health related response to natural disasters: the case of the bangladesh cyclone of 1991

Ser. SC;. Med. Vol. 36, No. 7. pp. 903-914, 1993 Printed in Great Britam. All rights reserved

0277.9536193 $6.00 + 0.00 Copyright Q 1993 Pergamon Press Ltd

HEALTH RELATED RESPONSE TO NATURAL DISASTERS: THE CASE OF THE BANGLADESH CYCLONE

OF 1991

M. OMAR RAHMAN’ and MICHAEL BENNISH’

‘RAND, 1700 Main Street, Santa Monica, CA 90407, U.S.A. and ?Departments ofpediatrics and Medicine, New England Medical Center, Tufts University School of Medicine, 750 Washington Street, Boston,

MA 0211 I, U.S.A.

Abstract-This paper evaluates the health related response to large natural disasters using the example of the recent Bangladesh cyclone of 1991. After providing a description of the extent of the health response, it focuses on three major issues: (i) assessment of needs (ii) coordination of major groups involved in health relief and rehabilitation efforts and (iii) appropriateness and effectiveness of the health response in terms of definable outcome criteria. The conclusions are that in the case of the Bangladesh cyclone: (a) the assessment of needs was more reactive rather than anticipatory and was not based on any systematic data gathering from the field; (b) in contrast to previous disaster situations there was excellent coordination of the major groups involved in the aid process (the government, the armed forces and non-governmental organizations) and (c) given the caveat of inadequate baseline information, it appears that the health response was prompt and effective in preventing any increase in mortality from diarrhea1 diseases and measles. The reasons for the deficiencies and successes of the health response are analysed and finally a list of detailed recommendations to facilitate future disaster/cyclone management and response is provided

Key wjords<yclone, health, Bangladesh

INTRODUCTION

On 30 April 1991 a cyclone of unprecedented force battered the south eastern coastal region of Bangladesh (Fig. l), leaving in its wake devastation of enormous proportions. It is estimated that as a result of the immediate impact of the cyclone, approx. 10 million people were affected with 139,000* deaths and 138,000 injuries. In addition there was extensive damage to livestock, property and physical infrastructure (water supplies and communications)- approximately, 10 million cattle/poultry were lost (81% of those affected), 1,630,OOO houses was damaged (91% of those affected), 764 miles of unpaved roads and 500 bridges and culverts were destroyed, 25% of tubewells were made non-functional and communications were severely disrupted (Tables 1 A and B).? Total damages are estimated by the Govern- ment of Bangladesh to be in the region of U.S.$2.4 billion [I].

*Recent information based on a careful epidemiologic sur- vey indicates that the final death toll may actually be considerably less-approx. 68,000 total deaths. In addition the death rates varied considerably both geo- graphically and by age and sex. In the worst affected areas (i.e. those with mortality rates ~5%) the breakdown was as follows: male (87.1/1000); female (124.1/1000); &14yr (154.5/1000); 1549yr (40.0/1000); 50 + yr (134.0/1000) and overall (105.6/1000) [12].

TWhile explicit denominators were not provided in any of the government reports, we have estimated them for select categories of loss in Table 1.

In the aftermath of a disaster of such magnitude there is usually, as was true in this case. a massive outpouring of aid both internal and external. Although disaster management (especially in this scale in developing countries) has become much more systematized in recent years [2-91, the assessment of needs, and the appropriateness and coordination of response remain somewhat under researched and relatively ad hoc exercises [2, 3, 5, 81. In this report we focus specifically on the health related response to this cyclone as a microcosm of the larger issues involved in overall disaster management.

HEALTH RESPONSE

In order to evaluate the health response to the

cyclone the following issues need to be considered:

(i) What was the extent of the health response? (ii) Was there an appropriate assessment of

needs? (iii) Was there effective co-ordination of the ma-

jor groups involved in relief and rehabilitation?

(iv) Was the response effective in terms of some definable outcome criteria?

Extent of the health response

Total disbursement of health related cyclone aid is difficult to quantify for two main reasons: (i) much of the aid was in kind, i.e. stocks of medical supplies

903

304 M. OMAR RAHMAN and MICHAEL BENNISH

I 9”

BHUTAN Bangladesh

- International boundary

- - District boundary

* National capital

!s

District capital

Cyclone of 1991

INDIA

0 20 40 60 kilometers

I II’ II I 0 20 40 60 miles

BURMA

~ Bay ‘of Bengal

I 88 90

Fig. 1

Health related response to natural disasters 905

(A) Table I

Affected National total % of National total

LJpaZil~S 7s 490 IS.31 Individuals 10721707 I.1 x 108 9.75 Households 1.79 x 106 18333333 9.15

Category Damaged At risk % Damaged

Crops damaged (acres) Fully 117753 2.86 x IO” 4.12 Partially 791621 2.86 x IO6 27.69 Total 909374 2.86 x IO6 31.81

Houses damaged (dwelling units) Fully 78008 I 1.79 x I06 43.65 Partially 850462 1.79 x I06 47.59 Total 1630543 1.79 x 106 91.25

Deaths 138866 10721707 I .30 Injuries 138849 10721707 1.30 Cattle/poultry 10030656 12383571 81.00

Note: The denominators for the ‘at risk’ category Were calculated on the basis of Ihe population affected in the cyclone (10,721,707) as reported by the government of Bangladesh. The following ratios are based on the Statistical Pocketbook of Bangladesh 1987 [l7].

