant part of WHO responseto disasters, like tsunami, are WHO

guidelines developed to aid thosewho are engaged in the reliefoperation. These are drafted andrevised from time to time afterlessons learnt from dealing withdisaster situations in differentparts of the world. In most disastersituations a large number of peopleengaged in the relief operation arenot trained to deal with all aspectsof such emergencies. Properinformation instils confidence andhelps them to handle the situationin a systematic way.

Immediately after the tsunami,WHO-SEARO sent out its standardguidelines for dealing with suchemergencies to the governments,international agencies, NGOs andothers engaged in relief operationsin all the affected countries. Thesewere also available in a dedicatedWHO website in a downloadableformat. Field response has indicatedthat these have been useful tomany relief workers.

The guidelines included, amongothers, information on:

General Management andHealth Systems

Disposal of Dead Bodies

Management of Hazardousand Infectious waste

Health Assessment

Women and Children

Psychological Support

Safe Water

Sanitation

Communicable Diseases

Vaccines and Immunization

Response 25

Food Safety and Nutrition

Logistics and Supplies

All these documents were meantfor field workers but someguidelines also had instructionsfor everyone including thevictims.

Good PPractice NNotes During 2004 four-page illustratednotes were prepared by WEDC6 forWHO to assist those working afteran emergency to plan appropriateresponses to the urgent andmedium-term water and sanitationneeds of affected populations. Thenotes are relevant to a wide rangeof emergency situations, includingboth natural and conflict-induceddisasters. They are suitable for fieldtechnicians, engineers and hygienepromoters, as well as staff fromagency headquarters.

The practice notes were revisedimmediately after the tsunami andpublished in early January 2005. Theywere also available on the Internet ina convenient downloadable format.They cover the following aspects ofemergency operations:

1 Cleaning and disinfectingwells

2 Cleaning and disinfectingboreholes

3 Cleaning and disinfectingwater storage tanks

4 Rehabilitating small-scalewater distribution systems

5 Emergency treatment ofdrinking water

6 Rehabilitating water treatmentworks

7 Solid waste management inemergencies

8 Disposal of dead bodies

9 Minimum water quantity

10 Essential hygiene messages 11 How to measure chlorine

residual12 Delivering safe water by

tanker

13 Emergency sanitation -planning

14 Emergency sanitation -technical options

Through the country level Watsancoordination mechanisms, WHOwidely distributed the Water,Sanitation and Health CD-RomLibrary, containing all currentWHO publications in the field.Courtesy of WEDC, copies of theCD-Rom on 'Emergency in WSH'and on 'Civil EngineeringContracting' were also provided.At WHO's request InternationalTraining Network ITN-Bangladeshcontributed their publication'Water Supply and Sanitation inRural and Low Income UrbanCommunities', for use byGovernment organizations, NGOSand WHO field offices.

6 The Water, Engineering and Development Centre (WEDC) is one of the world's leading institutions concerned with education,training, research, and consultancy relating to the planning, provision, and management of infrastructure for development

Environmental HealthStrategy

T he need to rehabilitateand rebuild the areasaffected by the tsunami

presented a unique opportunity toaddress the institutional, politicaland economic barriers that have, in the past, complicatedintegrated responses.

Although awareness of theimportance of environmentaldeterminants of health exists, thisawareness has so far been mainlyoutside mainstream health sectorpolicy. Health sector thinkingremains focused largely oncurative approaches to diseases,rather than on the broaderinteractions between people andthe surrounding eco-system. Onthe other hand, development andenvironment policies have alsooverlooked the links with healthdeterminants.

Public health was a key concernfollowing the tsunami destruction.WHO, as the agency leading onhealth, supported environmental

health assessments and providedtechnical assistance for theimmediate risks linked to water,sanitation and waste.

These assessments showed thatthere was a major need to scale upcapacity to address environmentalhealth issues on the ground. It was, thus, important to integrateenvironmental health considerationsin the planning and implementationof the rehabilitation andreconstruction of settlements andcommunities, including choices inshelter, land use, and rebuilding ofthe local economy.

As the phase of emergency responsemoved into rehabilitation andreconstruction, the environmentalhealth support refocused on adifferent set of issues raised byreconstruction. Opportunities aroseto promote public health and reduceenvironmental health risks bycollaborating with the developmentand reconstruction sectors at an early stage. Again, anenvironmental health presence inthe field was essential for this to

happen. It was backed up byexisting knowledge and experiencein addressing environmental healthin the economic activities beingredeveloped, such as coastalmanagement, fisheries, forestry,tourism and coastal agriculture.

