July 14, 2005
Presentation of Nicolas de Torrente
Mr. Vice-President of ECOSOC, Mr. Chairman, Excellencies, thank you very much for inviting Médecins sans Frontières to participate in this panel on lessons learned from the emergency response to the devastating tsunami which occurred a little over 6 months ago. MSF is an international medical humanitarian organization that focuses on providing emergency assistance to victims of crisis, and my remarks will center on our experience in responding in the aftermath of the tsunami, particularly in Indonesia and Sri Lanka.
I would like to make two main points and raise one question today:
The first point is that emergency needs of the population affected by the tsunami, particularly their medical needs, were relatively limited. In particular, the risk of a massive death toll from epidemic outbreaks directly following the tsunami was overstated. The second point is that local solidarity and national assistance played by far the most important role in the acute emergency response phase, yet this was widely underreported. This leads to my question: the international emergency response, in which MSF participated with some 200 international staff and 2000 MT in supplies, was quick, massive and very well funded, but how useful and relevant was it? Let me elaborate.
First, on the relatively limited emergency needs.
The catastrophic impact of the December 26 Indian Ocean earthquake and tsunami is well known by all here: a staggering number of deaths, a complete devastation of infrastructure and a severe disruption of economic activity in tsunami-affected areas. Hundreds of thousands lost everything: family members, housing, means of livelihood. Yet, in what appears as a paradox when seen in relation to the magnitude of this devastation, the acute emergency needs for the population that survived the catastrophe were relatively limited. To begin with, in contrast to conflict situations, the dead far outnumbered the injured requiring emergency medical and surgical treatment. The large number of displaced people, particularly those who found refuge in public buildings such as schools or mosques, or settled in open-air camps was the main consequence of the tsunami requiring urgent attention. The priorities for such situations are well established: providing clean water and sanitation, ensuring adequate vaccination coverage, particularly for measles, providing essential health services, setting up epidemiological surveillance, ensuring adequate food availability, etc, and this is what MSF and other actors focused on.
In such circumstances, preventing epidemic outbreaks is a key concern. Yet, there was no basis or evidence for alarmist claims that communicable diseases could well kill as many people as the tsunami itself. What is particularly disturbing is that these doomsday predictions were not just fuelled by the media, but emanated from agencies such as WHO that are entrusted with providing a sound foundation based on epidemiological fact and experience to guide the emergency response. Experience tells us that natural disasters themselves do not necessarily lead to epidemics. While population displacements increase risks, the fear of outbreaks of dengue, malaria, cholera and other communicable diseases was well overstated. Although most of the people affected by the tsunami were poor and their vaccination coverage was low, their nutritional and health status was generally good. And while the number of homeless was substantial, most of those displaced by the tsunami settled with host families, in makeshift shelters or small camps in unaffected areas soon after the disaster. These factors greatly reduced the chances of outbreaks. The most serious disease directly related to the tsunami was tetanus. In the month following the tsunami, there were 106 documented cases in Aceh resulting from people injured by the tsunami or while searching through the rubble, and MSF provided treatment and carried out tetanus prevention activities accordingly.
Second, on the local assistance:
In all the tsunami affected countries, not only in India and Thailand, local solidarity saved many more lives than international organizations. This should not be a surprise, as it is not a new phenomenon. As far as our institutional memory goes – and MSF experience in natural disasters dates back 1974 – local response to emergency needs is the most timely and effective intervention.
In the tsunami-affected areas, damages, although massive, were local. Outside of the coastal areas, countries were able to function. In contrast to wars, natural disasters do not result in a wholesale long-term disruption of health services. Victims themselves are not helpless, and they received assistance almost immediately from their neighbors and communities first, then from the rest of the country.
This does not mean that the local response, however significant, was able to meet all the emergency needs. Local health staff, themselves affected by the catastrophe, attempted to treat as many seriously injured patients as possible but did not always have the capacity to do so in these very difficult circumstances. Yet it would have been impossible, for example, for external surgical teams, many of which were deployed days and weeks later, to arrive in time to save the lives of the most seriously wounded.
What is certain is that solidarity at the local and national level was impressive. This we found to be true despite the portrayal in the international media that the majority of the assistance was being provided by the international response. We are heartened to see that the crucial role of the local response in Southeast Asia is now acknowledged in the report of the Secretary-General. However, the capacity of local response was not recognized until recently, and was certainly not acknowledged in the early days of the disaster.
Third, how relevant was the international emergency response?