Population/households = 6. Crop acreage/household = I .6. Houses/household = I. Cattle/poultry: cows = I h/household; poultry = 5.33/household.

rather than in cash and (ii) many organizations in their accounting procedures did not separate out health related expenditures from other aid.* Thus at present one can only give somewhat impressionistic descriptions of health sector needs and allotments.

Health aid was primarily allocated for (i) replacement of damaged health infrastructure in the affected areas (43 1 health institutions in 75 upajelas (sub-districts) under 15 districts were affected to varying degrees) and (ii) efforts to combat cyclone related acute injuries and outbreaks of diarrhea1 disease and acute respiratory tract infecti0ns.t For the latter, in addition to expenditures on medical supplies (e.g. oral rehydration packets, intravenous solutions, various antibiotics, measles vaccines) the major costs

*Part of the problem is arriving at a consistent definition of what constitutes health aid. For the purposes of this analysis, we are restricting health related aid to expenditures on health infrastructure, medical supplies (e.g. drugs, oral rehydration solutions, intravenous fluids, bandages), primary health care service delivery, (immunization, nutritional surveillance, health education), health personnel costs and replacement costs of health infrastructure. In particular we are excluding expenditures on water and sanitation.

tExcept for the U.N. agencies who collaborated with the government in the construction and repair of physical infrastructure most non-governmental development agencies were primarily involved in the distribution of drugs and medical supplies and the provision of medical manpower.

$The figure of U.S.$19.7 million in all likelihood does not capture the total extent of health aid provided by various non governmental organizations in the immediate aftermath of the cyclone. However given the relatively small scale nature of most of these endeavours, total cyclone- related health expenditure is unlikely to be significantly different than U.S.$20 million.

were for health teams to provide acute medical services, distribute oral rehydration packets in the community, provide vaccinations (primarily for measles) and do nutritional surveillance.

Cyclone related relief and rehabilitation needs in the health sector (not including water and sanitation) were estimated to be U.S.$l9.7 million, including U.S.$l5.2 million for short-term requirements (Table 2) [l]. The health sector needs outlined in Table 2 cover the following: (i) a short term Govern- ment-WHO collaborative program to repair, rehabil- itate and restore 11 district hospitals and specialized institutions, 50 Upazila-level health centres and 370 union-level centres, at an estimated cost of U.S.$5.7 million, including $2.8 million for equipment and supplies. (ii) A short-term Government-UNICEF collaborative programme to construct and equip 20 multi-purpose community centres with a provision for shelter and health services as well as to rehabili- tate 200 damaged health centres. The programme involved replacement of vaccines, cold chain and supplies for the expanded immunization programme: supply of ORS, IV fluids, antibiotics, various other drugs and kits, and medical equipment and supplies. This set of activities was costed at U.S.$9.5 million, including U.S.$7.7 million for equipment and supplies. (iii) For the medium term, WHO in collaboration with the Government of Bangladesh is developing a health-related disaster preparedness programme which will require U.S.$4.5 mil1ion.f In addition to the short and medium term estimates of health sector needs cited above, in the long run an expansion of normal health coverage activities in the cyclone affected areas may well be required to combat the yet unknown long term health consequences of such a major disaster (e.g. growth faltering for infants

906 M. OMAK RAHMAN and MICHAEL BENNISH

Table 2. Reconstruction and rehabilitation “roeramme cost estimates. Source: UNDP 111

I. Social .w(‘t,,rs

Health Water and ramtation Education Housing and community development Social services, rehabilitation and development

Sub-total -7 Agriuil/ure

Crop agriculture Forestry Fisherlea Lixstock Food

Sub-total 3. Phpul infrastrucrurr

Radway and roadqhighwaya Water resources. Rood control and irrigation Civil aviation Post Telecommunications Ports, shipping and inland watrr Power and gas Urban infrastructure Rural infrastructure (including roads)

Sub-total 4. Industr1

Public knterprises 25.0 33.0 0.0 58.0 EPZ 26.0 20.0 0.0 46.0 Small and cottage mdustrles IS.0 0.0 0.0 15.0 Medium and large industries 100.0 100.0 99.0 299.0

Sub-total 166.0 153.0 99.0 418.0 GRAND TOTAL 621.1 368.6 194.4 1784. I

Short term U.S.$ million

(up to June 1992)

Medium term U.S.$ million

(July 92-June 93)

Long term U.S.% million

(July 1993m ) Total

U.S.$ million

15.2 4.5 0.0 19.7 14.2 0.0 0.0 14.2 35.0 10.0 147.2 192.2 33.0 30.0 30.0 93.0 14 3 0.0 0.0 14.3

III 7 44.5 171.2 333.4

30.3 7.8 0.0 28.5 0.0 0.0 51.0 20.0 50.6

7.3 20.3 0.0 6.6 5.5 0.0

123.7 53.6 50.6

3x.1 28.5

121.6< 27.6 12.1

227 9

Il.4 41.0 23.0 75.4 60.0 62.7 200.0 322.1

2.0 13.8 0.0 15.8 0.6 0.0 4.2 4.8 3.0 0.0 99.8 102.8

54.4 0.0 73.3 127.1 39.6 0.0 5.1 44.7 25.3 0.0 20.0 45.3 23 4 0.0 42.2 65.6

219.7 117.5 467.6 804.8

due to the acute impact of food shortages, loss of breast milk from the death of the mother and various communicable diseases).*

It is important to note, that although health sector demands were little more than 1% of total aid (U.S.$1.78 billion) requested for the cyclone (the majority of which was allocated for replacement of non-health physical infrastructure such as edu- cational institutions, communication and transpor- tation systems, embankments, agricultural needs, and shelter-Table 2) this was not an unsubstantial request as it amounted to roughly 20% of yearly expenditure on health in Bangladesh [I 11.

