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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 29-April-2011, Vol 124 No 1333

Better be prepared than sorry: what should the New Zealand healthcare system learn from the 2009 Pacific Tsunami?
Sultan Al-Shaqsi
Abstract
On the early hours of the 29 September 2009, an earthquake in the Pacific generated a massive tsunami that caused significant destruction and claimed many lives across several Pacific nations. The disaster initiated an international relief operation from New Zealand (NZ), Australia, and the United States. The NZ healthcare response was adequate given the multiple challenges encountered. This article reviews the challenges faced by NZ healthcare responders to the Pacific Tsunami. Furthermore, it presents the lessons learnt from this operation in order to enhance the NZ healthcare system preparedness to respond to future disasters and mass emergencies nationally and internationally.

On 29 September 2009, at 06:48 am, the nations of the Pacific were awaken by a magnitude 8.1 earthquake on the Richter scale. Six minutes later, a tsunami hit the islands of Samoa, American Samoa and Tonga, causing significant destruction and loss of life.
In [Independent] Samoa, the tsunami damaged the South Coast of the main island of Upolu and the smaller island of Manono. The villages along the coastline in the South Western, South Eastern and the Southern part of Upolu were the most affected. This event was the most devastating disaster in the living memory of Samoa.
The Government of Samoa made a “Declaration of Disaster” which is the highest level of civil emergency Samoa recognises. The Samoan Ministry of Foreign Affairs initiated a formal request for assistance from the New Zealand and Australian Governments. New Zealand (NZ) immediately launched a governmental relief operation involving Ministry of Foreign Affairs and Trade, NZAid, Ministry of Health, Ministry of Civil Defence and Emergency Management, Ministry of Pacific Island Affairs, NZ Defence Force, NZ Police and NZ Customs.
This article presents the lessons learnt from the NZ health response to the 2009 Pacific Tsunami that can enhance the overall preparedness of NZ healthcare system. The main lessons revolve around the urgent need to establish NZ medical assistance teams, the importance of discreet and robust leadership and command during international emergency relief missions, and the need for preparedness in dealing with logistics and communication issues.
Finally, the article will draw on some recommendations that could greatly strengthen the level of NZ healthcare preparedness to respond to such events nationally and internationally.

Background

The magnitude 8.1 earthquake created tsunami waves that caused significant damage and loss of life in Samoa, American Samoa and Tonga. The Pacific Tsunami Warning Centre (PTWC) issued a tsunami alert 16 minutes after the onset of the earthquake.1 The PTWC recorded a 76 mm rise in water levels near the epicentre of the earthquake and NZ scientists later measured the tsunami waves to be 14 metres at their highest point next to the Samoan coast.2
The major destruction and loss of life occurred in Samoa where the tsunami struck the South Coast of the main island of Upolu and the smaller island of Manono. The villages located in the South Western, South Eastern and Southern parts of Upolu (1–2 hours drive from the capital Apia) were the most impacted. These areas are located 1-2 hours drive from the capital city of Apia. This event was the most devastating natural disaster in the living memory of Samoa.
In response to this event, the Government of Samoan declared a national disaster status and an international response from NZ and Australia was initiated.

Medical response to Pacific Tsunami 2009:

The initial health response was provided by the Samoan Government, including the Ministry of Health and the National Health Service (NHS), Samoan Red Cross, and other agencies and organisations. Initially, personnel from Apia were immediately despatched to the devastated areas to provide first aid, conduct triage and assessment and to provide transportation. Severely injured victims were transferred to the Tupua Tamaesese Meaole (TTM) National Hospital and Medcen private clinic which are located in the less impacted capital city, Apia.
A retrospective study showed that the initial local first responders were not well prepared to deal with injuries resulting from the event due to lack of prior training(3). However, the reception of patients in Apia, prior to the arrival of oversees responders, was well managed with the set-up of a “Tsunami ward” with controlled access in the National hospital.
At the request of the Samoan Government for health assistance, the NZ Ministry of Health deployed an Emergency Management Advisor with the initial objective of identifying and assessing the immediate medical needs. He joined a team consisting of NZ Defence Forces environmental health officers, NZ Red Cross representatives and Ministry of Foreign Affairs and Trade representatives arriving on the morning of the 30th of September. Australian Medical Assistance Teams (Ausmat) arrived concurrently. They were followed the same day by 14 members of NZ Defence Force Light Medical Team.
Due to good cooperation and networks between the Ministry of Health in Wellington and the Department of Health and Aging in Canberra, Australia, in the aftermath of the Tsunami, Health coordination of the NZ and Australian response teams were immediately effective in collaborating with Samoan Ministry of Health and the National Health Service (NHS) personnel.
Combined teams from NZ, Australia and Samoa were deployed to conduct rapid assessment of worst-affected areas and mobile temporary clinics were established in coastal and inland areas where victims had relocated. This collaborative initial approach proved to be invaluable to allow the local health authorities to assess its capabilities and reorganise its personnel.
The initial assessment deemed the existing capabilities of Samoan Health augmented by the Ausmats, NZ Health response team and foreign medical volunteers at that time to be adequate. However, medical issues were subsequently identified in areas such as:
  • Trauma surgery.
  • Wound nursing and care.
  • Respiratory complications of near drowning.
  • Logistics of medical evacuation of foreign patients.
  • Extra need for environmental health expertise.
  • Urgent support for primary and community-based health care services.
  • Psychological and emotional support.
It was agreed with the Ausmat Leader, that the NZ response team would provide additional specialist health care during and after the progressive withdrawal of the Australian teams from Samoa ending on the 7 October 2009. The first group of NZ specialists arrived in Samoa on 2 October followed by a successive rotation of health care personnel.
The NZ specialists’ rotations in Samoa continued until Sunday the 25 October 2009, when the medical assistance responsibility was transferred back to existing NZAid and Counties Manukau District Health Board which have well-established programmes and relationships with health services in Samoa.
Overall, 53 MoH, DHBs and Public Health Units personnel were deployed to Samoa as a part of the NZ government health response, with a peak of 33 staff on the ground between 8 and 10 of October 2009.
The NZ Government health response teams included the following specialities:
  • Emergency planners
  • Health coordinators
  • Anaesthetists
  • Orthopaedic surgeons
  • Plastic surgeons
  • General surgeons
  • Postoperative nurses
  • High dependency unit nurses
  • Emergency doctors
  • Emergency nurses
  • Theatre nurses
  • Wound care nurses
  • General nurses
  • General practitioners
  • Public health officers
  • Outpatient physicians
  • Psychologists
  • Infectious disease specialist
  • A Psychiatrist
  • Health Protection Officers
On 3 October, the Government of Samoa downgraded the state of emergency from “Declaration of Disaster” to a “Proclamation of Emergency”. This was followed 2 days later by the shift in response from “relief and rescue” to “recovery and restore” phase.
On the afternoon of 7 October, two earthquakes struck the area again leading to tsunami warnings. However, these warnings were withdrawn 2 hours later.
According to figures from the United Nations, the Tsunami killed 150 people including 14 members from a single family. The Samoan Ministry of Health estimated that the event directly affected at least 5300 people, which is 43% of the total population in the affected areas. Furthermore, the financial cost is speculated to be around $NZ 193 million equating to around 15% of the Gross Domestic Product (GDP) of Samoa.3
The impact and loss of life may have been higher if it was not for some education programmes and drills on how to respond in tsunami situations among school children.4

