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| Journal of the New Zealand Medical Association,
29-April-2011, Vol 124 No 1333
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Better be prepared than sorry: what should the New
Zealand healthcare system learn from the 2009 Pacific Tsunami?
Sultan Al-Shaqsi
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.
BackgroundThe 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:
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:
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 learntThe 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.
PersonnelThere 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 hurdlesPlanning 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:
ConclusionThe 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
References:
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