Most observers in the donor community and the government do not feel that the cyclone related health aid diverted funds from their normal health activities in the country as a whole, i.e. cyclone related health aid supplemented rather than substituted normal health expenditures. However, in the first months after the cyclone, there was some concern that the massive mobilization of resources to meet the short term acute health needs of cyclone affected areas did hamper to some extent routine preventative health activities such as immunization coverage and distribution of vitamin A capsules in the cyclone affected

*Recent evidence from nutritional surveillance carried out by Helen Keller International suggests that there was a significant increase in malnutrition for children 1-5 yr of age in the first 6 months following the cyclone with 24% of the children being classified as severely malnourished [lo, 121.

parts of the country. As shown in Fig. 2, this concern was born out. Immunization coverage in the cyclone affected areas of Chittagong and Cox’s Bazar de- clined significantly in the immediate post-cyclone

Cyclone hits Bangladesh: 30 April 1991

62.5

, / , / / I

/

/

/

I

/

/

/

/

/

/

/

April May

65.4 -

q Chittagong q Cox’s Bazar q National

Fig. 2. Reported DPT3 and OPV3 immunization coverage, April-May 1991. Source: From Crisis to Development [12].


period from 62% (in April the month prior to the cyclone) to 13% (in May, the month following the cyclone) [ 121 and vitamin A capsule distribution was well below the national average of 35% (no actual figure cited) [ 121.

Assessment of health needs

Health needs in the period following a natural disaster such as a cyclone, can be conceptually divided into short and long term requirements. In the short run, conventional wisdom dictates that due to the possibility of extensive damage to water supplies, acute food shortages, and the resulting overcrowding of displaced populations in shelters, one of the major foci should be on minimizing morbidity and mortality from communicable diseases particularly diarrhea1 diseases and acute respiratory infections [3,4, 8, 13P15]. It is important to note however, that the fear of a significant increase in communicable diseases in the post-cyclone period although plausible, is by and large based on anecdotal evidence with little systematic data in the literature to support it [3, 5, 13, 151. Another short run concern is the treatment of acute injuries resulting from the direct physical effect of the cyclone [3]. The long run needs revolve around the replacement of damaged health infrastructure (health clinics, medical stocks and supplies) and the continuation of ongoing primary health care services such as immunization programs, nutritional surveillance etc.

13, 131. In the case of the Bangladesh cyclone, two days

after the cyclone struck, the health ministry of the government of Bangladesh with the guidance of WHO submitted a request to International donors amounting to a total of Tk 1141 million (U.S.$31 million) [13]. Emergency medical supplies to treat acute injuries and to combat anticipated communicable disease outbreaks amounted to U.S.$12 million with the rest being requested for the replacement of damaged primary health care facilities including existing medical stocks.* On the non-governmental side, multilateral organizations and local Non-Gov- ernmental Organizations (NGO’S)t came up with their own assessments of immediate health needs. One of the larger multi-lateral organization for example allocated U.S.$270,000 initially followed up by an extra U.S.$3 million 850 thousand for anti-

*Later estimates were downsized to U.S.Sl9.7 million as noted above.

tNonGovernmenta1 Organizations (NGO’S) represent a wide spectrum in terms of manpower, resources and organizational capacity. However they constitute a particularly important arm of any systemic response in the context of Bangladesh, as much of the International aid is funnelled via their auspices.

SCyclonic storms generally occur in the months of April-May and October-November. Although small storms are frequent, severe cyclones are not that common and the magnitude is often difficult to predict, resulting in many false alarms [17]. Between 1947 and 1988 13 severe cyclones hit Bangladesh [16].

biotics, oral rehydration solutions, intravenous fluids, health education and immunization campaigns.

In trying to evaluate the appropriateness of the above needs assessments, two issues which come to mind are: (i) To what extent were cyclone related health needs anticipated prior to the cyclone as opposed to a reaction to the cyclone? and (ii) What was the basis for these assessments?

It is fair to say that for both the government and for non-government organizations, health needs assessment was more a reactive rather than an anticipatory process. There are a number of reasons why this was so. Firstly, although cyclones in Bangladesh are frequent and have a relatively distinct seasonal patternS the last cyclone of such a magnitude took place two decades ago in 1970 and there has not been a major cyclone in this area of Bangladesh since 1960. Secondly, in developing countries such as Bangladesh where funds in both the government and the non-government sectors are very limited, allocating resources for current problems takes precedence over preparing (for example investing in cyclone proof shelters, building up reserves of extra stocks of medical supplies in the cyclone season etc.) for future contin- gencies which may or may not materialize. Finally although contingency plans along the lines of standard WHO protocols did exist in the relevant government departments, the utility of such plans to guide responses to such a disaster was markedly diminished by the fact that due to the high turnover of individuals, usually the only people who were aware of the plans were no longer there when the disaster struck.