Lessons learnt

The need for NZ Medical Assistance Teams—An important lesson learnt during the response is that NZ requires a Medical Assistance Team ready to be deployed at a short notice to such events. The Ministry of Health defines the NZ Medical Assistance Team (NZMAT) as a ‘multidisciplinary team of health practitioners and other health and supporting personnel with the necessary skills, qualifications and training to collaborate in a health emergency response in an affected area in NZ or overseas’.5
By definition, the team should be self sufficient and have the ability to deploy at short notice when a major incident or emergency occurs. Depending on the nature of the emergency, the team may include experts from a wide range of health areas such as public health, pre-hospital trauma, trauma, surgical, medical, environmental health, and mental health. The team should also incorporate administrative, logistics and communications support.5
Currently, NZ does not have such teams that could be deployed at a short notice to disaster stricken areas nationally or internationally. For the response to Samoa the lack of established medical response teams led the Ministry of Health to send a regional emergency advisor who was experienced in international relief operations, to identify the needs and medical assistance required in the initial stages of the Samoan response. This was appropriate given the lack of ready-to-go medical assessment and response teams in NZ.
Disasters are increasing in frequency and severity worldwide and it is inevitable that the NZ health care system will be called upon to respond to similar events in the pacific region or even nationally.6
The core objective of medical assistance teams is to provide prompt and life-saving medical care to victims of disasters by self-sufficient group(s) of medical personnel. The ideal medical assistance teams require members of the team to train and prepare together before being deployed. It is unrealistic to expect members of a team to work efficiently and effectively together if they have not done this. Moreover, it is counter-productive to formulate a medical response team on the day of the event with members from different disciplines meeting for the first time at the pre-deployment briefing session.
Therefore, it is essential to build the essence of teamwork and team approach ahead of events. This cannot be achieved without investment in medical assistance teams’ preparedness and training during peace and non-disaster times.
NZ base their MATs on those of countries such as Israel, the United States, Japan, and in particular Australia, who all have a well-established medical assistance teams that have been proven to be useful in saving lives during international and national disasters. For example, the Israeli medical response teams were deployed and fully functional in Haiti 24 hours after the 2010, January earthquake.7
These teams have provided remarkable medical assistance services in many international disasters and serves as an example of a well-established and self-sufficient medical assistance teams that save lives.8,9
Internationally, there are two main general frameworks used to establish medical assistance teams.10–12 The first approach is advocated by the International Federation of Red Cross and is based on utilising two teams; one is for rapid assessment followed by the second which is a needs-tailored team.
The role of the first team is to conduct an initial needs assessment and evaluate the requirements for the full deployment of a specialised medical team. Obviously, in this approach there are different specialised pre-established teams such as Medical and Surgical Emergency Response Team, Environmental Health Team, Infectious Control Team, Health Logistics Team, Search and Rescue Team. This approach allows the response to be tailored to the needs of the event and prevents unwarranted and unwanted assistance responses. However, there is a possible time delay between the assessment of needs and the actual delivery of assistance. Furthermore, the needs may change in this time period which is another drawback of this approach.12
This philosophy of assistance teams is widely adopted by most non-governmental organisations such as the International Federation of the Red Cross and Doctors Without Borders.