Resettling in a HealthierEnvironment The aftermath of the tsunamiprovided an opportunity for thegovernments and the internationalagencies, including WHO, todesign the rebuilding process insuch a way as to improve qualityof life of the people. It waspossible to provide a more secureenvironment in many affectedareas. As previously discussed,various activities were identifiedfor action, particularly, clinicalwaste management, water qualityprotection, human and solid wastemanagement, and integratedvector management.

For the medium and long-termrehabilitation period, variousactivities were proposed in shelterand settlement (re)development,

4 Rehabilitation andReconstruction

livelihood restoration andemergency preparedness. It isessential to undertake suchactivities in consultation with thecommunities and local authorities,and apply environmental healthimpact assessments. This ensuresthat optimum socio-economic andhealth gains can be achieved. Forexample, temporary shelters(tents) and block toilets providedby an international agency inMullaitivu in Sri Lanka had to bedismantled to accommodate localconditions. The tents wererejected by the IDPs as they werevery hot and did not preventrainwater seeping into the floorarea. These were replaced bytemporary structures using locallyavailable material.

The approaches developed in thecontext of healthy settings orhealthy city programme, and thehealthy environment for children

initiative, offers guidance andtools that could readily beapplied.

Greater attention to environmentalhealth and to the restoration and maintenance of theengineering elements necessary to ensure a functioning physical environment, should go a long way to reduce the health risks associated with another disaster in the future.


7 Water resources tsunami impact assessment and sustainable water sector recovery strategies for the Maldives Water andSanitation Authority. Carpenter, C. GWP Consultants, WHO. September 2005.

Strengthening EmergencyResponse SystemsRegardless of their cause or nature,disasters can disrupt healthsystems. Post-crisis settings areoften characterized by greatnational expectations and intenseinternational attention. Local andnational authorities, often severelyweakened, must absorb majorinfluxes of external aid within avery short time frame. Indeed, thesetransitions have been described asperiods when partnerships with theinternational community arecrucial in underpinning fragilenational processes.

Plans for rehabilitation andreconstruction demand an in-depth understanding of national

realities and must be tailored tothe specific local and nationalcontexts. In any transition,rehabilitation and reconstructionstarts with a needs assessment.The needs assessment is usuallyundertaken by national and otherstakeholders: the UN agencies,humanitarian and developmentNGOs, civil society, thedevelopment banks and theprivate sector. In these contexts,WHO is generally called upon toperform the following functions:

1. To ensure links betweenhealth relief, rehabilitationand reconstruction.

2. To provide technical standardsfor a comprehensive needsassessment in the healthsector.

3. To support nationalauthorities with politicaland negotiating skills as well as high-qualityleadership to manage allthe aspects of theassessment and planningprocess in the health sector.

4. To serve as a bridge linkingcountry health authoritiesand the developmentcommunity.

PreparednessDisasters occur without anywarning and create havoc. The bestway to minimize the impact is to bealert and prepared. In the aftermathof the tsunami, one of the lessonsthat emerged is that communitiesand agencies should be betterorganized to deal with these events.

Rehabilitation and Reconstruction 29

Preparedness can reduce the impactin terms of fatalities and damage.Thus, there is an urgent need to

establish disaster preparednessmechanisms in many countries andavail of early warning systems forcyclones, earthquakes, floods,famine etc. Preparedness plans areneeded for the water and sanitationsector to facilitate emergencyresponse and early restoration ofessential services. Such plans wouldalso help prevent serious epidemics.

The best preparedness lies ingood functioning systems duringnormal periods. It was clear from the aftermath of thetsunami that in areas where civil authorities and sectoragencies where operating andcommunicating well, it was mucheasier to have basic servicesquickly restored.


T he tsunami of December26, 2004 caused majorloss of infrastructure,

destroying and damaging houses, hospitals, water supplyand sanitation, roads andcommunication links. Very largenumbers of people were displacedand many essential servicesdisrupted.

The damage and the impact in theaffected countries varied. In Acehand the Andaman and Nicobarislands it took weeks to make aproper assessment, while SouthIndia and Sri Lanka managed aquick overview of the affected areasand could rapidly mobilizeassistance. In the Maldives mostislands experienced physical andenvironmental damage.

