Consultation by an MSF staff member in a mobile clinic in the area of Sigli. Photo © Stefan Pleger

Six months have passed since an enormous tsunami hit parts of South Asia, leaving behind a horrifying trail of destruction and suffering. Within days of the December 26, 2004 disaster, Doctors Without Borders/Médecins Sans Frontières (MSF) teams began working alongside national efforts to provide assistance to individuals in need of medical care, food, clean water, shelter, and other basic necessities. The majority of MSF's work focused on hard-hit communities in Indonesia and Sri Lanka, though staff provided assistance to people in Thailand and India too. Initial exploratory teams assessed needs in Malaysia, Myanmar, Bangladesh, and Somalia as well, but did not find any serious unmet medical needs.

Today, MSF has reoriented its work in Indonesia and has closed its tsunami-related programs in other countries except India. 93 international staff and over 650 national staff continue to work in tsunami-affected areas in Indonesia (89 international, 637 national staff) and India (4 international, 29 national staff). As an emergency medical organization, MSF believes is not the best suited to engage in long-term development programs or large-scale rehabilitation and reconstruction which are still required in many of the tsunami-affected areas.

MSF continues to support people affected by the tsunami in Indonesia and India, mainly by providing psychosocial care. At the same time MSF is continuing to help communities in Aceh, who, as a result of the ongoing conflict, have little or no access to basic quality care.

1. SIX MONTHS OPERATIONS OVERVIEW

Start-up chronology:

• Sri Lanka - 27 December: simultaneous assessments and relief
• Southern India - 27 December : assessments followed by operations as of 4 January.
• Malaysia - 27 December: assessment, no activities
• Indonesia - 28 December: simultaneous assessments and relief
• Thailand - 29 December: assessments followed by emergency support to hospitals as of 30 December.
• Myanmar - 30 December: assessment, no activities
• Andaman Islands, India – 31 December: assessment, no activities

INDONESIA

According to the Indonesian government, to date, over 126,002 bodies have been found and over 93,638 people remain missing in Aceh. There are an estimated 514, 150 displaced persons.

HISTORY OF ACTION

An MSF team of 8 people, including 3 nurses and 2 doctors arrived in Banda Aceh, the regional capital, on Dec 28. They brought with them 3.5 metric tons of medical and relief materials. They immediately set up a medical clinic in the city and began assessments and relief operations in Banda Aceh and, by helicopter, in locations along the western and northeastern coasts.

Nearly 200 metric tons of additional medical, water/sanitation and relief materials as well as dozens of additional MSF personnel (doctors, nurses, psychologists, logisticians, water & sanitation experts) arrived in Aceh the week following the tsunami.

During the first week following the tsunami, MSF:

• Provided medical and sanitation support to main hospital of Banda Aceh;
• Ran mobile clinics in camps throughout the city;
• Attached psychologists to mobile clinics;
• Conducted over 1,200 consultations (in 8 days) Complaints: wounds, respiratory infections, diarrhea, skin disease, trauma
• Set up water bladders and water systems in camps and hospital;
• Distributed body bags

Up and down the coast MSF ran mobile clinics, evacuated by helicopter those in urgent need of care, ran counselling sessions and donated food, tarpaulins and medical equipment.

By the second week MSF was supporting two other district hospitals in Meulaboh and Sigli and launched further distributions of non-food items down the west coast including family tents, kitchen kits, tools etc. Teams were also sent to assess the situation in Simeulue island and the Banyak Archipelago.

Days after another undersea earthquake hit the island of Nias on March 28, 2005, MSF teams distributed tents and relief items in the island's northeastern district of Tuhenberua.

MSF continued to reinforce its activities, particularly psychological support. A tetanus vaccination campaign was launched in response to the high number of cases coming forward.

