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Health and housing after the Indian Ocean tsunami
Special Report
Health and housing after the Indian Ocean tsunami Over 2 years after the 2004 Indian Ocean tsunami caused massive devastation in southeast Asia, people are still living in temporary shelters. Reconstruction projects are struggling to ensure that new housing has clean water supplies and good sanitation. Margaret Harris Cheng reports. At the sites in Sri Lanka recovering from the havoc wreaked by the December, 2004, tsunami, recovery is a questionable word. The conflict between the majority Sinhalese government and the separatist group the Liberation Tigers of Tamil Eelam (LTTE) has reignited with renewed vigour and is adding to the mix of problems caused by the tsunamis. The tsunamis killed over 35 000 people in Sri Lanka. The conflict between the government and LTTE, spanning over 20 years, is taking lives daily and seems, for many Sri Lankans, never-ending. Although the politics vary, in most of the areas hit by the tsunamis, housing reconstruction projects have not progressed as quickly as those implementing and funding them would have wished, leaving many people living in temporary shelters. In December, 2006, an Oxfam progress report noted that in Indonesia’s capital Aceh, public-health conditions in the ”baraks”—long low buildings still housing more than 70 000 Bangladesh
India Burma Thailand Phuket Isand Sri Lanka
Somalia Maldives
Malaysia Indonesia
Seychelles
INDIAN OCEAN Madagascar
Countries most affected by the Tsunami
Australia
The tsunamis were triggered by an undersea earthquake off the coast of Indonesia
2066
people—“are an area of increasing concern”. Another 20 000 households are still living in self-constructed shelters, usually tents. Many of the people living in temporary housing, whether in large camps for displaced people or tents in someone’s backyard, are living in cramped conditions with inadequate living space, lighting, and ventilation, and poor hygiene. “Diarrhoea is prevalent”, said Floyd Burnaby, who is managing several construction projects for the Hong Kong Red Cross in Aceh. “Vector-borne diseases, dengue, and malaria are here too.” Personal hygiene is poor— people still follow traditional methods of human waste disposal, dumping it in the back yard, even though many NGOs (non-governmental organisations) have developed hygiene-promotion programmes. In Aceh, by March, 2006, even the hosts were so frustrated by the rate of progress that Kuntoro Magkusubroto, the head of Bandan Rehabilitasi dan Reckonstruski (BRR)—the government-appointed rehabilitation and reconstruction agency for Aceh and Nias—blasted NGOs involved in housing in The Jakarta Post, accusing some of being “slow” and duplicitous. At that time, very few (235 of 16 000) temporary shelters needed to house the 70 000 Acehnese still living in tents had been constructed and only 12% of the estimated 130 000 permanent new houses needed had been built. Construction has sped up since then. According to government numbers, close to 50% (over 58 000), of the houses needed in Aceh have now been built. But coordination of other services has not always kept pace with construction. Some of the new houses lie empty because the infrastructure
projects have not caught up, leaving the homes without water, electricity, or adequate roads. “Water and sanitation is the most difficult part of construction here”, said Burnaby. “Before the tsunami, people used to get fairly good water from wells. After the tsunami 70–80% of wells were rendered useless and they are still very saline”, he said. The number of people still lacking adequate water and sanitation services is unclear. But what is clear is that the rush to put up houses without accompanying water and sanitation has created new problems. The tsunamis raised the water table, making it likely that the contents of poorly constructed and managed septic tanks will leak out and may eventually find their way into the groundwater. In their 2-year post-tsunami report BRR said: “It is recognised that during the emergency phase, many NGOs provided rudimentary sanitation (or even no sanitation at all) for the houses they constructed. While this was an understandable initial response to the disaster, the challenge now is to provide sustainable sanitation for the permanent housing programmes, and safeguard indefinitely the health of families.” Although housing and water and sanitation projects have attracted a lot of criticism, the public-health response, particularly prevention of communicable diseases, has been a gold star performer. The predicted mass diarrhoeal disease outbreaks did not happen, despite small outbreaks in the transitional camps in Aceh. It is not resting on laurels time yet, said Agostino Borra, head of WHO’s office in Sri Lanka. What was being assessed when agencies looked at www.thelancet.com Vol 369 June 23, 2007
Special Report
www.thelancet.com Vol 369 June 23, 2007
The printed journal includes an image merely for illustration Still Pictures
