1. Garfield, Richard DrPH, RN
  2. Hamid, Achir Yani DNSc

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On December 26, 2004, a 9.0 magnitude earthquake, the second most powerful temblor in recorded history, struck the floor of the Indian Ocean about 150 miles off the coast of Sumatra Island, Indonesia. The ensuing tidal wave-or tsunami-killed more than 270,000 people in 11 countries, injured 500,000, and affected about 5 million, according to the World Health Organization (WHO). 1 Hardest hit was Indonesia's Aceh province, which covers roughly 42,000 square miles on the northwest side of Sumatra Island. The WHO estimates that 128,000 people in Aceh were killed by the tsunami, and a quarter of the province's 4.5 million people were injured or lost their homes. 2


Among the confirmed dead in Aceh were 189 of the province's 17,000 nurses and 64 of its 5,500 midwives, according to the Indonesian National Nursing Association. But these deaths represent only a fraction of the tsunami's toll on Aceh's nursing infrastructure. The lack of a medical disaster plan, including supply stockpiles and systems to organize, support, and deploy personnel, was painfully evident in the immediate aftermath of the tsunami. A retrospective look at what happened offers lessons for organized nursing worldwide, especially with regard to disaster preparedness.

FIGURE. Coauthor Ric... - Click to enlarge in new windowFIGURE. Coauthor Richard Garfield and a local nurse make a well-child home visit to a family living in a barracks shelter after the tsunami.

The tsunami caused extensive damage to the five hospitals in Aceh's capital city, Banda Aceh. Surviving medical personnel and clinical networks beyond the hospitals were left in disarray. Communications and transportation systems were disrupted. There was no food for nurses and other health care personnel tending to the staggering number of victims. Even paper for clinical notes was in short supply, which resulted in wasted effort as patients were repeatedly rediagnosed rather than moved along a treatment continuum. Staff records were lost. There was no supply of uniforms for personnel, and many nurses, although able to assume clinical duties, had no shoes or other basic attire; in some cases the tidal wave had shredded the clothes they were wearing, even as it destroyed their homes and possessions.


This last aspect-the personal loss suffered by Aceh's nursing cadre-went largely unrecognized in the weeks after the tsunami, when emergency health care services were being organized around field hospitals and volunteer staff that poured in from other countries. Health care workers were universally viewed as rescuers; the international teams overlooked the fact that local nurses might also be traumatized tsunami victims. Many had lost loved ones, homes, possessions, bank and other important records, as well as reliable income.


Consider the experiences of some of the students and professors in an Aceh bachelor of science in nursing program. Of 480 students, five male and 42 female students died. The rest were scattered. Hajul (many Indonesians use only one name), one of the nursing professors, was supervising students at a community health center on an island north of Banda Aceh that day. It took him all day to make his way back to the city in a small boat. He then walked for hours through flattened neighborhoods to reach his home. Remarkably, all of his family members survived. The next day Hajul reported for work, one of only a few nurses to show up in the city's hospitals. Some who didn't were injured and many others were tending to immediate family. Aftershocks also kept nurses from returning to work because they feared further loss of homes and injury to family members.


Many of the early relief efforts were directed at cleaning up and restoring medical facilities. Muck and debris were everywhere. An ED was established in a field in front of Banda Aceh's main hospital, and the routine of morning report was reestablished. Hospital directors met one by one with staff to determine whether and when they could return to work. Health care and mental health care needs were identified, and working schedules were created. Nursing staff began with short shifts of three to five hours that increased gradually over several weeks to full time. The government gave salary advances so that nurses could provide for themselves. Nurses who had lost their homes moved into tents on hospital grounds or into the large wooden pavilions set up for displaced people. These makeshift living conditions would last for months.

FIGURE. This home in... - Click to enlarge in new windowFIGURE. This home in Banda Aceh was turned into a hospital after the owner, a local physician, died in the tsunami; his wife donated the house so that others affected by the tsunami could receive care.