In all instances water supplies weredamaged and community andhousehold wells unusable due tosalinity and dirt. Debris anddamaged buildings posed a risk of

injury and changed the vector bornedisease risk potential. Displacementexposed the population to a newsituation in which access to water,sanitation, food and shelterdemanded adjustments that mayhave introduced exposure to health risks.

In May 2005, five months afterthe tsunami, WHO organized aconference on the "HealthAspects of the tsunami Disaster"in Phuket, Thailand. Conferenceparticipants included keypersonnel from local and national

communities and internationalagencies. The conferencefindings, presented to the WorldHealth Assembly8 in May 2005,influenced the adoption of aresolution, unanimously passedby WHO's Member States, askingthe Organization to increaseits capacity to help themprepare for, and respond quicklyto, health aspects of disastersand crises.

At the conference, there wasconsensus on a number of stepsthat would lead to stronger

5 Lessons Learnt

8 WHO's governing body, the policy and decision making forum represented by all Member States

national disaster managementsystems in order to reduce loss oflife when disasters strike:

Co-ordinating responsesGovernments of disaster-pronecountries indicated that they needthe UN system's authoritativesupport with responding to (and, attimes, directing and controlling)offers of human resources,equipment and materials madeavailable through externalassistance - with WHO serving asthe health arm of the UN system.This is vital when numerousexternal groups offer assistance,creating major challenges for theplanning and phasing of externalinputs. When external assistancereaches a disaster-affected country,it should be managed through aparticipatory structure that involvesrepresentatives from both therecipient and donor communities.

A functioning coordinationmechanism allows capacity buildingfor emergency preparedness,including prior agreement on localstandards and approaches for waterand sanitation, taking into account

national expertise and the SPHEREstandards.

Post-disaster needsassessmentsThere are advantages in undertakingprompt assessments of people'shealth situations and needs when adisaster strikes. The assessmenttechniques should be well tested in advance, take advantage of pre-existing data, be based on universally available GIS data, for example, and use standardized multi-stagemethodologies. Techniques mustyield population-based information(expressed as rates and not asabsolute numbers).

Needs assessments should beundertaken by multidisciplinary

teams that address a range ofissues relevant to the emergency.The teams should at least havecompetencies in public health,water and sanitation, nutritionand food security; and if possibleprimary health care/maternal andchild health. The team wouldconsist of government officials toensure adequate consideration of cultural conditions and feed-back to local authorities.Duplicate assessments waste time and frustrate disaster-affectedcommunities.

The environmental healthcomponent of the assessmentconcentrates on immediate reliefin water supply and sanitation.The pre-disaster situation, withrespect to water supply, should betaken into account. If at allpossible, such information shouldbe collected before theassessment.

For example, in Sri Lanka pipedschemes in the towns and dugwells in the coastal belt weredamaged. Plans of existing pipedschemes helped to restoresupplies quickly (a reasonablesupply within 4 days) and allowed


Lessons Learnt 33

water distribution tocommunities, not linked up with apiped scheme, through tankering.

While the initial water andsanitation assessment reportswere deemed adequate for thepurpose of immediate relief,community consultation and

sensitivity toc u l t u r a l needs andexpectat ionswould allow foran improvedresponse.

A consolidatedpost-disastera s s e s s m e n tshould beconducted for as p e c i f i cp o p u l a t i o n .Further datacollection willbe needed overmany years -p a r t i c u l a r l ya m o n gv u l n e r a b l epopulations -to enable

proper planningand management

of support and assistance to trackevolving health needs and accessto services. Data should bedisaggregated by location andgender.

WHO is working with NGOs, theRed Cross, other UN systemsagencies and the IOM to develop

standardized health assessmenttools.

Effective Guidance inDisaster ResponseMember countries called for up-dated and evidence-basedguidance, and well-functioningprofessional networks, to helpimprove responses to specificproblems faced by crisis-affectedpopulations - including:

psychological reactions tothreats and losses andmental ill health,

gender equity and theparticular health andnutritional threats (includingthreats to reproductivehealth) faced by women,

food, nutrition and healthcare needs of children,

standard approaches foridentifying dead bodies andthe management of deadbodies,

ways to involve volunteerhealth workers and managein-kind donations duringdisaster response.