With regard to the basis for the cyclone related health needs estimates, it is clear that, the requisite assessments in the post disaster period (and here we are concentrating primarily on short run needs) was not derived from any systematized information base. While the government in principle has a fairly extensive disease surveillance system, in practice the quality of data collected is less than desirable even in non-crisis situations. In the post cyclone period due to a breakdown in communications and transpor- tation, a lack of standardized reporting criteria and due to deficiencies in co-ordinating information re- trival from field surveillance in the affected areas, very little useable data was available to base allocative decisions. Furthermore the absence of reliable baseline information (from the pre-cyclone period) made it very difficult to assess the magnitude of change in the health situation in the affected areas. The Govern- ment and some of the larger (NGO’S) non-governmental organizations (including the United Nations agencies) for the most part ended up extrapolating from their experience in the 1988 floods, and or made some rough calculations to guide their response (one of the more explicit assessments is presented in Table 3). Most other aid organizations on the other hand had even less explicit information/criteria to guide their actions.

908 M. OMAR RAHMAN and MICHAEL RENNISH

Table 3. Post cyclone dwrhoeal diseases projectmn

?&hdluc .XKI - 100,000 cues x 5 = 500,000 tablets

While the absence of explicit field data based criteria for needs assessment is justifiable in the immediate period following a natural disaster of such a magnitude. the cotltinuing lack of systematically collected data in subsequent weeks (either by more co-ordinated reporting from the existing surveillance system or by using rapid assessment techniques, both of which could have been achieved with relatively few time, money and manpower resources [ 181) sub- sequently resulted in needs assessments and corre- sponding levels of supplies to the affected areas which were not entirely warranted on the basis of the actual situation.

A case in point is the supply of drugs to government health institutions in aftermath of the cyclone. As noted above there was a massive outpouring of drugs and medical supplies to the cyclone-affected areas, much of which however was not needed and some of which was needed was not supplied. Table 4

shows (for a particular ‘union‘, an administrative unit of approx. 2S,OOO people in one of the worst affected areas) the supply of drugs for the government health center in the month following the cyclone was significantly higher than normal levels.

In order to investigate whether this increased supply was commensurate with the need, calculations were made based on the disease profile of patients seen in the same period in the health center [ 131. The total number of patients seen in May 1991 was 4300 of which 1181 (27?/0) complained of diarrhea1 related illness. Based on the diarrhea1 disease profile, the drug need for patients visiting the government health center in May 1991 was estimated to be 1407 packets of oral rehydration therapy (3 packets for each of the 469 patients with watery or mucoid stool) and 14240 tablets of nalidixic acid (20 tablets for each of the 712 patients with bloody dysentery). As shown in Fig. 3. 8300 packets of ORS and 1000 tablets of Nalidixic

Table 4. Antimxrobial drugs suuohed to Eidnaon union, Cox’s Bazar District, January 1990 Aor I99 I

Antimicrobral drue

Regular supply

January 199s

Auril 1991

Emergency supply

Mav-June 1991

Emergency

supplq as %

of total SUDDIV

Metromdazole tablets 30,400

Co-trimoxazole tablets 5000

Ampiallin capsules I 1,000

Ampicdlin suspension, bottles I45

Tetracycline capsules 2000

Nalidlxic acid 0

Sachets of oral rehydration salts 4000

Intrwenous cholera saline, bags 20

Source: Report of UNICEF Cyclone Review Group [I31

16,000 35

5030 50

8000 42

20 I?

20 81

1000 100

8300 68

40 67


q Drugs supplied

0 Drugs needed

Metron Nal. acid ORS Tetrac.

Fig. 3. Drug supply vs drug need for diarrhea, Eidgaon union, May 1991. Source: UNICEF Cyclone Review Group

u31.

acid were supplied. Assuming that 10% of patients with dysentery had amoebiasis the requirement for metronidiazole is an estimated 1495 tablets, while the supply was a stupendous 16,000 tablets. The need for tetracycline is more difficult to assess as it is not known whether any patients presented with cholera. Since no deaths from dehydrating diarrhea were reported in this union, the presence of cholera is unlikely and the use of tetracycline not justified. Nevertheless 8500 tablets of tetracycline were supplied.

From the above results it is apparent that there was little co-ordination of information gathering to guide decisions about supplies. Adequate monitoring of patient registers in hospitals and health clinics in the affected areas (a not very resource intensive exercise) would have allowed for a more rational assessment of drug needs and distribution.

In an analogous fashion to the oversupply of drugs, vast quantities of water purification tablets were supplied to the cyclone affected areas in response to an assumed wide-spread lack of drinking water. Subsequent surveys by UNICEF showed however that the lack of potable water was a relatively modest problem (only about 25% of tubewells were out of commission [13]) and much of the water purification tablets were unnecessary. Parenthetically

March April May

Week

Fig. 4. Weekly number of medical teams, Bahnskhali upazila, March-May 1991. Source: UNICEF Cyclone Review

Group [13].

: f 100

L

2 80

2 e, 60 _;; 3 40

‘_ 0 z 20 m

; 0 March April May

Week

Fig. 5. Weekly cases of watery diarrhea, Cox’s Bazar hospital (March-May 1991). Source: UNICEF Cyclone

Review Group [13].

due to a combination of problems stemming from inappropriate labelling instructions and bad quality the tablets were not used as effectively as they could have been.