The second approach is to have a full comprehensive team that carry out both tasks of needs assessment and provision of urgent medical care. The team is composed of medical personnel (doctors, nurses, paramedics) and non-medicals (logisticians, fire-fighters, search and rescue). The Australian Medical Assistance Team is an example of this approach. The advantage of this strategy is that all the needs recognised during the initial assessment are addressed by the same team immediately. However, there is always the risk of duplication in services provided by the team and that some specialized assistance might not be required immediately or at all.
At present, there is no such team available in NZ.(The NZ Defence Force has a Light Medical Assistance Team that consists mainly of army medics, usually augmented by civilian doctors and surgeons.) The first step in establishing a NZ Medical Assistance Team would be to create a database of potential health care personnel who have the skills, experience, and attributes to be members of an assistance team.
A process of selecting, identifying, training and equipping health care personnel to form teams ready to be deployed with short notice for incidents in NZ and internationally are a pressing need. Research has shown that at least 32% of doctors, nurses, and paramedics in NZ have some experience in dealing with mass emergencies which is a desirable attribute in formulating Medical Assistance Teams.13 Establishing a database of health care providers will not be an easy task because of the high rates of turnover among the NZ medical workforce.14
In short, there is a pressing need to establish a scheme where a NZ Medical Assistance Team can be trained and funded to effectively respond to emergencies and mass casualty incidents in NZ and overseas.
Leadership and co-ordination—Leadership and coordination are key elements for the success of any MAT response. Experiences from international disasters have shown that disorganisation of response efforts is probably the single most hampering factor.15–18
Leadership and coordination is the single most important factor to establish order after a chaotic emergency. Emergencies by definition are chaotic situations and multiple agencies are usually involved in dealing with these chaotic events. Therefore, unless the efforts from all different agencies are coordinated, it is very likely that the overall response will be fragmented and ineffective. The most accepted approach to establish leadership and coordination is to follow the principles of a Incident Command Structure19,20 which in NZ is called Coordinated Incident Management System (CIMS).21
During the NZ health response to the 2009 Pacific Tsunami, it was clear that the majority of NZ health care team, NZAid and MFAT members were not familiar with the incident command principles. A study has shown that 60% of NZ doctors, nurses, and paramedics are not aware of the existence of the Coordinated Incident Management System that is the fundamental to leadership and coordination of multi-agency response to an emergency.13 This finding highlighted a training issue that is wider than just MAT preparedness.
Team leadership has to be robust and well-respected among all members of the team. The members cannot act outside the terms and objectives of the overall mission and must consult with the team leader before embarking on any task. During the Samoan response there was confusion when individual members of the health response teams, requested resources directly from NZ. Such spontaneous actions highlight the lack of prior training as mentioned above.
Members of the team cannot function individually and outside the established coordination structure. This ensures smooth coordination of different agencies aiming to achieve the same goals and objectives. It would also provide a line of responsibility and liability as a team rather than individual members. Therefore, it is imperative that all members must be trained in principles of command and control for an effective overall emergency response.
It is also critically important to have leadership, coordination and cooperation around the time of transitioning and ending the relief mission. This step is usually left until the end and is not well established in many international relief missions.22 The coordination of the health care provision when the Ausmat teams left Samoa and handed over to the NZ team was smooth.
It is important to recognise the local health care system capacity before transition in discussion with local health services in order to be realistic about the level of care capable of being delivered during the transition and following the exit phases of a mission. This is an integral aspect as it helps to obviate unsustainable expectations of the local population.