public health in tsunami-affected areas were things seen after the great African disasters and conflicts, when hundreds of thousands of malnourished and exhausted people were crowded together in very poor conditions. ”Noone even looks at certain indicators… so many of the surveys were based on African surveys”, said Borra, pointing out that the greatest disease burden in Sri Lanka is from non-communicable disease. “15% of the adult population here is diabetic”, he said, “and this country has the highest suicide rate in the world”. In Sri Lanka, tsunami survivors are now mixed with those fleeing conflict, particularly in the Batticaloa, Trincomalee, and Jaffna areas in the east and north of the country. But regardless of how they got into the camps, providing services to stop infectious disease outbreaks and deal with Sri Lanka’s growing burden of chronic diseases, such as diabetes, depression, cardiac disease, is very difficult. Even establishing who is in the camps and what their needs are can be problematic, said John Mahoney who heads WHO’s mental health programme in Sri Lanka. It is when people have reached some sort of settled safety, such as a camp, that mental health problems, put on hold while fleeing from danger or dealing with crisis, re-emerge. Persuading funders to support something less tangible than blankets and tents is difficult though, said Mahoney, pointing out that a request to the UN for funds to identify people with psychoses in the camps for internally displaced people (IDP) in the north and east was the only item rejected. “We know that of 150 000 IDPs, at least 1500 will have severe mental illness—schizophrenia or depression. But we have lost contact with at least half of the 150 000, and have no money to trace those who need help now”, said Mahoney. “One of the issues the tsunami has brought forward is the crisis in resources in
In Indonesia’s capital Aceh, 167 000 people were killed and over 70 000 displaced by the tsunamis
health in the north and the east [of Sri Lanka]”, said Borra. Loss of health professionals, facilities, and infrastructure in the tsunami has made it difficult for Sri Lanka to manage existing health problems. However, says Borra, the tsunami provided an opportunity to create new systems to deal with old problems. Working with WHO in the months after the tsunami, the Sri Lankan government developed a mental health strategy. And the policy has gone a lot further than words and documents. In each district, a hospital ward has been designated for people with acute psychosis (in many areas none existed before) and community support officers have been trained to identify people with signs of serious mental illness, support those on treatment, provide information to the community, and help people get access to resources. “Mental health became a national programme, a national strategy because the psychological impact when the world turns upside down in 20 seconds and you have lost everything, was recognised”, said Borra. “We have taken maximum advantage of this and have done something that should have been done 10 years ago. Even if it looks like such a happy island, it is the opposite. The levels of social stress in this island are just appalling.”
Some of the factors slowing down construction in Aceh were specific choices made by agencies such as Oxfam and the different Red Cross societies that use environmentally friendly building materials like plantation timber from proven, legal sources, such as New Zealand. Oxfam also suspended activities in Aceh for a period because an internal audit revealed governance problems. But many of the problems have been beyond the control of individual agencies, such as the lack of skilled local labour, particularly water and sanitation engineers. The combination of massive losses inflicted by the tsunami and the long-term loss of young men to conflict meant there have been few skilled workers available. Costs rose rapidly because many projects started at the same time and were in competition for scarce materials and labour. Superimposed on these problems was the slow and difficult process of establishing land title. In some ways, says Burnaby, it has been a good thing that the Hong Kong Red Cross projects have been able to take their time because “it has given us a chance to learn from the mistakes of others”. Construction of the 780 permanent houses they plan to build got underway in April and they expect to finish by September of this year. Each house will have a septic tank and a 2067
Special Report
AP Photos
The printed journal includes an image merely for illustration
Thousands of people are still living in temporary shelters
wetland system, in which grey water first runs into the septic tank, then on into a second tank containing plants able to extract nutrients, and into a soak pit. All the newly built villages will also have electricity and piped water. If, as seems to be a recurring problem in Aceh, the pipes have not been laid in time, “the American Red Cross has committed to trucking water in”, said Burnaby. In some parts of Sri Lanka, reconstruction has gone ahead remarkably quickly. In fact, according to a housing progress update provided by the Sri Lankan government’s Reconstruction and Development Agency (RADA), in some southern Sinhalese provinces more houses than are actually needed have been, or are being, built. But in the north and east of the country, which are mainly Tamil areas, where the pain wrought by both the tsunamis and the conflict is most acute, far fewer homes have been built. Of the 37 223 new homes the Sri Lankan government has estimated need building, 11 108 or less than a third have been completed and handed over to beneficiaries, according to RADA. The numbers are better in the south and west, with 44% of houses needed now completed and handed over, compared with 17% in the north and east of the country. Province by province the disparities are even greater. In Hambantota, a coastal 2068