TODAY

Mental health is considered one of the greatest ongoing needs in Aceh and almost all MSF programs have a mental health component. Water and sanitation in displaced camps are also a concern, particularly during heavy rains. MSF has handed over the majority of its water & sanitation projects but continues to monitor for disease outbreaks. MSF is now looking to provide basic health care in a number of areas where people have little or no access to it as a result of the ongoing conflict.

MSF is presently running medical (•) and non-medical (ø) programs in 6 districts: Banda Aceh, Aceh Barat, Pidie, Aceh Utara, Aceh Barat Daya, Simeulue:

BANDA ACEH:

• Mental health care

ACEH BARAT (Lamno):

• Mental health care
• 1 health clinic (rehabilitated)
• Surgery
• 2 pre-fabricated health units
• Mobile clinic
• Vaccination (measles and other)
• TB
ø Water & sanitation
ø Distribution of non-food items
ø Training Ministry of Health staff

(Meulaboh):

• 4 Health clinics
• Mental health care
• Vaccination
ø Water & sanitation
ø Distribution of non-food items
ø Training Ministry of Health staff

PIDIE DISTRICT (Sigli):

• Support to 2 hospitals: surgery and post-op care
• 3 mobile clinics to remote areas
• 3 health clinics
• Support to network of clinics
• Mental health care in the trauma center of Sigli

ACEH UTARA (Lhokseumawe)

• Mental health care
• Vaccination
• Malaria assessment & preparation
ø Water & sanitation
ø Distribution of non-food items
ø Training Ministry of Health staff

ACEH BARAT DAYA

• Mental health care
• Tetanus & measles vaccination
ø Distribution of non-food items
ø House construction

SIMEULUE

• Mental health care
• Measles vaccination
• Epidemiological surveillance & early warning systems
ø Water & sanitation
ø Rehabilitation of temporary health centers

OVER SIX MONTHS
(see annex for detailed overview per location)

Medical care
Total medical consultations: approx 28,000

8 Primary health care clinics
4 Mobile clinics
2 Surgical programs
Support to 2 hospitals
Support to more than 50 basic health care units
Training of Ministry of Health staff
Extensive rehabilitation of clinics and units including waste management
Main pathologies: respiratory infections, skin infections, diarrhea, trauma

Distribution
Since its arrival in Aceh at the end of December, MSF has distributed tens of thousands of non-food items to people who lost everything in the tsunami. This has included hygiene kits, kitchen sets, tents and blankets – anything people needed until shelter was provided. MSF continues to distribute relocation/construction kits and has also been involved in low scale boat building and house construction.

Mental health care
MSF found mental health to be one of the most important needs. Teams have offered care to people suffering from post-traumatic stress disorder (PTSD) as a result of the tsunami and possibly also of the ongoing conflict.

• Activities range from community based activities (cooking, boat building...) to group discussions and individual counselling (both adults and children) by international and national psychologists;
• Psychosocial education to community leaders, religious heads, schools, other non-governmental organizations, Ministry of Health staff; introduction of referral network and Ministry of Health staff training;
• Many programs linked to medical activities such as outreach and primary health clinics;
• Average of 32 new individual consultations a month.

Vaccination campaigns
Vaccination campaigns focusing on measles and tetanus were organized in seven districts covering more than 120,000 people. Measles vaccination campaigns are still planned for Sigli camps. Vitamin A was distributed during the measles vaccination campaigns, and in some locations a deworming was organized for all children over age 2.

Water & sanitation
Clean water was provided to displaced families through a combination of water trucking, bladders, well cleaning and construction. Hundreds of latrines were built, waste disposal was organised for clinics and hospitals. Many of these activities have been handed over.

Early warning system & epidemiological surveillance
As water and sanitation conditions in camps are still quite poor, MSF mobile teams are monitoring them for disease outbreaks (cholera, measles, malaria, dengue fever). Supplies are on stand-by in Banda Aceh and Jakarta and Ministry of Health staff is being trained to recognize and report cases. MSF is also providing hygiene education.