Apart from an oversupply of oral rehydration solutions, various antibiotics and water purification tablets and an undersupply of some needed antibiotics, there was also arguably an oversupply of medical teams. Data from Bashkhali upajela (a sub- district of about 200,000 people in one of the worst affected areas) shows there was a huge increase in medical manpower following the cyclone (Fig. 4). While some increase was clearly indicated due to the rise in prevalence of diarrhea1 diseases (Fig. S), it is unlikely that the situation warranted a l&15 fold increase in medical manpower. Here again the lack of reliable data from the field make definitive conclusions about needs assessment difficult. We have chosen to present hospital data as evidence of increases in post cyclone prevalence of diarrhea1 disease as there is some consistency in the ascertainment methods before and after the cyclone. Population level data (derived from the government surveillance system) on post-cyclone diarrhea1 prevalence on the other hand is significantly confounded by much higher levels of reporting in the post cyclone period relative to the pre-cyclone period and due to multiple reporting of the same case by different medical teams

1131. There were a number of consequences of the

oversupply of drugs and medical teams. Firstly, as alluded to earlier, the mobilization of huge numbers of local health personnel to provide curative medical care and to distribute the vast quantities of medical supplies sent to the cyclone affected areas caused a shortage of manpower to carry out routine preventative health services such as immunizations and Vita- min A distribution [12]. This led to a significant decline in immunization and Vitamin A coverage in the cyclone affected areas (Fig. 2). Secondly, partially due to the oversupply of drugs some of them were inappropriately prescribed-Metronidiazole for example was widely used in cases of watery diarrhea despite recommendations that it only be used for amoebiasis present in only about an estimated 10%

910 M. OMAR RAHMAN and MICHAEL BENNSH

of cases [13]. Thirdly, one of the inadvertant side effects of the large number of medical teams was an exaggeration of the increase in reported cases of diarrhea in the immediate post-cyclone period, due to as mentioned above, (a) much higher levels of reporting from the field compared to pre-cyclone levels and (b) multiple reports of the same case by different teams [l3].

It is important to note that the Bangladesh case is not unique--needs assessment in disaster situations based on actual data from the field collected in a

systematic manner and definable criteria is still not

common, particularly in the developing world. Part of the problem is the strong psychological association between disasters and epidemics. There is a great deal of pressure to respond immediately and massively with the anticipation of significant outbreaks of diarrhea1 diseases and acute respiratory tract infections. As mentioned above however there is little data in the literature to support such fears [2. 3, 141.

Coordination qf‘ mqjor groups involved in the health response

By I May 1991 (2 days after the cyclone hit the south eastern coast of Bangladesh) an Emergency Relief Co-ordination Committee headed by the Prime Minister of Bangladesh was established to provide guidance to The Emergency Relief Management Committee. The latter body headed by the Relief Minister in the Government of Bangladesh and con- sisting of key Secretaries of the Government (the highest bureacratic position in the civil service) was responsible for coordinating and implementing all relief efforts. The affected areas were divided into two zones under two senior zonal co-ordinators (high level bureaucrats) with headquarters in Chittagong and Barisal, the two major cities in the affected area. Coordination cells were set up at the zonal, district (I 5/64 districts were affected each with an estimated population of 1.72 million) upazila (75 out of 490 upazilas were affected each with an approximate population of 225,000 individuals) and union level (approx. 650/4401 were affected each with an approximate population of 25,000 people) with representatives of the local civilian administration, the armed forces and relevant NGO’s [I].

Thus at a systemic level, the health response to the Bangladesh cyclone involved the following groups: (i) The civilian administration of the Government of Bangladesh represented through the Ministries of Health and Relief and Rehabilitation and the local administrative structure. (ii) The Bangladesh Armed Forces assisted in part by the U.S. Marine task force, and last but not least (iii) Non-governmental Organ-

*A number of the larger NGOS both national and international had a well established organizational infrastructure in many of the affected areas due to their development work and this institutional and logistic experience was very effectively put to use.

izations engaged in developmental work (including national and international groups).

While under normal circumstances the use of many different groups with different chains of command and lines of authority to disburse services is fraught with pitfalls, in a post disaster situation, rapid effective response may require multiple outreach avenues. In the past, disaster management in Bangladesh (ris ci ais the floods of 1985 and 1988) has suffered due to the over centralization of authority within the government system. Most observers believe that m a conspicuous break with the past the government this time around encouraged significant autonomy in terms of decision making at the local field level and accommodated non-governmental groups to the fullest extent. Furthermore there was a conscious effort on the part of the government to recognize its limitations and delegate responsibilities to other non governmental groups with the requisite resources at the local level.*

An important point to note in analysing the government response is that, in contrast to 1985. 1988 (where the country had a long entrenched military government), the government in power at the end of April 1991 when the cyclone hit, was a month old. newly elected democratic civilian regime (the first since 1979) which had recently assumed office. Politi- cally there was intense media and public scrutiny and pressure to respond effectively to the disaster. In fact it would not be unreasonable to say that the credi- bility and legitimacy of the government was riding on its ability to respond. It is likely that the relative ‘newness’ of the regime and its desire not to fumble in its first big test of governance made it less beholden to entrenched bureacratic practice and caused it to open up avenues of collaboration with other non- governmental agencies and organizations

The Bangladesh Armed forces played a major role in both maintaining order and stability in the disaster affected areas as well as providing a well-disciplined, organized and experienced source of logistic support for the carrying out of relief and rehabilitation activities. The army has been involved in all major relief efforts in Bangladesh and is one of the primary sources of institutional experience in dealing with disaster management [l6]. Credit should also be given to the military authorities for their role in integrating their activities with the civilian administration and working under a unified civilian command structure.

