Disease threatens millions in wake of tsunami
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7482.59 (Published 06 January 2005) Cite this as: BMJ 2005;330:59All rapid responses
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The manual "Protecting the Future: a guide to incorporating HIV prevention and care in refugee and post-conflict settings" can be downloaded free of charge from the International Rescue Committee web-site at www.theirc.org. It provides advice that might be helpful to NGOs working in tsunami affected areas.
Competing interests: None declared
Competing interests: No competing interests
According to the World Health Organization’s 1998 statement, the world was comforted that there were effective early warning systems in place for climate change, problems with food production, aerial attacks, and a developing international effort in infectious disease control and management.1 Yet there was no Tsunami alert. Hence, more than 150,000 people were killed and millions others are facing unimaginable devastation including not only the loss of loved ones, but also the lack of basic necessities of life such as food, shelter, medicines along with the looming threat of infectious diseases.
From the medical standpoint, disaster situations are characterized by an acute and unforeseen imbalance between the capacity and resources of the medical profession and the needs of the victims or the people whose health is threatened, over a given period of time.2 There is no doubt in anyone’s mind that in the immediate post-Tsumani period, there is an emergent need to curtail the spread of communicable diseases. Per Dr. David Nabarro of the World Health Organization, "There is certainly a chance we could have as many dying from communicable diseases as from the Tsunami.” Diseases like malaria, dengue fever and cholera have the potential to spread in the unsanitary conditions that prevail across all the effected areas.
What is obvious is that there is an urgent need for safe drinking water, sanitation equipment and supplies, oral rehydration kits, medicines and food. What is not so obvious, or perhaps not something the world would want to dwell over, are the long-term consequences of the Tsunami disaster. The current state of the effected populations; homelessness, poverty, malnutrition and communicable diseases are all the right ingredients to contribute to long term adverse physical and mental outcomes including the possibility of a bigger disaster in the form of creation of a colossal nidus for the spread of HIV and AIDS. When resources are scarce, marginalized and vulnerable populations may also suffer from a decline in social and human capitals, both of which have been shown to be associated with HIV/AIDS risk.3,4
We certainly do not want to sound as pessimistic as Malthus,5 but it also would not be wise to ignore the long-term impact of the Tsumani. So what are the questions we are left with? Where did we fall short? What can we learn from the unfortunate tragedy? And most important of all, how can we do better in the future? Finding detailed answers to these questions may take a long time. All we can say at this time is that there certainly was a lack of an effective early warning system, which could have prevented the loss of precious lives. The relevant agencies need to get their acts together to prevent such an occurrence in the future. In this day and age, we certainly should have the necessary tools to disseminate late-breaking, critically important information rapidly and efficiently to protect individuals and populations. More importantly, all possible resources need to be made available to the disaster-hit areas to prevent any further catastrophes, particularly preventable ones such as HIV/AIDS.
References
1. World Health Organization. Global infectious disease surveillance. World Health Organization Fact Sheet No 200. June 1998.
2. World Medical Association. Bull Med Ethics. 1994 Oct;No. 102:9-11.
3. Hasnain M, Mensah EK, Levy JA, Sinacore JM. Social Capital as a Predictor of HIV/AIDS Risk Behaviors. Presented at the XIV International AIDS Conference, Barcelona, Spain, July 2002.
4. Hasnain M, Levy JA, Sinacore JM, Mensah EK. Human Capital and HIV Risk in Injection Drug Users. Presented at the XV International AIDS Conference, Bangkok, Thailand, July 2004.
5. Malthus TR. An Essay on the Principle of Population, as it Affects the Future Improvement of Society with Remarks on the Speculations of Mr. Godwin, M. Condorcet, and Other Writers. London, printed for J. Johnson, in St. Paul's Church Yard, 1798.
Competing interests: None declared
Competing interests: No competing interests
Very Happy New Year. Excellent and timely contribution. Very important to mainstream a HIV&AIDS prevention response into our Tsunami Disaster relief, rehabilitation and long term development work. So glad that that Dr. Joe Thomas and the BMJ has stated this so eloquently, and the article clearly explains the principles and what should be taken into consideration.