SRI LANKA

MSF provided emergency medical aid through mobile clinics and existing medical facilities and distributed relief goods and drinkable water during the first weeks after the tsunami.

In a second phase, MSF tried to support some of the most vulnerable people by clearing land parcels so that they could rebuild their homes, providing drinkable water and sanitation facilities, cleaning and reconstructing wells and latrines, distributing fishing nets and tool kits (in Batticaloa region) and building semi-permanent houses (for 180 families in the Tangalla region). In the same area of the southern coast, MSF started an outpatient clinic and set up shelters for local homeless families. In the nearby town of Matara, an MSF team assisted more than 3,000 displaced people and started mobile medical clinics. An outpatient clinic was also opened in nearby Hambantoa. Once emergency medical needs were met, MSF began organizing a network of local doctors to provide psychosocial support to the many people traumatized by the disaster and its consequences.

In Ampara and Killinochi, MSF provided psychosocial support through the local non-governmental organization Shade till the end of April.

INDIA

Because of quick government and community mobilization, emergency medical needs caused by the tsunami were mostly covered in this country. The principal problem for many communities was psychological trauma, with some people suffering from post-traumatic stress disorder. In response, MSF began offering psychological support in Cuddalore and Nagappatinam districts by training NGO community volunteers as counselors and psychosocial assistants. In Tamil Nadu, in southern India, MSF trained medical students to spot people with health care problems or psychological trauma who were living in displaced persons camps so that they could be helped more quickly and referred to needed services. MSF also runs a mobile clinic. In addition to giving medical consultations, the mobile team also identifies the most severely traumatized survivors of the tsunami.

A team of 4 international and 29 national staff continues to provide mental health care in Cuddalore, Nagappatinam and Tamil Nadu as well as operate a mobile medical clinic in Tamil Nadu.

THAILAND

In general, the Thai emergency response was found to be fast and well-organized. MSF decided to help improve the situation for Burmese migrant workers affected by the tsunami. More than 50,000 Burmese migrants are registered as workers in six provinces along the western coast of southern Thailand, but as many as 500,000 are actually thought to live in the area. An estimated 5,000 Burmese were missing after the tsunami struck the coast and many more found themselves in a precarious situation having lost their papers or job after the tourist industry collapsed. MSF is now working with a local NGO to set up public health workshops to inform migrants from different parts of Phang Nga province about basic health care and sanitation and to help them gain access to needed health care.

2. SIX MONTHS FINANCIAL OVERVIEW

In an extraordinary outpouring of support, MSF sections worldwide received 105 million Euros in donations to provide emergency relief to people affected by the tsunami. By the end of April 2005, MSF had spent 17.9 million Euros on tsunami-related operations in South Asia. In total the organisation will most likely spend 24.5 million Euro for activities in the regions affected by the tsunami in 2004 and 2005.

MSF Operational Budget
- India € 0.54
- Indonesia € 19.51
- Malaysia € 0.20
- Sri Lanka € 4.11
- Thailand € 0.11
Total € 24.47

MSF Expenses (end of April)
- India € 0.29
- Indonesia € 13.61
- Malaysia € 0.05
- Sri Lanka € 3.88
- Thailand € 0.06
Total € 17.89

The generosity of hundreds of thousands of MSF donors worldwide made it possible for MSF teams to begin assessing the needs and providing medical relief in the most-affected areas of Indonesia, Sri Lanka, Thailand, and other countries within 48 hours of the disaster.

Less than a week after the tsunami, estimating that we had already received sufficient funds for our foreseen emergency activities, MSF began asking donors to stop giving donations for MSF's response to this particular emergency. Instead they were encouraged to support our work providing medical care in other emergencies and ongoing conflicts such as the Democratic Republic of Congo, Somalia or the Darfur region of Sudan.

MSF offices around the world also began contacting individuals requesting their permission to use their funds to support MSF's work in emergencies elsewhere in the world. This process is still ongoing, but so far an overwhelming majority of donors have accepted that we use their donations elsewhere. 52% of the funds initially received for the emergency can now be used to support MSF's other emergency medical programs around the world. MSF seeks to derestrict a further 23.5% of the donations and 1% has been refunded on request.