The arrival of the U.S. marine task force (in response to a request from the Government of Bangladesh for logistic and material support) provided an additional but crucial outreach mechanism with particular relevance to the relatively inaccessible but badly affected islands of Kutubdia and Sandwip. The U.S. marines worked closely with the Bangladesh Armed forces under joint civilian leadership of the Zonal Administrator and it is probably true that without the kind of technical logistic support (helicopters, landing craft, ground transport and fixed


wing aircraft) provided by the marines effective response would have been significantly delayed in those areas.

From the point of view of the NGO’s, after some initial confusion, and unlike previous disaster situations, there was a concerted effort to co-ordinate tasks, avoid duplication, delegate responsibility and in general work with the local administration and the armed forces rather than independently by them- selves. Furthermore, the decision by the government to designate NGOs with extensive local networks and experience as lead agencies in the distribution of health services in the community greatly facilitated the whole relief and rehabilitation process. Special mention needs to be made of the exemplary role of the Association of Development Agencies of Bangladesh (ADAB), an umbrella organization which greatly facilitated NGO-NGO and NGO-government co-ordination.

In summary, there were a number of elements in the co-ordination process which contributed to the success of the recent post-cyclone relief efforts and are worth emulating in future disaster situations. Firstly, there was strong and immediate political commitment to and scrutiny of relief and rehabilation efforts as evidenced by the formation of a high level committee (headed by the Minister of Relief and Rehabilitation with participation from Sec- retaries of all the relevant government ministries, high level representatives of the armed forces and representatives of major donor agencies/ organizations) answerable directly to the Prime Minister. Secondly, the formation of a rational regional command structure (Zonal-District-Sub- District and Sub-Sub-District) in the affected areas, headed by high level bureaucrats (Zonal Administra- tors) answerable to Dhaka (the Capital) but with the authority to make field decisions without refer- ring everything back helped streamline the flow of relief material. Thirdly and perhaps most impor- tantly, the formation of co-ordination cells at each level (under overall civilian command), which included representatives of the local civilian administration, the armed forces and relevant non-government organizations and the subsequent division of tasks according to organizational experience and logistic capabilities greatly facilitated the relief and rehabilitation process. This process of co-ordination with non-governmental groups was a significant de- parture from previous disaster situations and was partially due to the intense media coverage, both international and national (this was the first disaster which was under the spotlight of a free Bangladeshi press).

*One factor which partially accounts for the prompt health response is the institutional experience gained by the government, the armed forces and the NGOs in providing post-disaster health aid lo combat communicable diseases as a result of past disasters.

Effectiveness of the health response

A number of indicators can be used to gauge the effectiveness of the health response to the cyclone. From the point of view of measures such as the

availability of medical services in affected areas, the response was very effective. In all areas that were physically accessible, there was very rapid mobilization of health teams who provided acute medical care, and other primary health care services such as, distribution of oral rehydration solutions, antibiotics and other drugs and dissemination of health education messages. Data from Bashkhali upajela (in one of the worst affected areas) shows there was a huge increase in drug availability (Table 4) and medical manpower following the cyclone (Fig. 4). In the physically inaccessible areas (mainly the outlying islands of Kutubdia and Sandwip), delivery of health services had to wait until access could be provided by the U.S. marine task force. However, once access was ensured, health teams were quickly in place. In fact one could argue that in the post-cyclone period the cyclone affected areas actually received a much higher level of health services than they ever had before.*

In addition to the availability of drugs and medical manpower in the post-cyclone period, another set of measures of the effectiveness of post cyclone health interventions is a comparison of pre- and post- cyclone morbidity and mortality levels from communicable diseases such as diarrhea and acute respiratory tract infections which may potentially rise sharply in incidence as a result of the cyclone. Here however, the absence of reliable pre-cyclone baseline information is a big hindrance. Although in principle Bangladesh has a very detailed surveillance system for communicable diseases (particularly diarrhea), due to a variety of reasons such as, non-standardiz- ation of reporting protocols (e.g. what falls under the rubric of ‘diarrhea1 disease’), low levels of reporting and delayed reporting from the field in non-crisis situations, it is difficult to establish with confidence pre-cyclone levels of diarrhea1 disease [13].

The lack of a reliable pre-cyclone baseline, the inevitable increase in the completeness of field reporting in the post-cyclone period due to increased scrutiny and evidence of multiple recording of the same diarrhea1 case in the post cyclone period by various medical teams, makes it difficult to draw definitive conclusions. Given these caveats however, there does not appear to have been a diarrhea epidemic following the cyclone [12, 131. As Fig. 5 indicates, there was a significant increase in the first few weeks after the cyclone (particularly for adults). However subsequent epidemiologic studies [ 121 have confirmed that 6 weeks after the cyclone, diarrhea1 point prevalence in children ages l-5 in the worst affected areas was about lo%, not indicative of a major epidemic and consistent with the pre-cyclone hyper endemic diarrhea prevalence in Bangladesh. It is certainly possible that the lack of a post-cyclone

912 M. OMAR RAHMAN and MICHAEL BENNISH

diarrhea1 epidemic was due to the promptness of the health relief efforts supplemented in part by the wide spread community acceptability and knowledge about the use and preparation of oral rehydration in the event of diarrhea as a result of earlier community education programmes. However due to lack of definitive data one cannot rule out totally the alterna- tive possibility that diarrhea prevalence was not significantly affected by the cyclone.