Strengthening CapacityParticipants from nationalgovernments confirmed that theywere ready to be better prepared for

OXFAM, in Aceh, reported positive results with the rapid community consultation. Theseassessments were done by a health and engineering team who were able to startimplementation within 24 hours with an action plan set in motion often by mobile phone on thejourney back to the office. Knowledge of pre-crisis levels of health awareness, health-seekingbehaviour, community social structures and women's status were supplied by the national staffmembers. The assessments were generally effective and efficient when community-driven orundertaken in consultation with the community.

Solar disinfection: SODIS

major disasters and that they wantto strengthen their own capacity fordisaster risk management andvulnerability reduction. Fundingshould be available to supportnational capacity building fordisaster preparedness andvulnerability reduction.

Immediate relief

Water ssupplyDrinking water was not a veryserious problem in most affectedareas. In Aceh, water andfirewood were available and aspeople normally boil water, mostcommunities survived until aidarrived. The use of hypochloritebased disinfectants for water wascautioned against by theGovernment of Indonesia as it isnot normally used i.e. people boilwater after disinfection.

Adequate supplies of drinking waterof reasonable quality were availablein Sri Lanka in the affected areas

within a few days. Most of thewater was supplied by tankers.However, adequate chlorination ofthe water at the collection point orhousehold level was a challenge.Residual chlorine at the distributionpoint was checked withchloroscopes, provided to publichealth inspectors and NGO fieldstaff to facilitate water qualitysurveillance.

In this emergency, wheredisplaced people lost nearlyeverything, provision of safewater containers or buckets witha lid, would be have been useful.

The tsunami crisis did howevercause a mismatch between needsand long-term sustainability of supplies. For example,desalination plants were providedeven though such equipmentcannot be maintained long-termby the community, withoutexternal assistance. While there isa need for quick fixes that can

produce large quantities of safewater, the final water supplyoption should meet communitycapabilities in operation andmaintenance, management andaffordability.

Limited attention seems to havebeen given to restoration orconstruction of institutional watersupply and sanitation systems inhealth facilities and schools.

SanitationSanitation in IDPs was a problemdue to improper site design orlocation of latrines, as it wasreported that women and childrencould not use the latrines duringthe night. Pit latrines were notacceptable in Aceh, as thepopulation was used to analcleansing using water. Theinhabitants of former fishingvillages in the affected coastalareas also did not have muchexperience with latrines.

The limited number of latrinescaused problems withmaintenance (regular cleaningand desludging). Suitable sites fordischarging latrine waste werenot easily available.

Some of the agencies thatassisted did not have experiencewith the challenges in sanitationand the design of camps.

HygieneIt is important to maintainhygiene standards by providingsufficient water, soap, hygiene


kits, etc. It is equally importantnot to take away from deeplytraumatised people the lastvestiges of dignity by assumingthat they are not aware of thebasic concepts of hygiene. Thus,hygiene promotion should bedone with sensitive reference tothe local cultural and socio-economic context.

Lessons LLearnt Restoration of water supplyservices, adequate and acceptablesanitation arrangements, propershelter and ability to maintainpersonal hygiene are importantinstruments to restore physical andmental health in the household.Items such as plastic sheeting and abasic household kit support thiseffort as these items enable thehouseholds to flexibility look aftertheir own affairs e.g. a plastic sheetis multi-functional as it provides aroof, can protect household assets,can help to collect rainwater, etc.

Food SSafetyAfter the tsunami food safety wasmonitored, but no outbreaks offood-borne diseases were recorded.Hand-washing was identified asprobably the most effective way ofavoiding infectious disease in thesecircumstances.

In Aceh, due to the timely andsignificant response from themulti-national militaries, basicfood staples, particularly rice andnoodles, were distributed byhelicopter to most locations onthe west coast. However, in most

areas, food supplies did notinclude protein, oil, sugar andvegetables. There was notargeting of food relief and little effort to get food to themost vulnerable populations(children under 5 years, elderly,pregnant and lactating women).Fortunately no acute, moderate orsevere malnutrition was noted.

Lessons LLearnt Food security has to beimproved to meet the basic nutritional needs, inparticular in infants, youngchildren and pregnantwomen

Distribution of food shouldbe coordinated by a singleagency and carried outthrough the civilianauthorities (rather than themilitary)

Each household should haveaccess to cooking andeating utensils, and waterstorage facilities

The tsunami experience alsohighlighted the need for food safety authorities to review all stages of the foodsupply, from procurement,processing, production, storage,transport, distribution, and sale, to preparation in food service,catering establishments andhouseholds. Good personalhygiene of food handlers andsound waste management are alsoimportant.

