AP Photo/Gurinder Osan	More NurseWeek Features   Smoke-Free Zone   Nurses and patients tackle nicotine addiction   Bloodless Survival     Surgical techniques to use when transfusion drops out of the equation
A boy reacts as he receives a tetanus shot from a medic Dec. 28 at a relief camp at Nagore, in the southern Indian state of Tamil Nadu.

The tsunami that struck South Asia the day after Christmas has triggered a flood of questions about why only a trickle of relief reached survivors immediately and what possible disasters they’ll face next. The answers offer a sobering picture of how difficult it is to manage a major disaster, particularly one that has devastated at least 11 countries on two continents.

“The primary issues are sanitation, food and water safety, ease of disease transmission, insect infestation, attraction of large animals, interruption of existing traditional medical care, likely cessation of immunizations, and infections, including malaria and cholera,” says Ruth Carrico, RN, PhD, CIC, director of infection control and infusion services at the University of Louisville Hospital in Kentucky.

Decomposing bodies, either exposed or buried in waterlogged soil, attract insects and larger animals that may bite humans, transmitting infectious organisms, says Carrico, who is also incoming chair of the Bioterrorism and Emerging Infections Taskforce of the Association of Professionals in Infection Control and Epidemiology.

Sewage overflow and a lack of sanitation facilities mean raw sewage is mixing with water and food. Starving residents are trying to find everything buried in the soil, especially since existing food is rotting or contaminated due to a lack of refrigeration and dry storage.

“The tsunami has caused a total disruption of health care, but residents continue to have routine health needs, and the already compromised population will have trouble,” Carrico says. And fast-spreading infections, such as cholera, can prove fatal almost immediately, even in otherwise healthy populations.

Regions at risk

The tsunami struck prosperous, modern, developed regions, as well as others that are poverty stricken and lacking modern conveniences, equipment, and structures. The people in both areas now lack homes, possessions, the means to make a living, and the essential elements for survival. More than 5 million are homeless.

“Getting money, food, medical supplies, and goods for disaster areas is usually not the problem,” says Linda Hoffman, a travel writer and tour leader specializing in remote regions who has lived in Indonesia for 15 years and is based in Yogyakarta, Central Java.

“More often it’s a matter of getting those things to the people who need them because entire infrastructures — roads, bridges, communication lines, etc. — have been destroyed. Much of the food that’s sent rots because they cannot get it to those in need. Many of the coastal areas where supplies are most desperately needed are still inaccessible.”

Problems also include lack of operational trucks, equipment, and fuel, plus blocked roads and waterlogged soil that hinders vehicles.

The restoration of power, communication, health care, and other vital functions is impeded because many essential workers were killed in the tragedy and resources were destroyed. “The Jakarta Post reported that the Aceh [Sumatra] provincial government, which would have coordinated relief efforts, was decimated because only half of its employees survived and most government buildings were destroyed,” she says. “And there aren’t enough workers left in these areas to bury the dead. Survivors are too grief stricken or weak to help.”

The unstable political situation in some affected areas could complicate relief efforts, says Hoffman, citing the recent bombing that devastated Bali.

“The people of Aceh, North Sumatra, have been involved in armed ‘conflict’ for several years 85 which has been off and on under military law,” she says. “Thousands of lives have already been lost. The good news out of all this is that the freedom fighters in Aceh have agreed to lay down their arms 85 for now.”

CNN News reports that the rebel Tamil government, which controls the north and some eastern portions of Sri Lanka, allows relief trucks through its roadblocks only during the day.

Bodies, burial, and bereavement

Tsunami survivors are confronting another tragedy as well: how to deal with more than 150,000 deaths. Tens of thousands of bodies washed up as the waves receded, and tens of thousands more are being uncovered as the rubble is cleared. Besides overwhelming grief, these deaths also pose problems and hazards.

“If bodies have diseases, as they decompose, or through fecal contamination, they can contaminate drinking water,” says Faye Otto, RN, SANR, president and CEO of American Forensic Nurses, Palm Springs, Calif. “Insects are involved, and when gasses explode from bodies, the odor is phenomenal.”

Without refrigeration, even bodies that have been retrieved and placed in makeshift morgues or coffins will bloat, making identification difficult even when recovery teams in some areas have attempted to photograph victims.

“In this situation, mass burials are for the better, but because they lack our protocols and don’t have grave sites such as we have here, it’s very, very difficult to identify people in mass graves,” says Otto, who has visited Sri Lanka. “Forensic nurses can help them try to identify victims, tag the bodies, and map the burial sites. Forensic teams can collect samples of the bone, saliva, and hair follicles from the deceased before burial and mark the grave.”

The initial resistance to mass graves and cremations will probably increase. “After the shock, identification becomes more important,” says Otto, but it may be impossible for many. “DNA samples must match or be genetically compatible to a survivor. The cost ranges from $200 to $400 here in the U.S., and Sri Lanka and other affected countries lack the necessary laboratories.”

Survivors face yet another horror: sexual abuse. “Several studies have shown that with the stress of homelessness and disaster, incidents of sexual assault, battery, and trauma become much more prevalent,” she says.

“Victims need psychological care, but there are almost no resources to work with, other than talking to the involved victims and subjects. Corrections are almost an impossibility when police are dealing with emergencies.”