With regard to post-cyclone mortality from communicable diseases, reports from government surveillance suggest that post-cyclone diarrhea1 case fatality in the cyclone affected areas in Bangladesh was not significantly different than pre-cyclone levels, once physical access to the affected areas was ensured. Evidence from Cox’s Bazar Hospital (in one of the worst affected areas) indicates that pre-cyclone diarrhea] case fatality was 2. I deaths; 100 diarrhea cases for the month of April 1991 (just prior to the cyclone) while post cyclone diarrhea] case fatality was I.6 deaths/100 diarrhea cases for May I99 I [ 131.

While analogous figures are not available for all respiratory tract infections, we do know that there have been very few reported cases of measles, a particular concern for children under 5. This can plausibly be attributed to the vigorous measles immunization campaign promoted by the UNICEF spon- sored Expanded Program for Immunization (EPI). As alluded to earlier. in contrast to the increased levels of measles vaccination in the cyclone affected arcas there appears to have been a significant decline in immunization coverage for diptheria. pertussis. tetanus and polio and in vitamin A capsule distribution. While the long term effect of this decrease is not clear, the fact that it happened is a cautionary note in considering the trade off between responding to short term acute care needs in the aftermath of a disaster ois d uis maintaining long term preventative care programs.

One final point with regard to comparing pre- and post-cyclone morbidity. Recent data from a study conducted by Helen Keller International [IO. 121 shows that by 6 months after the cyclone there had been a significant rise in malnutrition in the cyclone affected areas for children aged IL5 years with mean mid-upper arm circumference (MUAC) decreasing from 132 mm in September 199 I (4 months after the cyclone) to 134 mm in December 1991. The prevalence of severe malnutrition as measured by MUAC < 125 mm also increased from 21% in October 1991 to 24% in November 1991 compared to only 10% in

non-cyclone affected areas. To the extent that nutri-

*It is not clear how feasible and cost-effective nutritional supplementation programs really are. This ic an area which needs further investigation.

twhether the lack of increase in post-cyclone diarrhea1 morbidity from communicable diseases such as diarrhea and respiratory tract infections can be justifiably attributed to good post-cyclone care remains a moot point as discussed earlier.

tional surveillance followed by food supplementation programs for children at high risk of malnutrition could have averted this situation,* this suggests that there were deficiencies in the post cyclone medium to long term health response.

StiMMARY AND RECOMMENDATIONS

In conclusion, after careful evaluation of the available data and contrary to some reports (in the press and otherwise) the health related response to the Bangladesh cyclone appears to have been very effective in that health services to combat communicable diseases (such as diarrhea and respiratory tract infections) were provided rapidly to the affected population and there was no significant increase in post-cyclone morbidity? and mortality. The effectiveness of the health response can be attributed to a number of factors: (i) a high level of political commitment by a newly elected civilian government to the relief process backed up by a rational relief distribution structure which at every level included input from all the major players (the government, the army and the non-governmental organizations) and divided up responsibility according to logistic and infrastruc- tural capabilities. (ii) Intense international and national media coverage of the process (this was the first disaster in a long time which was under the spotlight of a free local press). (iii) A significant amount of institutional experience in distributing health relief among the government. the armed forces and the non-government development agencies gained from previous disasters. (iv) A heightened knowledge among the community about the utility of oral rehydration solutions in the management of diarrhea due to extensive long standing health education programs [ 121. (v) The efficient functioning of the private market sector in providing goods and services (primarily food and clothing) even to the most inaccessible areas and (vi) last but not least a massive outpouring of public volunteer support which provided a ready pool of personnel to deliver health relief.

On the other hand, due to a lack of a systematic data base on which to base allocative decisions in the weeks following the cyclone, there appears to have been an over emphasis on providing acute medical care (as shown by the vast outpouring of supplies and medical manpower) which in part contributed to decreases in immunization and vitamin A coverage, the long term implications of which are not clear. Finally, increases in malnutrition among children under 5 suggest some deficiencies in medium to long term nutritional surveillance and supplementation of high risk groups.

The following recommendations summarize the lessons to be learnt from this experience:

Given the frequency of natural disasters in Bangladesh and their relatively predictable seasonal pattern [l6, 171 explicit contingency plans should be


prepared not only by the government of Bangladesh (where such plans apparently already exist on paper) but also by other non-governmental agencies involved in health and development activities. It is crucial that these plans should not be just theoretical exercises but widely disseminated, well rehearsed protocols and that planning for health needs be integrated with generalized relief plans to provide food, clothing and shelter.

diseases and acute respiratory tract infections) in disaster prone areas. The government health surveillance system (which is fairly extensive) suffers from a surfeit of data of questionable quality [13]. It would be better to concentrate on sentinel sites and collect only essential information (e.g. mortality and prevalence of diarrhea1 disease and acute respiratory tract infections) in a standardized format.

There should be a serious attempt to co-ordinate government contingency planning with that of major non-government development organizations who are active in high risk areas. At the very least the role of non-governmental organizations as active partici- pants in the relief and rehabilation process should be explicitly acknowledged and integrated into any planning exercise. As was the case in this cyclone the lead agency within the government should be the Ministry of Relief and Rehabilitation, which should have the responsibility of putting together a co-ordination team with appropriate representation from various ministries, the armed forces and various non-governmental organisations.

(iii) Access to affected areas. Access and transpor- tation of supplies to disaster affected areas are crucial for effective health relief and rehabilitation. Plans for mobilizing helicopters, shallow landing craft, and other means of transport to access outlying islands and other potentially difficult to reach areas should be in place. The possibility of a Regional Task Force, under the auspices of SAARC (South Asian Associ- ation for Regional Cooperation) to provide this type of support should be explored.