It is vital to monitor the qualityand safety aspects of incomingfood and ensure it is secure andhygienically stored. It is alsoimportant to reinforce guidelinesfor safe reconstitution of driedproducts given as food aid.

Food safety authorities should alsoensure that salvageable foods areare adequately protected and arenot exposed to sources ofmicrobial, chemical and physical

Lessons Learnt 35

contamination. The extent andtype of contamination should beassessed, and a decision maderegarding the separation andreconditioning of salvageablefood. Unsalvageable food shouldbe disposed of properly, either byusing it as animal feed, ifappropriate, or by destroying it. Inaddition, before food businessesresume their activities, they shouldbe monitored to ensure that theyhave regained the ability to ensurefood safety.

Institutional Capacity andCoordinationWhere the main government set-upwas not seriously affected, or inareas that were not so remote,essential services were quicklyrestored. The local governments inThailand, India and Sri Lankabasically remained in charge of the relief efforts. The existence of a decentralized structure ofgovernment and water supplyagencies ensured quick andreasonably effective action (TamilNadu, Sri Lanka).

In Sri Lanka, sector coordination is institutionalized informallythrough a network of Governmentagencies, NGOS and sector supportinstitutions, led by the NationalWater Supply and Drainage Board.The group meets quarterly,supports action-research, developspolicies and exchanges sectorexperiences. This entity allowed

for rapid coordination andnetworking, cooperative action andunderstanding of needs. Anemerging effort in India with theexistence of a roster of emergency-mitigation trained engineers underRedR- India,9 allowed rapiddeployment of additional expertiseto support relief efforts in water supply, sanitation andenvironmental health.

Pre-crisis existence of thesemechanisms enhanced coordinationand speeded up deployment ofnational experts. In Indonesia, asimilar set-up was establishedduring the tsunami crisis. Thesecoordination mechanisms assistedGovernment and NGO developmentpartners, who were already workingin the country before theemergency, to guide the inputs ofnew humanitarian aid agencies. Theexistence of similar mechanisms inBangladesh in both emergency

response and in the water andsanitation sector, has, over the lastfew years, allowed for faster andmore effective responses toemergencies.

Lessons LLearnt A functioning needs-based watsan sector network enhancespreparedness, facilitates agreementon minimum standards foremergency and disaster response,speeds up initial response andassists in matching externalsupport to local needs.

Lessons oof tthe ffirst wweeks With limited Environmental Healthstaff in countries (only Indonesiaand India), WHO, in the first days, facilitated action bydistributing straightforward 4-pagetechnical guidance fact sheets ondisinfection, source selection,sanitation, etc. to relevant fieldagencies.


9 RedR: Registered Engineers for Disaster Relief: [email protected]; www.redr.org

Provision of bleaching powder forpiped supplies and tankerdistribution and water qualitytesting equipment helped tomaintain bacteriological waterquality standards.

It is noted that many countries in the region are becomingsophisticated market economieswhere bottled water and watersupply and sanitation equipmentcan locally be arranged quickly, ata local level.

In addition to boiling water(Aceh, Sri Lanka), householdwater treatment options(disinfection by hypochlorite,SODIS) could be promotedthrough public informationcampaigns in emergencyprone areas, as part of the emergency preparednesstoolkit.

Providing an adequate quantity ofwater for hygiene and domesticuse may have been a problem asprovision of storage at the homeand in the IDP camps took time toestablish. This was noted in Acehwhere scabies and conjunctivitiswere reported, probably due tonon-availability of soap andwashing powder.

For the next time, largedistributions of soap,detergent, hygiene kits forwomen, all fitted in a bucket(OXFAM) or other watercontainer, should be arranged.

When the overall sanitationsituation is poor, or non-existent(e.g. no latrines, no drains)attention should be given to

personal hygiene. Typically, watersupply receives a lot of attention,but sanitation and hygienepromotion are also essential toavoid communicable diseaseoutbreaks.

Attention should be givento design of IDP camps,especially with respect to sanitation, includingdrainage, waste disposaland vector control.

Capacity Building andEmergency PreparednessFirst of all, it should be emphasizedthat some capacity is alwaysavailable in the country or in theaffected area. However, for avariety of reasons, competencemay have been eroded andpersonnel may need to be trainedand updated on StandardOperating Procedures (includingappropriate technical guidelines onwater supply and sanitation in

emergencies). Resources may alsobe available within the military andcould be included in the EmergencyPreparedness plan.