Fundraising situation (end of May)
- Funds collected € 105.4    100%

- Funds derestricted or re-directed to other crises € 55.0   52%
- Funds reimbursed € 1.2   1%
- Remaining restricted funds € 49.2   47%

- Remaining deristriction target € 24.7   23.5%
- Funds budgeted for operations € 24.5   23.5%

MSF is extremely grateful for the unprecedented surge of spontaneous donations we received following the tsunami disaster and will continue to use this money to provide medical and psychosocial care in the regions affected by the tsunami. At the same time, we are heartened by the trust our supporters have placed in us in allowing us to use their funds where they are needed most. We believe that being open and transparent with our donors about how we use their funds is essential, as it is their support that allows us to alleviate the suffering of the most vulnerable in the worst conflicts and disasters around the world.

ANNEX: Indonesia Six Months Operations Overview in detail

MEDICAL CARE

BANDA ACEH: total consultations week 1-5 = 2184; no medical activities now.

MEULABOH

• total consultations week 1-5 = 2593
• week 6 – today: total 6419 medical consultations
• support to 4 health clinics
• training of Ministry of Health staff

LAMNO

• total 3011 medical consultations
• rehabilitation of health clinic to include surgery and 17 bed in-patient dept
• surgeon and anaesthetist conducting average 10 operations/wk
• 2 pre-fabricated basic health care units erected
• 1 daily mobile clinic to camps, villages, barracks
• TB treatment: 30 new patients in 2 months

SIGLI

• target population approx 41,000
• total 13,357 medical consultations
• rehabilitation and running of 3 health clinics + 4 basic health units
• support to extensive unit of basic health posts
• erection of 2 pre-fabricated clinics
• 2 daily mobile clinics to 2 displaced camps and 5 relocation camps
• outreach activities
• ongoing assessments including of 3 orphanages
• Support to Sigli hospital plus one part time mobile clinic: dressings in surgical ward, 4 beds in intensive care unit, introduction in May of international surgical team, provision of surgical materials

BEURENOUN

• Support to hospital: 15 bed in-patient facility opened
• Average of 8-10 in-patients hospitalized plus increasing number of out-patient department consultations
• part time mobile clinics in 5 health centers and 1 dispensary

SIMEULUE

• construction of 3 temporary health centres plus 2 more planned

DISTRIBUTION

BANDA ACEH

• 500 pairs of boots and 1500 gloves to help prevent tetanus
• 1000 body bags for collection of human remains

LAMNO

• relocation kits (hammer, nails, saw) to displaced people returning to villages
• construction of approximately 140 boats

MEULABOH AND LHOKSEUMAWE

• 1700 tents
• 1550 hygiene kits (towels, soap, detergent, toothbrushes, combs)
• 1230 basic construction kits (wood saw, bow, hammer, gloves, nails)
• thousands of kitchen sets, flip flops, jerry cans, lanterns, sleeping mats, soap.

SIGLI

• non-food items including tents, tools and reconstruction material to 20,000 families between Jan-March;
• non-food items to 1 500 families after Nias earthquake;
• construction of 81 boats

SELATAN, SIMEULUE, TELUK DALAM, SALANG, TEPUA BARAT
distributed hygiene kits, mosquito nets, blankets, construction kits and tarpaulin to 8455 families;

MENTAL HEALTH CARE

BANDA ACEH

• Training of Ministry of Health staff and development of referral system;
• MSF psychologist present in 2 clinics on a weekly basis;
• Newly opened a mental health clinic for individual counselling;
• Community activities/ group discussions in 5 different displaced people's locations;
• Broad reaching pyschosocial education.