town in the south of the island, an area so ravaged by the tsunamis that bodies and boats filled the harbour in the days that followed, 64% of the planned 5476 new homes have been completed. However, Hambantota’s success has attracted plenty of finger pointing because it also happens to have been the parliamentary seat of Sri Lanka’s current president Mahinda Rajapaksa since 1989. The housing reconstruction in Sri Lanka differs from other tsunamiaffected places not only in pace and politically drawn maps but also in policy. Instead of simply building new settlements to rehouse those displaced by the tsunami (known as donor-driven houses), many agencies now favour what they call owner-driven housing: providing a sum of money, expertise, supervision, and planning assistance but essentially letting the beneficiary build the house him or herself. The need for owner-driven housing became apparent when the Sri Lankan government relaxed a buffer zone that banned any building close to the water’s edge. People who had been displaced by the buffer zone rule suddenly had land to go back to but, in many cases, found just a pile of rubble where their homes once stood. “I couldn’t even work out where my house had been”, said DS Hemani Mallika, still tearful as she recollected seeing what was left
of her village on television. “There seemed to be no houses”, she said. She had been in Colombo visiting her sister for Christmas when the tsunami wiped out her house. Seated in the living room of the nearly finished two-bedroom house, the 61-year-old widow explained how she and her daughter carried bricks and mixed cement every day while her sons built their new house. Arjan Blanken, of the Netherlands Red Cross, the agency managing the owner-driven housing scheme under which Mrs Mallika’s house is being built said that they decided quite early, in April, 2005, to move toward owner-driven housing. “We wanted to support people in their development… its more about empowering people to build their own houses.” Donor-driven housing projects are totally new settlements set on land provided by the government. The land is wherever it can be found—not always close to the coast and sometimes in the middle of other communities. But, as in Aceh, putting the houses up is often a lot easier than making sure they have a good water supply. Locating a good source of water near new housing settlements may take donors onto private land where the landlord needs to be persuaded to allow a well on his land. Sometimes it is not only the landlord but also host communities who need persuading, said Hasan Hamou, who is supervising the 26 water and sanitation projects being run by the International Red Cross in partnership with Sri Lanka’s national water board. When his team went to check a potential well site, the villagers came out “and demonstrated against them…it was a little bit aggressive”. “They were convinced it [the well] would suck out the water from their shallow well… still the negotiation is going on”, he said. Overcoming these attitudes is yet another hurdle for the agencies involved in reconstruction.
Margaret Harris Cheng www.thelancet.com Vol 369 June 23, 2007
Health and housing after the Indian Ocean tsunami Over 2 years after the 2004 Indian Ocean tsunami caused massive devastation in southeast Asia, people are still living in temporary shelters. Reconstruction projects are struggling to ensure that new housing has clean water supplies and good sanitation. Margaret Harris Cheng reports. At the sites in Sri Lanka recovering from the havoc wreaked by the December, 2004, tsunami, recovery is a questionable word. The conflict between the majority Sinhalese government and the separatist group the Liberation Tigers of Tamil Eelam (LTTE) has reignited with renewed vigour and is adding to the mix of problems caused by the tsunamis. The tsunamis killed over 35 000 people in Sri Lanka. The conflict between the government and LTTE, spanning over 20 years, is taking lives daily and seems, for many Sri Lankans, never-ending. Although the politics vary, in most of the areas hit by the tsunamis, housing reconstruction projects have not progressed as quickly as those implementing and funding them would have wished, leaving many people living in temporary shelters. In December, 2006, an Oxfam progress report noted that in Indonesia’s capital Aceh, public-health conditions in the ”baraks”—long low buildings still housing more than 70 000 Bangladesh
India Burma Thailand Phuket Isand Sri Lanka
Somalia Maldives
Malaysia Indonesia
Seychelles
INDIAN OCEAN Madagascar
Countries most affected by the Tsunami
Australia
The tsunamis were triggered by an undersea earthquake off the coast of Indonesia
2066
