Days after an enormous tsunami battered parts of South Asia on 26 December 2004, 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 also provided assistance to people in Thailand and India. 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 where a team of 4 international and 29 national staff continues activities in an area heavily affected by the tsunami. In Indonesia more than 60 international and 400 national staff are providing psychosocial and medical care in tsunami-affected areas and elsewhere in Achehnese communities that have little or no access to basic health care.

1. NINE MONTHS OPERATIONS OVERVIEW

Start-up chronology:

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

INDONESIA

MSF was already active in Indonesia before the tsunami struck, bringing basic medical care to communities who would otherwise have none. This proximity enabled MSF to get emergency teams to areas destroyed by the tsunami soon after the catastrophe. On December 28, the first team arrived with 3.5 metric tons of relief supplies in Aceh's regional capital of Banda Aceh. They immediately set up a medical clinic and began assessments and relief operations. From this base, more MSF staff and materials poured into Indonesia, bolstered by unprecedented support from international donors. While the roads were still impassable, MSF teams traveled by helicopter to areas along the western and northeastern coasts, rapidly assessing needs, dropping emergency materials and mobile teams, and transporting the most seriously injured to hospitals.

Additional logistical support was provided by Greenpeace's flagship, the Rainbow Warrior, allowing MSF to reach isolated areas quickly. Nearly 200 metric tons of additional medical, water/sanitation and relief materials, as well as dozens of MSF doctors, nurses, psychologists, logisticians, and water and sanitation experts arrived in Aceh the week following the tsunami.

By the second week, MSF was supporting two other district hospitals in the devastated towns of Meulaboh and Sigli, and teams carried out assessments on Simeulue Island and in the Banyak Archipelago, south of Aceh. When another undersea earthquake hit the island of Nias, located near Simeulue, on March 28, 2005, MSF teams distributed tents and relief items in the island's northeastern district of Tuhenberua.

By March, the acute emergency phase had ended. Teams began focusing on rehabilitating health structures and addressing the basic health needs of affected communities. Particular attention was given to communities' mental health needs. From the beginning of the disaster response, MSF psychologists were part of the emergency teams, counseling hundreds and hundreds of patients. Education sessions were also organized to provide information about the tsunami itself and describe the many possible physical and emotional reactions to it.

Current activities

In the second half of 2005, medical aid became more easily available in parts of Indonesia hit by the tsunami. MSF's distribution of emergency aid items and projects to provide water and sanitation have for the most part been completed or handed over to partners. However, MSF is running mobile clinics to treat people in villages and camps for displaced people in areas affected by the disaster. Teams are also setting up basic health services in remote areas including inland areas in the Aceh Barat district and the town of Takengon, in Bener Meriah district in the central mountains, where access to medical care is severely limited, due in part to the protracted conflict between rebels and the government in Aceh. In some areas, clinics that were rehabilitated by MSF are now able to carry out surgical procedures that weren't possible before–enabling people who have survived for years with painful conditions such as hernias to finally get treatment.

Mental health is one of the greatest ongoing needs in Aceh, and almost all MSF programs contain a mental health element. MSF is doing what it can to reach out to those traumatized first by war, then by catastrophe. A team of psychologists travels to camps, relocation centers, villages and schools, offering a combination of psychosocial education, group discussions, and individual counseling. Teachers and health staff receive ongoing training to recognize common symptoms of trauma. In Aceh, more than 10,000 people affected by the tsunami have attended psychosocial and psycho-educational group sessions in Meulaboh and Lamno (west coast), Sigli and Lhokseumawe (north coast) and Banda Aceh. Indonesian and international psychologists continue to offer individual treatment to hundreds of patients each month.

MSF is presently running medical (•) and non-medical (ø) programs in 7 districts: Banda Aceh, Aceh Jaya, Aceh Barat, Pidie, Aceh Utara, Bener Meriah, Simeulue:

BANDA ACEH:
• Mental health care

ACEH JAYA (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

ACEH BARAT (Meulaboh):
• Health clinics (in the tsunami affected costal area as well as in conflict-affected areas further inland)
• Mental health care
ø Water & sanitation
ø Training Ministry of Health staff

PIDIE DISTRICT (Sigli and Beureunoun):
• 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 activities in Sigli and Beureunoun and opened mental health clinic in Sigli
ø Water & sanitation

ACEH UTARA (Lhokseumawe):
• Mental health care

BENER MERIAH (Takengon):
• Support to basic health care structures
ø Rehabilitation of water & sanitation in health structures
ø Training Ministry of Health staff

SIMEULUE:
• Rehabilitation of temporary health centers

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.

A team of 4 international and 29 national staff continues to provide mental health care and started emergency preparedness in view of the typhoon season in Tamil Nadu.

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 NGO Shade till the end of April.

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. NINE MONTHS FINANCIAL OVERVIEW

In an extraordinary outpouring of support, MSF sections worldwide received 109 million Euros in donations to provide emergency relief to people affected by the tsunami. By the end of August 2005, MSF had spent 21 million Euros on tsunami-related operations in South Asia. In total the organization will most likely spend 24.6 million Euro for activities in the regions affected by the tsunami in 2004 and 2005.

MSF Operational Budget

India	M€ 0.61
Indonesia	M€ 19.54
Malaysia	M€ 0.23
Sri Lanka	M€ 4.10
Thailand	M€ 0.11
Total	M€ 24.59

MSF Expenses (end of August)

India	M€ 0.47
Indonesia	M€ 16.04
Malaysia	M€ 0.12
Sri Lanka	M€ 4.19
Thailand	M€ 0.09
Total	M€ 20.91

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 the donors have accepted that we will use their donations elsewhere. Fifty-seven percent of the funds initially received for the emergency can now be used to support MSF's other emergency programs around the world such as in Niger today. MSF seeks to derestrict a further 19.5% of the donations and 1% has been refunded on request.

Fundraising situation

Funds collected	M€ 109.1	100%
of which:
Funds derestricted or re-directed to other crises	M€ 62	56.9 %
Funds reimbursed	M€ 1.2	1.1%
Remaining restricted funds	M€ 45.9	42%
of which:
Remaining de-restriction target	M€ 21.3	19.5 %
Funds budgeted for Tsunami operations 2004/2005	M€ 24.6	22.5 %

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 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.