Lessons LLearntA sector that functions well, undernormal circumstances, will findthat its infrastructure is easier torehabilitate than a sector that hassuffered from neglect. In Sri Lankaand Tamil Nadu, water supplyservices were up and runningquite quickly, while in some areasin Aceh, it will still take time torehabilitate the systems as thetreatment plants were notfunctioning ever before thedisaster.

At present, it may be possible toplan better, through the use ofcomputerized scenarios, andensure that agency assets areidentified in such scenarioplanning and designated for

Lessons Learnt 37

emergency duties (reservoirs,treatment plant, certain vehicles).This also means that annualdisaster preparedness reviewsneed to include inspection ofthese assets and reconfirmation of their availability. Additionalengineering and securityprotection measures will alsoensure that water supplies andwaste (water) management plantsare not easily compromised in theevent of a disaster

Lessons LLearnt Emergency preparedness fordisruptions in water and sanitationservices, for hazardous waste spillsand explosions, and other incidentsthat threaten to expose thepopulation to environmental healthrisks, need to be strengthenedurgently at national and local level,in a multi-disciplinary way. Thisshould bring together localauthorities, health and engineeringcompetencies. A national/localframework of preparedness andresponse policies, strategies andSOPs should be formulated.

Now, at the end of 2005, reviewingthe work that was done by thecountries with the support of WHO,UNICEF and all partners in water,sanitation and environmentalhealth, the following strengths andweaknesses were observed:

StrengthsA well-built administrativeset up armed with well-defined rules andregulations available atnational and local levels.

International assistance withbilateral and multilateralcooperation.

The governments' positiveand proactive approach.

WeaknessesLimited resources in termsof finance and manpower

Procedural delays inimplementation of projectactivities

Lack of professional skillsand local technologies.

OpportunitiesAdversities could beconverted in to

developmental activitieswith the objective ofimproving the services.

National staff could betrained and motivated.

Long term planning couldenhance sustainability ofsystems

ThreatsCivil unrest and ethnicconflicts

Lack of motivation andfatigue in staff

Poor community response.

This information leads us toformulate a set of actions thatneed to be considered in orderfor us to perform better the nexttime. This includes the following:

Better coordination; moreeffective use of resourcesand less duplication

Better pre-event intelligenceto improve the quality of theneeds assessments

Better logistical managementso that supplies andequipment are distributedquickly with agreementbetween agencies

SPHERE guidelines or otheragreed national standardsto be known and applied byall actors includingstandards for the design oflatrines, shelter and waterprovision/ water disinfection

Consistent provision oftechnical support toGovernment Agencies andNGOs

WHO-wide preparedness,through attitudinal adjustment


complemented by generalcapacity building to fulfil itsroles in emergencies anddisasters.

WHO's ability to recruit andretain staff for longerassignment periods inemergency affected areas

ConclusionThe tsunami was anunprecedented catastrophe thataffected millions of people. Theway various agencies andgovernments worked together tosupport affected communities willinfluence generations to come -both those immediately affected

by the tragedy, and those whoprovided help.

WHO staff at all levels of the organization contributedenormously to affected countries.While the immediate impact of thetsunami was catastrophic in termsof human suffering and physicallosses, the subsequent healthimpacts seem to have beenmanaged reasonably well by thecombined efforts of all. No seriousdisease outbreaks were reported,and water, sanitation, food andshelter were provided to all in need.

The challenges with respect torestoring people's lives, givingthem - young and old- the mentalstrength to overcome theirsuffering and losses, will remainwith us for quite a while. WHOthrough its policy guidance andcountry level support can

hopefully continue to contributeto sustained improvements inwater quality surveillance andwater safety plans, food safety,hazardous and clinical wastemanagement, and improvementsin water supply and sanitation inhealth facilities and schools.Primary health care andenvironmental health complementeach other in promoting healthyvillages and cities and this canfurther contribute to bettersettlement planning and animproved health future for all.

WHO's response to the tsunamicrisis, and the lessons learnt fromit, will challenge the Organizationto improve future responseoperations and work with MemberStates, their local authorities andcivil society to ensure that we areall better prepared to reduce theimpact of the next disaster.

Lessons Learnt 39

Mahatma Gandhi Marg

Indraprastha Estate

New Delhi-110002

Tel: 91-11-23370804

Fax: 91-11-23370197

www.whosea.org

in South East Asia - WHO

Documents

Transcript of in South East Asia - WHO