LAMNO

• Training of Ministry of Health staff and development of referral system;
• Psychologist present in MSF health clinic and in mobile clinic for individual counselling;
• Outreach activities to schools, camps, barracks and villages;
• Group activities (boat building) and discussions.

SIGLI

• Training of Ministry of Health staff and development of referral system;
• 2-3 psychologists in 3 primary health care clinics and in mobile clinics;
• Since March consultations in villages held as patients leave camps to return;
• Mental health clinic opening in Sigli town with 3 individual consultation rooms;
• Overseeing publishing of book produced by religious leaders which includes chapters on causes of the tsunami and basic recommendations for coping with psychosomatic and psychological symptoms.
• Group activities with teachers and pupils and in Orphans' House.
• Consultations in Sigli: hospital and trauma center.
• Consultations in Beurenoun: hospital and health center.

MEULABOH

• 289 consultations since January;
• Individual counselling and/or group activities in 5 health centres;
• Distribution of psychosocial educative material and work shops with high schools.

LHOKSEUMAWE

• 3 trauma centres for individual counselling;
• Also provide outreach services;
• Community based outreach services by mental health team offering group therapy and individual counselling in villages.

SIMEULUE AND BARAT DAYA

• First psychosocial assessment of Simeulue in March 2005;
• 1 Programme in Labuhan Bakti, soon in Sinabang;
• No individual consultations;
• Focus group discussions and social activities;
• A community center with information corner is build in Labuhan Bakti.
• Ongoing assessment in Blangpidie, Aceh Barat Daya.

VACCINATION CAMPAIGNS

SIMEULUE: measles 15,040
ACEH BARAT DAYA: measles 35,013 tetanus 3,187
ACEH SELATAN: measles 51,520 tetanus 3,650
BANDA ACEH: tetanus 322
LAMNO: measles 4,046
SIGLI: measles 6,541
MEULABOH: tetanus 1,636

WATER & SANITATION

SIMEULUE

• water & sanitation activities benefiting over 902 households
• water trucking, construction of tanks and dams, well-cleaning, latrines

ACEH BARAT DAYA

• water & sanitation activities benefiting over 210 families
• monitoring water quality distributed on a weekly basis
• facilitating refuse collection

BANDA ACEH

• provided water & sanitation for 2 hospitals, no longer any activities.

LAMNO

• latrines built in over 20 destroyed villages
• ongoing water trucking to 2 displaced camps
• rehabilitation of the waste disposal and water & sanitation in the health center

SIGLI

• initial water and sanitation support to 16 camps covering 11 500 people
• 15 water bladders installed
• waste collection set up in 7 camps
• 35 latrines built

MEULABOH

• number of beneficiaries 7,000.
• 190 wells cleaned, 3 wells rehabilitated or constructed
• 113 latrines built
• provision of 13 water bladders plus water trucking
• wells, boreholes, drainage systems, waste facilities for health clinics

LHOKSEUMAWE

• number of beneficiaries well cleaning approx 14,000
• number of beneficiaries water points approx 20,000
• 281 wells cleaned
• 2 wells rehabilitated
• 39 water points/tanks supplied daily

EARLY WARNING SYSTEM & EPIDEMIOLOGICAL SURVEILLANCE

MEULABOH AND LHOKSEUMAWE

• Emergency-preparedness stocks in Banda Aceh: basic kits, cholera kit, vaccination materials;
• On-going assessments, training and provision of the antimalarial ACT (artemisinin-containing combination therapy).

SIMEULUE

• Worked with local health authorities to introduce Early Warning System (EWS) and reinforce Epidemiological Surveillance System (ESS) set up by the Ministry of Health after the Tsunami. EWS now being handed back to Ministry of Health;
• Helped develop the systematic, weekly collection of data from all sub-districts.

JAKARTA, LAMNO AND SIGLI

• Emergency preparedness base with supplies in Jakarta;
• Systematic collection of health data and hygiene education by mobile clinics in villages and camps;
• Emergency-preparedness guidelines and stocks being prepared for individual locations.