Once the magnitude of the disaster became known, outside aid poured in. In the first week, five nurses traveled 800 miles from Indonesia's capital city, Jakarta, to help treat Aceh's injured and assist in finding and organizing surviving nurses. The 80,000-member Indonesian National Nursing Association subsequently mobilized 1,000 nurses. They arrived in Aceh each week in groups of 100. The relief nurses were prepared for the makeshift working and living conditions that prevailed for months after the disaster; they brought their own bedrolls, enabling them to sleep wherever there was shelter: emergency camps, offices, even abandoned homes. These relief nurses were rotated out on a regular basis to prevent burnout. The nursing association received aid from both government sources and nursing associations in Canada, Norway, and Japan in the form of treatment kits, uniforms, underwear, paper for clinical notes, and emergency cash. The groups also provided critically important vouchers for nurses to acquire gasoline and mobile telephones.


International nongovernmental organizations (NGOs) also provided emergency assistance, but this had an unanticipated consequence. Many local nurses, feeling inferior to the expert emergency teams and unfamiliar with their work styles and equipment, retreated from the foreign medical personnel. Indonesian nursing leaders intervened to get the NGOs to provide training on the equipment they had brought to Aceh and to integrate local nurses into treatment teams. It was these nurses, after all, who would operate the equipment once the foreign teams had left.



In the year since the disaster struck, 55 camps, housing 300,000 displaced residents, have been set up in Aceh. Each has a clinic staffed by two physicians and six nurses. The initial medical staff tended to be new graduates of nursing or medical schools who lacked community health training. An in-service training program is now in operation. Some of these satellite health clinics will become permanent facilities when permanent communities form around them. Others may be integrated into the regular district clinic system as residents gradually move back to their home communities. Work to repair damaged facilities at Aceh's nursing schools is also underway. Because of the disruption caused by the tsunami, including injury, loss of homes, and difficult living conditions for months afterwards, only about 10% of nursing students completed the academic year.


The disaster brought to light chronic problems in the health systems of Indonesia and Aceh province, including confusion over the roles of nurses and midwives, inadequate clinical outreach, and a paucity of community health models and strategies. More than half of all working medical staff hadn't received in-service education in the previous five years, including training in mental health, disaster preparedness, or emergency response. These deficiencies are now being addressed. Nursing leaders also undertook a tracing project to identify all nurses with hardships, building a comprehensive database that has been essential to providing assistance. This nursing database proved superior to existing systems of information, and helped in identifying where to send the international humanitarian workers. It also became the foundation for government efforts to reconstruct public records of property ownership as residents displaced by the tsunami sought to return to home villages and rebuild. Using the nurses' tracing procedures, civil authorities were able to identify neighbors who could back up property owners' claims.

FIGURE. Coauthor Ric... - Click to enlarge in new windowFIGURE. Coauthor Richard Garfield visits with nursing students at their school near Banda Aceh.


After the tsunami, it became clear that there was no emergency response plan in place in Aceh. Thailand's Ministry of Public Health was a step ahead, having warehoused shelters that were quickly airlifted to affected areas to house those providing care. International volunteer groups covered their own needs, and there were donations for patients, but the needs of local health care workers were not in anyone's plan. Nurses lacked uniforms, basic medical supplies, transportation, and housing.


It's now recognized that Indonesia needs a national public health leadership committee, established emergency procedures and disaster training, and a single national coordinator for distribution of supplies. Work is also underway to address weaknesses that the tsunami disaster exposed in Aceh's existing health care infrastructure. Such systems take more time to develop and fine-tune than the bricks-and-mortar job of rebuilding health facilities. Acehinese leaders realize that investing in broad-based infrastructure improvements will benefit routine care while putting the island province in a much better position to respond to future disasters.




1. Jong-wook L. Statement by Dr. Lee Jong-wook, WHO Director General. WHO Conference on the Health Aspects of the Tsunami Disaster in Asia; 2005 May 4-6; Phuket, Thailand. [Context Link]


2. World Health Organization Regional Office for South-East Asia. Chapter 1: the emergency and its aftermath. In:Moving beyond the tsunami: the WHO story. New Delhi, India: The Organization; 2005. p. 4-39. [Context Link]