All staff involved in the Tsunami Disaster response and all recipients of assistance have a right to HIV&AIDS protection, prevention and treatment services. In support of this, Concern Worldwide has a 'Programme Participant Protection Policy' (Feb. 2004) which includes a 'Concern Staff Code of Conduct'. Acceptance of this policy should be a requirement of any partnership agreement that Concern enters into with other development actors. Mututal respect and policy protection for staff, partner staff and programme participants alike can I believe contribute to reducing HIV vulnerability and prevent new HIV infections.
breda.gahan@concern.net
Competing interests: None declared
Competing interests: No competing interests
Dr. Joe Thomas stated:
"The Tsunami disaster could contribute to inadequate safe blood, shortage of clean injecting equipments for injecting drug users, an insufficient supply of condoms and health care; and the vulnerability of displaced people, especially women and children to sexual abuse and violence. In addition, during the periods of population displacement, HIV/AIDS prevention and care is often disrupted. The HIV epidemic presents key challenges to both humanitarian and development assistance, and to the interface between them. The challenges raised by the HIV pandemic in the Asia Pacific are only beginning to be fully realised now, and HIV is clearly a massive crisis in all the Tsunami affected areas and can be described as an emergency."
This is pure 'HIV' propaganda cynically exploiting the Tsunami tragedy. To date: 'HIV' has never been isolated from blood or blood products, injecting equipment or semen. As 'HIV' is an endogenous entity how can condoms eradicate it? The aftermath of the Tsunami tragedy could lead to disease conditions which will make people test ‘HIV positive’. Remember: 'HIV' does not cause 'AIDS': rather certain disease conditions cause endogenous 'HIV' expression. There is no "HIV pandemic in the Asia Pacific": there are specific disease conditions that make people test 'HIV positive': hence: 'HIV' is merely an endogenous marker for prevailing disease conditions in this region. We know poor sanitation, malaria and TB make people test ‘HIV’ positive.
Dr. Joe Thomas concludes: "Though natural calamities do not transmit HIV, however, some of the post disaster situations may provide a fertile environment which would enhance vulnerability of individuals to HIV."
Of course, natural calamities do not transmit 'HIV' and neither do human beings: to repeat: 'HIV' is not a transmissible agent. Yet the 'post disaster situation' may indeed provide 'a fertile environment' which 'would enhance vulnerability of individuals' to endogenous 'HIV expression'. History has shown us that 'HIV' has remained rigorously locked into the original 'high-risk groups': 'death-styles' relating to poverty in the Third World and 'lifestyles' relating to excess and wealth in the West.
Diseases relating to poor sanitation, malnutrition and poverty following the Tsunami tragedy will no doubt make many more people test 'HIV positive': the Tsunami Syndrome is indeed 'marker' for endogenous 'HIV' expression.
The aftermath of 'Tsunami' will cause endogenous 'HIV' expression: this cannot be prevented: it is already there.
Competing interests: None declared
Competing interests: No competing interests
The direct and indirect impact of the ‘Asian Tsunami’ is staggering. The latest estimates of deaths are over 146 000 (anticipated to rise over 185 000), with over 525 000 injured, over 20 000 missing, close to 1.6 million displaced, and over 1 million estimated homeless (Moszynski, 2005).
The initial governmental and community response to this terrible disaster was to organise an immediate relief operation consisting of food, shelter and medical attention. The global response was extraordinary. Even, aid recipient country such as India, declined bilateral aid, so that aid could go to other needy countries and deployed 32 warships, over 80 aircrafts, unmanned aerial vehicles and 17,500 members of the army to locate and aid the survivors and victims and pledged US$25 million aid to the Tsunami affected neighbouring countries.
As we are gradually moving into the next phase (the long term) of the Tsunami disaster response, it is imperative to mainstream HIV/AIDS prevention and care programs as part of a long term re-reconstruction of the affected communities and individuals.
Though natural calamities do not transmit HIV, however, some of the post disaster situations may provide a fertile environment which would enhance vulnerability of individuals to HIV. Although, a systematic analysis has yet to be undertaken on how natural disasters could enhance vulnerability to HIV, based on our understandings about the social context of HIV vulnerability, we could safely predict that the post Tsunami situation could lead to insecure conditions, exacerbating the spread of HIV/AIDS. The Tsunami disaster could contribute to inadequate safe blood, shortage of clean injecting equipments for injecting drug users, an insufficient supply of condoms and health care; and the vulnerability of displaced people, especially women and children to sexual abuse and violence. In addition, during the periods of population displacement, HIV/AIDS prevention and care is often disrupted.
The HIV epidemic presents key challenges to both humanitarian and development assistance, and to the interface between them. The challenges raised by the HIV pandemic in the Asia Pacific are only beginning to be fully realised now, and HIV is clearly a massive crisis in all the Tsunami affected areas and can be described as an emergency.