As stated above, emergency needs, particularly medical needs, were relatively limited and the local response was impressive. However, in sharp contrast to virtually every other catastrophe that humanitarian organizations have had to address, the tsunami generated an exceptional outpouring of goodwill, solidarity and generosity on an international level. In addition to the very large volume of spontaneous donations, successful fundraising campaigns highlighting immediate needs were launched, supported by intense media attention. This gave rise to an unprecedented situation: NGOs had important financial means and were under significant pressure to respond immediately, as did the UN agencies, donor governments and military forces that rushed to the scene. High expectations affected all aid actors, including MSF, even though we did not carry out fundraising efforts and stopped accepting restricted donations for the tsunami one week after the disaster when we realized that our emergency operations were sufficiently funded.
The massive deployment of governments, military forces, UN agencies and NGOs created a 'humanitarian traffic jam' in many areas. Under intense scrutiny, NGOs searched for programs to put to use the large quantities of funds they were generating. And for many, available funds exceeded the capacity to effectively carry out relevant and needed emergency activities. This situation puts the issue of coordination in different light. In many ways, national and regional authorities did their best to facilitate and coordinate the massive influx of aid. But properly identifying and responding to actual needs was the real problem. With such an abundance of means and pressure to act, coordination efforts could not prevent situations of duplication and wasteful assistance. In certain well accessible areas of Sri Lanka, where local authorities welcomed a more than tenfold increase in the number of NGOs, there were several different organizations carrying out mobile clinics per day in the same small camp. The large number of field hospitals set up in Aceh weeks after the disaster is another illustration of this overcapacity.
This does not mean that external assistance was unnecessary, but in our experience, it was most relevant and legitimate when it filled a gap that local actors had less capacity or experience in addressing, such as psychological support. Working with a network of experienced national psychologists, MSF carried out mental health programs to address the trauma caused by the tsunami – MSF field teams have considered this perhaps their most valuable contribution to the affected population. The presence of international organizations can also guard against discrimination and inequity in the local response, particularly when the natural disaster strikes in areas of underlying conflict or political tension, as in Aceh or Sri Lanka.
The provision of external assistance to Burmese migrants in Thailand is a case in point. Moreover, there were also shortfalls in the local response that warranted external support, particularly in the difficult logistical circumstances where roads were destroyed roads and affected communities scattered and isolated. Water and sanitation in displaced camps, particularly in Aceh, received insufficient attention. Many displaced communities also lacked shelter materials, in particular tents, in the initial weeks following the tsunami. While MSF was among the first organizations to provide thousands of tents, our distributions were late and only started three weeks after the tsunami struck when we realized that despite the large number of organizations present there were still gaps in the distribution of basic non-food items.
As the tsunami was generating massive funding and attention, many NGO and UN agencies warned that the tsunami should not distract efforts from 'forgotten humanitarian crises'. But in fact, this is happening currently. In Niger today, a massive nutritional crisis is affecting tens of thousands – MSF has treated more than 10,000 severely malnourished children in one area of Niger alone this year, and the situation is rapidly worsening. Yet there are few NGOs present and WFP is struggling to secure an additional 12 million dollars in funding. The international response in Niger is late and significantly short of meeting the emergency needs of the affected communities. A key principle in humanitarian assistance is proportionality – the provision of aid according to needs to ensure survival and prevent suffering. In light of the massive emergency response to the tsunami, international aid providers and donor governments must ask themselves how this principle is being implemented today.
The tsunami was an exceptional catastrophe in many ways, particularly in the staggering number of deaths it caused. Yet, despite the magnitude of the devastation, similarities with other natural disasters, such as the relatively limited emergency medical needs among survivors, the absence of epidemic outbreaks and the predominant role played by the local response, abound. What is most remarkable about the tsunami is the unprecedented level of funding and scope of the international relief effort. While certain external interventions were relevant in meeting needs, the massive influx of assistance from a variety of actors also generated activities of little added value even while gaps remained.
What is critical is to recognize that the acute emergency phase is limited in scope and in time: recovery must take place as soon as possible as this is what the people want and need, and emergency relief efforts should not delay it. We found that the few initiatives we were able to take in providing economic means that directly benefit the affected population, such as boat rebuilding, were important.
Beyond recovery, the massive reconstruction needs resulting from the tsunami are clear – the rebuilding of infrastructure, such as roads, schools, and clinics; the reconstruction of housing, the restoration of livelihoods, and the relaunching of economic activity. This is an area that is primarily a responsibility of states and specialized inter-governmental organizations for which government funding has been mobilized on a large scale. For its part, MSF intends to remain present to provide access to medical care for populations affected by ongoing conflict in Aceh.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)