Personnel

There was a high turnover rate of deployed personnel during the response period. Taking into account that such response missions can be exhaustive and demanding, longer deployment times would facilitate continuity in long-term planning, proper allocation of roles, cost reduction , and discourage “humanitarian and disaster tourism”.23
It was also obvious that many more health professionals from NZ and elsewhere appeared in the field as “self-volunteers”. This created confusion among responders and team leaders alike as to who was a volunteer and who was sent by the MOH or a DHB in NZ. The officially deployed personnel should not be labelled as volunteers and their equipment should distinguish them from self-volunteers who were managed and deployed under the umbrella of the Samoan MOH and NHS. The issue of self-volunteering in international emergencies is long debated and it is very detrimental the overall response.24

Coordination, logistics and communication hurdles

Planning and preparedness for emergencies is centralised around proper and flexible logistics. Like other international emergencies of similar magnitude, the early hours of the 2009 Pacific Tsunami were chaotic and led to uncoordinated outpouring of personnel and resources. For instance, ordering of supplies and equipment proved to be a daunting task as confusion occurred about what is available and what is needed urgently.
Prioritisation of the most urgent supplies needed was extremely difficult due to the lack of coordination in the initial stages of the response. This confusion led to individual responding agencies prioritising the need for urgent supplies differently and they went ahead with ordering the supplies directly from their contacts in NZ without prior consultation with the overall response leaders. Furthermore, the initial packed supplies were not well documented and detailed descriptions of contents of received packages were missing. This further delayed the custom clearance and caused difficulty in tracing orders.
The absence of logistic procedures complicated the despatch of items to appropriate field teams (i.e. surgical teams and mobile clinics). Although logistics in any emergency will be challenging and complex, pre-planned communication, documentation mechanisms and a single point of contact will mitigate some of the logistical hurdles encountered during the 2009 Pacific Tsunami response.
Coordination of response efforts requires the recognition by government officials of the special circumstances under which responding personnel operate. Hence, facilitate the processing of official requests faster for things which are time-sensitive such as evacuating victims and injured patients to other hospitals.
The decision-making process has to take into consideration the overall situation and the exceptional circumstances of such events. For example, among the victims of the 2009 tsunami were two individuals who were neither Australian nor NZ residents for whom their evacuation out of Samoa was delayed for a long time, as they required specific approval. Despite the fact that they eventually were evacuated with the other patients, the decision-making process was complex and based on political rather than humanitarian grounds.
Communication during the response to the 2009 Pacific Tsunami in Samoa was a struggle. International roaming service was not set up ahead of the deployment. Therefore, the initial reporting between the response leader in Samoa and the Ministry of Health National Health Coordination Centre (NHCC) in NZ was erratic and irregular and made through the satellite phone (SatPhone) until international roaming services were activated for the Team Leader.
In Samoa, key personnel deployed in the field were provided with local mobile phones with pre-paid cards provided by the NZ High Commission. However, there were issues with payment of pre-paid cards and tracing of mobile phones was difficult due to high turnover of team leaders and staff.
Internet access was problematic and non-existent other than in the capital city of Apia. The limited Internet and international phone line access highlighted the importance of having a self-sufficient responding team to avoid overloading the already stressed local structures while a disaster occurs. As for other pieces of equipment, it is particularly relevant to have a communication technology that adaptable and specifically designed for such deployments.
Another issue to discuss is that resources of funding for such international response missions are unclear. During the initial stages of the 2009 response, expenses were covered by personal credit cards as there was no other alternative provided. Later a source of “Temporary” funding for the response expenses was found. Accordingly, it is vital to have pre-planned and well-established funds ready to be utilised in such incidents.

Recommendations:

  • Creating a NZ Medical Assistance Team, selected, trained, equipped and self-sufficient to be deployed at a short notice to respond to national and international incidents.
  • Personnel from all agencies with the potential to be called on to respond to an emergency must have regular training for command, leadership and coordination during emergency relief missions.
  • Preparedness for logistics, communication and financial issues must take place ahead of any deployment and must be a regular objective to enhance emergency health preparedness in NZ.

Conclusion

The overall NZ health response to the 2009 Pacific Tsunami achieved the objectives outlined in the action plans. The response was managed to an acceptable level taking into consideration that at the time of deployment there was neither pre-existing NZ Medical Assistance Team nor established robust procedures and policies in place to outline the details of such emergency missions. This outcome can be attributed to a positive assistance response within the NZ Health sector, as well as improvisation, adaptation and commitment of individuals and organisations involved in Samoa.
Competing interests: None.
Disclaimer: The views and recommendations presented in this article are solely those of the author and do not necessarily represent the view of the Ministry of Health team members deployed to Samoa or Samoan health officials.
Note: The article was written before the devastating Canterbury, NZ Earthquakes (Sept 2010 and Feb 2011) and North-East Japan Earthquake and Tsunami (March 2011).
Author information: Sultan Al-Shaqsi, MBChB/PhD candidate, Preventive and Social Medicine Department, Dunedin School of Medicine, University of Otago, Dunedin;
Acknowledgments: This article is in remembrance of the wonderful souls whose lives were cut short by the power of nature. My thanks to all people (medical and non-medical) who devoted their time and efforts to help those in need during the event.
I also thank Gerard Clerc (NZ Health Response Leader, Samoa 2009) and Graeme McColl (NZ National Health Coordination Centre Response Manager during 2009 Pacific Tsunami) for sharing the lessons learnt from the 2009 Pacific Tsunami Response.
Correspondence: Sultan Al-Shaqsi, Preventative and Social Medicine Department, Dunedin School of Medicine, PO Box 913, Dunedin 9054, New Zealand. Email: alssu455@student.otago.ac.nz
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