HIV/AIDS has profound humanitarian consequences, both by directly causing illness and death, and in terms of the wider impact it has on societies. These consequences will develop over decades. The existing models of humanitarian response to natural calamities may not be appropriate in understanding and integrating an effective HIV response. Equally, existing models of development assistance are likely to prove inadequate in developing an HIV response.
There is ample evidence to advocate for mainstreaming an effective HIV response to the Tsunami Disaster response. Elsey and Kutengule (2002) defined mainstreaming HIV/AIDS into disaster relief as the process of analysing how HIV/AIDS impacts on post disaster situations and developing appropriate responses, including the impact of the disaster on people who are already living with HIV/AIDS and survived the disaster. Mainstreaming HIV programming into humanitarian responses is to determine how each sector should respond based on its comparative advantage. In this context the specific organisational response may include: putting in place policies and practices that protect staff from vulnerability to infection and support staff who are living with HIV/AIDS, whilst also ensuring that training and recruitment takes into consideration future staff depletion rates, and future planning takes into consideration the disruption caused by increased morbidity and mortality. Humanitarian organisations must ensure those infected and affected by the pandemic are included and are able to benefit from their activities. Agencies must also ensure that their activities do not increase the vulnerability of the communities to HIV/STIs, or undermine their options for coping with the affects of the pandemic.
The “Tsunami response” is now moving from the immediate humanitarian response to developmental phase. The UNAIDS Working Definition of Mainstreaming AIDS (2004) into development work is more illuminating “Mainstreaming AIDS is a process that enables development actors to address the causes and effects of AIDS in an effective and sustained manner, both through their usual work and within their workplace”. ‘Development actors’ are all the people and institutions involved in development, including all sectors and levels of government, the business sector, civil society, and international agencies. Whilst ‘usual work’ is the work that development actors are supposed to do as set forth by their mandate, mission or business interests.
Based on current experiences aimed at mainstreaming HIV/AIDS at different levels, five simple principles have emerged that attempts to provide a comprehensive framework to analyse where and when to introduce and implement HIV/AIDS mainstreaming (UNADS/GTZ 2002).
Principle 1 underscores the importance of developing a clearly defined and focused entry point or theme for mainstreaming HIV/AIDS in order to maintain the critical focus necessary to make an impact.
Principle 2 maintains that, at the country level, mainstreaming does not take place outside of the existing national context. Thus National Policies or Strategic Frameworks for HIV/AIDS should be used as the frame of reference. Mainstreaming efforts should be located within existing institutional structures.
Principle 3 necessitates advocacy, sensitisation and capacity building in order to place people in a better position to undertake mainstreaming. Mainstreaming cannot be expected to develop of its own accord.
Principle 4 asserts the need to maintain a distinction between two domains in mainstreaming: the internal domain or workplace, where staff risks and vulnerabilities are addressed; and the external domain, where the institution undertakes HIV/AIDS interventions based on its mandate and capacities in support of local or national strategic efforts.
Principle 5 highlights the importance of developing strategic partnerships based upon comparative advantage, cost effectiveness and collaboration.
Tsunami response presents an opportunity to use the community links established through disaster relief programs to ensure that men, women and children are aware of their rights to aid which is not conditional on accepting sexual exploitation. The long term disaster relief staff should have access to HIV/AIDS awareness, and to train them to opportunities to carry out HIV education as part of the overall disaster response.
The United Nations Inter-Agency Standing Committee Task Force on HIV/AIDS in Emergency Settings has produced a detailed guideline for HIV/AIDS interventions in emergency settings. The purpose of this guideline is to enable governments and cooperating agencies, including UN Agencies and NGOs, to deliver the minimum required multi-sectoral response to HIV/AIDS during the early phase of any emergency situation. These guidelines, focusing on the early phase of an emergency, should not prevent organizations from integrating such activities in their preparedness planning. As a general rule, this response should be integrated into existing plans and the use of local resources should be encouraged. A close and positive relationship with local authorities is fundamental to the success of the response and will allow for strengthening of the local capacity in the future
Paul Harvey (2004) analysed the relationship between livelihood and HIV/AIDS in the context of humanitarian programming. Livelihood insecurity due to Tsunami could increase HIV vulnerability as local social security networks have been severely disturbed by the disaster. Based on Harvey’s and UNADS/GTZ observations the following points in relation to humanitarian programming in the context of an HIV/AIDS epidemic should be taken into consideration:
1. Early-warning systems and assessments need to incorporate analyses of HIV/AIDS and its impact on livelihoods.
2. The emergence of new types and areas of vulnerability due to HIV/AIDS should be considered in assessment. Groups such as widows, the elderly and orphans may be particularly vulnerable, and urban and peri- urban areas may need to be assessed.