2. Response to the disaster

It is worth noting that disaster planning is a complex and sophisticated process which while emi- nently desirable is often derailed due to financial constraints. As mentioned earlier, competing demands on limited budgets both within the government and outside make it easier to focus on current concerns rather than allocate resources to respond to future eventualities which may or may not materialize. Given Bangladesh’s limited internal resources, much of the funds for appropriate disaster planning must come from International Donors and technical and logistic support for capacity building in disaster management on the part of the government (particularly at the district level and below) and non governmental organizations would be a worthwhile donor investment.

In terms of anticipatory disaster management special attention should be paid to the following issues:

The urge to respond with a massive outpouring of medical supplies and manpower based on concerns about averting epidemics in the post cyclone period, must be tempered by actual data from the field to guide one’s responses. In the post-disaster period systematic data collection must be maintained through the continuation of regular standard surveillance protocols supplemented if needed by rapid epidemiologic assessments [16] in order to rationally streamline relief and rehabilitation. Systematic surveillance is essential as assessment by medical teams on the basis of convenience samples is potentially problematic. Continual surveillance of morbidity and mortality (focusing on key problems) should be used for the first few weeks to refine and update the assessment of needs (e.g. the types and quantities of drugs and medical supplies and amount of medical manpower). Long term monitoring of morbidity, particularly nutritional status for children under 5 should be instituted in the post disaster situation to identify high risk groups followed, by nutritional supplementation programs if needed.

(i) Multi-purpose cyclone shelters. Both current and Co-ordination within and between the various previous experience suggest that the absence of cy- parties involved in disaster management (the civilian clone resistant shelters is a major determinant of government, the armed forces and local and inter- cyclone related mortality and morbidity [12, 131 with national aid and development organizations) is a key estimates suggesting that there would have been 20% factor in effective relief efforts, including health re- more deaths in the Bangladesh cyclone in the absence sponses. The success of such efforts as shown by the of shelters [12]. Given the prohibitive cost of con- current cyclone experience depends on a high level of structing uni-purpose cyclone shelters and the im- political commitment to and media scrutiny of the

portance of functioning health centers for relief process, backed up by a multi-level decision coordinating effective responses to the health needs of making and co-ordination structure which at every

cyclone/disaster affected areas, it would seem advis- stage includes input from all relevant groups and able to construct upajela (sub-district) level health which is allowed considerable flexibility to delegate clinics to be cyclone resistant. responsibility and make field decisions.

(ii) Baseline information. Effective health contingency planning and assessment of needs is very much dependent on reliable baseline (i.e. non-cyclone period) information on population size, morbidity and mortality patterns (particularly from diarrhea1

In the post-disaster period the internal response (from within the country as opposed to from outside) must be maximized. Food and most medical supplies are usually available internally within the country and as far as possible procurement should be made

914 ‘M. OMAR RAHMAN and MICHAEL BENNISH

locally. This not only makes the logistics of transport easier but also helps the local economy. The evidence from the recent post-cyclone period suggests that the private market sector in Bangladesh (in contrast to previous disasters) was very efficient in supplying goods and services (food and clothing in particular) even to the least accessible areas. The very effective functioning of the local market sector very quickly nfter the disaster greatly facilitated relief and rehabilitation. Future efforts at distribution of goods and services following a disaster should utilize (rather than bypass) market mechanisms as much as possible.

With regard to providing health care services. the mobilization of medical teams who are well versed m diarrhea management. treatment of acute injuries. and immunizations should be a priority in the immediate aftermath of a natural disaster. Standardized protocols of treatment should be used to avoid inappropriate prescription of drugs. As far as possible local recruits (under the surveillance of medical professionals) should be used.

With regard to medical supplies to disaster victims. appeals for donor assistance must be clearly couched on the basis of what can be used in the field. The Ministry of Health should have standard protocols (lists of essential drugs and supplies in appropriate volumes and concentrations) which should be widely disseminated to donors. and all other organizations involved in relief and rehabilitation in the post disaster situation. This would help avoid some of the problems with well intentioned but inappropriate medical supplies (e.g. medications past their expiry date. oral rehydratiun packets with non-standard volumes and concentrations etc. ).*

Last but not least, the continuation or ongoing health programs (immunization, nutritional surveillance. health education) must not be hampered by short term needs of the natur:J disaster. This applies to both the areas affected and other areas of the country from which resources (both human and

financial) at-r transferred. As discussed car-her there is

a tendency for acute medical care needs to override long term preventative care requirements m the post disaster situation. In order to counter act this predis- position, special efforts need to be made to allocate resources for the continuation ol‘ key preventative care programs such as child immunizations 2nd vita-, min A distribution.

ACk~2OIl.l~d~CMel2/.~~This study was conducted while the authors were part of a team of health professionals spon-

*As screening medical supplies once they have arrived is ditlicult logistically. especially in a disaster situation, the emphasis should be on clear instructions to donors to avoid problems of inappropriateness

sored by the Bangladesh office of the United Nation’s Children’s Fund (UNICEF) to evaluate the health impact of the Bangladesh Cyclone. The authors while grateful for the assistance provided by UNICEF. Bangladesh, acknowledge that the conclusions m this study are theirs alone and not necessarily endorsed by UNICEF.

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REFERENCES

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health related response to natural disasters: the case of the bangladesh cyclone of 1991

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