3. Targeting and the delivery of aid must be sensitive to the possibility of AIDS-related stigma and discrimination.
4. The HIV/AIDS epidemic reinforces the existing need for humanitarian programmes to be gender-sensitive.
5. Emergency interventions must aim to ensure that they do not increase people’s susceptibility to infection with HIV/AIDS.
6. Food aid in the context of HIV/AIDS should review ration sizes and types of food and assess delivery and distribution mechanisms in light of HIV/AIDS related vulnerabilities, such as illness, reduced labour and increased caring burdens.
7. Labour-intensive public works programmes should consider the needs of labour-constrained households, the elderly and the chronically ill.
8. HIV/AIDS reinforces the need for health issues to be considered as a part of any humanitarian response.
9. Support to agricultural production (including seed distribution) and pisciculture support should recognise adaptations that people are making in response to HIV/AIDS.
10. Micro economic impact on people living with HIV in the disaster affected areas to be considered.
11. As part of the Tsunami disaster challenge, all the agencies must be encouraged to explore the possibility of mainstreaming HIV prevention into their work.
12. All long term responses must explore the possibility of distribution of condoms, where appropriate, in line with the UNAIDS minimum package for HIV prevention in emergencies.
13. Mainstreaming HIV response into disaster relief starts with the concerns of the community; policy makers and institutions need to understand these issues.
14. There is an urgent need to document the evaluation and monitoring of mainstreaming work into Tsunami response.
15. Tsunami response must also have an enabling environment which would provide space for sharing HIV and AIDS concerns and to propose solutions.
16. HIV prevention and care needs to be integrated into the Tsunami disaster needs assessment
17. Long term Tsunami response must take into account HIV prevention and care needs of the community
18. Tsunami affected national governments must ask their national HIV programs to assess the impact of the disaster on their HIV programs and to respond adequately.
19. Donor agencies and humanitarian agencies must allocate line item specific funding for integrating HIV programs into the current humanitarian responses.
20. UNAIDS along with other key stake holders may take leadership to establish a regional mechanism to monitor the progress of mainstreaming HIV into humanitarian responses and for rapid diffusion of lessons learned from each setting.
References:
Peter Moszynski (2005) Disease threatens millions in wake of Tsunami BMJ, 330:59 (8January), doi:10.1136/bmj.330.7482.59
IASC TF (Not dated) Guidelines for HIV/AIDS interventions in emergency settings. The Inter-Agency Standing Committee Task Force on HIV/AIDS in Emergency Settings
UNAIDS/GTZ (2002) Mainstreaming HIV/AIDS: A conceptual framework and implementing principles. June 2002
Elsey, Helen & Kutengule, Priscilla (2003): HIV/AIDS Mainstreaming: A Definition, Some Experiences and Strategies. Liverpool School of Tropical Medicine, HEARD, DFID Ghana.
UNAIDS (2004) Support to Mainstreaming AIDS in Development
Oxfam (2001) Lessons Learnt in Mainstreaming HIV/AIDS: Oxfam, Malawi.
Harvey, P., (2004) HIV/AIDS and humanitarian action. Humanitarian Policy Group, Overseas Development Institute. UK. April 2004
Murphy. L., (2004) HIV/AIDS and humanitarian action: Insights from US and Kenya-based agencies. Humanitarian Policy Group, Overseas Development Institute. UK April 2004
Harvey, P., (2003) HIV/AIDS: What are the Implications for Humanitarian Action? A Literature Review. Overseas Development Institute, July 2003 (draft), http://www.odi.org.uk/Food-Security- Forum/docs/Harvey.pdf
Competing interests: Dr Thomas is the convenor of Asia Pacific people's alliance to combat HIV and AIDS (APPACHA)
Competing interests: No competing interests
In response to the article, I would like to draw attention to this note, which inter alia, may serve to better preparedness of medical and other professionals, to calamities of monumental dimensions such as the tsunami and eathquake in South east Asia
Three weeks before the massive earthquake shook the undersea tectonic plates in southeast Asia, and produced, the most destructive tsunami of modern times, a medical college professor from India, and a BMJ author (Vol. 19:3:2003, March Vol. 20:3:2004 South Asian Ed.) had written a scientific note carried by, the specialty natural history site <nathistory-india@Princeton.EDU, USA, predicting the event, almost to the day.
The author, Dr. Arunachalam Kumar, a well known anatomist and biologist, had cited the mass stranding of cetaceans such as whales and dolphins off an Australian coast, as an alarming, and natural alert to a massive quake. The professor, on the faculty of the Kasturba Medical College at Mangalore, wrote that he had made a five year record of dates and locales whale strandings, plotted their locales, and correlated them to occurrences of upheavals on land or undersea, and had observed a remarkable connection between the events.
The larger the pod of mammals that breach, the more certain and powerful the quake will be, Dr. Kumar adds. The Australian stranding consisted of more than 180 cetaceans. His reasoning was that the shifting of geotectonic submarine continental plates are preceded by changes and alterations in the geomagnetic fields, which in turn disorient the natural cerebral compasses in these large marine mammals. Biologists are well aware of the enormous distances and definite directions dolphins and whales, course and cover during their annual migrations, and that their route alignments are fixed through internal compasses these mammals possess.
A number of newspapers, in India and abroad, have already featured the extraordinary ‘prediction-come-true’ piece in their columns, and a number of scientists are in touch with the professor for more information on his theory.
Dr. Kumar is of the opinion that, if the connection between unnatural whale deaths and tremor is thoroughly established and proven, through long term observation, unexplained cetacean deaths could serve as an early warning alert system for mass disasters on land or sea. Evacuation of vulnerable populations, and preparation for medical contingencies for calamities, could be based on levels of alert reported and save life, limb and property. The professor, in his note ‘Whale Suicide & Earthquakes (4th December 2004) wrote that he was certain that within a couple of weeks a massive earthquake would follow.
References: The Hindu , The Times of India The Deccan Herald (Bangalore), The Mid Day (Mumbai) The New Indian Express , The Straits Times (in press- Singapore) Nathistory-india@Princeton.EDU www.sulekha.com www.andaman.org www.gocool.org www.DCRegistry.com
Competing interests: None declared
Competing interests: No competing interests
The recent tsunami disaster [1] has highlighted the gap in science and technology between the different regions of the world. As pointed out in an editorial in the journal Nature, an effective tsunami warning system covering the Indian Ocean might well have reduced the scale of the human suffering [2]. There are strong ethical reasons for why this type of technology needs to be transferred from the developed to the developing world [3]. Enlightened self-interest arguments may also apply, given that disasters in the developing world also kill westerners and some threats have global impacts (eg, infectious diseases spread and climate change). For these reasons there needs to be far greater transfer to the developing world of life-protecting technologies. Further examples include technologies for: sanitation systems, water purification, immunisation, family planning, electronic communication, and clean energy production. Health professionals in developed countries can support these moves by advocating to their governments to increase aid budgets and to specifically support the transfer of appropriate technologies.
References
1) Moszynski P. Disease threatens millions in wake of tsunami. BMJ 2005;330:59.
2) Editorial. A divided world. Nature 2005;433:1.
3) Singer P. One World: The ethics of globalization. New Haven: Yale University Press, 2002.
Competing interests: None declared
Competing interests: No competing interests
Disasters an opportunity for the affected countries
I think we should also stress that Disasters could be seen as opportunities for the affected countries and donors to review their Policies and strategies on HIV and AIDS and Health in General. It should not be left to the donor agencies alone to mainstream but the affected countries should be encouraged to mainstream as well .Remember that after the disaster donors leave and the country and its people remain. We should therefore capacitate communities and countries on how to mainstream IV and AIDS. I am not seeing much of this in papers that have been published. Further we should have concrete examples of how to mainstream. For instance, because of displacement, breakdown in social structures etc, communities especially women may become more vulnerable to HIV. What therefore do we advise these countries to do well in advance to avert the creation of an epidemic. Development projects of different levels will be part of recovery after a disaster. Observations in Southern Africa show that whenever Development Project are brought into or closer to communities teenage pregnancies, alcoholism and STIs go up. Ironically governmnets only do Environmental impact assessments before projects are started and never look at the social and health impact assessments.
I suggest therefore that for any projects envisaged in the affected countries only companies with a mainstreamed response (internal and external domain) should be given tenders to do Development Projects. This should also be stressed to the governmnets of the affected regions. Further the communities in the affected areas need to be mobilised to protect themselves. We need to develop AIDS Competent communities in these affected areas.By the time donors leave, the national and local governmnets and communities should be in a position to make sure that every development project that comes has mainstreaming as a component. Last but not least, the UN or who ever is coordination emergency relief must make sure that every donor who comes in has a mainstreamed package for itself,that is, HIV AIDS Policy and AIDS at the workplace programme.
Most donors know how to tell others about mainstreaming when they themselves have no programmes. Remember charity begins at home.
Competing interests: None declared
Competing interests: No competing interests