people—“are an area of increasing concern”. Another 20 000 households are still living in self-constructed shelters, usually tents. Many of the people living in temporary housing, whether in large camps for displaced people or tents in someone’s backyard, are living in cramped conditions with inadequate living space, lighting, and ventilation, and poor hygiene. “Diarrhoea is prevalent”, said Floyd Burnaby, who is managing several construction projects for the Hong Kong Red Cross in Aceh. “Vector-borne diseases, dengue, and malaria are here too.” Personal hygiene is poor— people still follow traditional methods of human waste disposal, dumping it in the back yard, even though many NGOs (non-governmental organisations) have developed hygiene-promotion programmes. In Aceh, by March, 2006, even the hosts were so frustrated by the rate of progress that Kuntoro Magkusubroto, the head of Bandan Rehabilitasi dan Reckonstruski (BRR)—the government-appointed rehabilitation and reconstruction agency for Aceh and Nias—blasted NGOs involved in housing in The Jakarta Post, accusing some of being “slow” and duplicitous. At that time, very few (235 of 16 000) temporary shelters needed to house the 70 000 Acehnese still living in tents had been constructed and only 12% of the estimated 130 000 permanent new houses needed had been built. Construction has sped up since then. According to government numbers, close to 50% (over 58 000), of the houses needed in Aceh have now been built. But coordination of other services has not always kept pace with construction. Some of the new houses lie empty because the infrastructure
projects have not caught up, leaving the homes without water, electricity, or adequate roads. “Water and sanitation is the most difficult part of construction here”, said Burnaby. “Before the tsunami, people used to get fairly good water from wells. After the tsunami 70–80% of wells were rendered useless and they are still very saline”, he said. The number of people still lacking adequate water and sanitation services is unclear. But what is clear is that the rush to put up houses without accompanying water and sanitation has created new problems. The tsunamis raised the water table, making it likely that the contents of poorly constructed and managed septic tanks will leak out and may eventually find their way into the groundwater. In their 2-year post-tsunami report BRR said: “It is recognised that during the emergency phase, many NGOs provided rudimentary sanitation (or even no sanitation at all) for the houses they constructed. While this was an understandable initial response to the disaster, the challenge now is to provide sustainable sanitation for the permanent housing programmes, and safeguard indefinitely the health of families.” Although housing and water and sanitation projects have attracted a lot of criticism, the public-health response, particularly prevention of communicable diseases, has been a gold star performer. The predicted mass diarrhoeal disease outbreaks did not happen, despite small outbreaks in the transitional camps in Aceh. It is not resting on laurels time yet, said Agostino Borra, head of WHO’s office in Sri Lanka. What was being assessed when agencies looked at www.thelancet.com Vol 369 June 23, 2007
Special Report
www.thelancet.com Vol 369 June 23, 2007
The printed journal includes an image merely for illustration Still Pictures
public health in tsunami-affected areas were things seen after the great African disasters and conflicts, when hundreds of thousands of malnourished and exhausted people were crowded together in very poor conditions. ”Noone even looks at certain indicators… so many of the surveys were based on African surveys”, said Borra, pointing out that the greatest disease burden in Sri Lanka is from non-communicable disease. “15% of the adult population here is diabetic”, he said, “and this country has the highest suicide rate in the world”. In Sri Lanka, tsunami survivors are now mixed with those fleeing conflict, particularly in the Batticaloa, Trincomalee, and Jaffna areas in the east and north of the country. But regardless of how they got into the camps, providing services to stop infectious disease outbreaks and deal with Sri Lanka’s growing burden of chronic diseases, such as diabetes, depression, cardiac disease, is very difficult. Even establishing who is in the camps and what their needs are can be problematic, said John Mahoney who heads WHO’s mental health programme in Sri Lanka. It is when people have reached some sort of settled safety, such as a camp, that mental health problems, put on hold while fleeing from danger or dealing with crisis, re-emerge. Persuading funders to support something less tangible than blankets and tents is difficult though, said Mahoney, pointing out that a request to the UN for funds to identify people with psychoses in the camps for internally displaced people (IDP) in the north and east was the only item rejected. “We know that of 150 000 IDPs, at least 1500 will have severe mental illness—schizophrenia or depression. But we have lost contact with at least half of the 150 000, and have no money to trace those who need help now”, said Mahoney. “One of the issues the tsunami has brought forward is the crisis in resources in
In Indonesia’s capital Aceh, 167 000 people were killed and over 70 000 displaced by the tsunamis
health in the north and the east [of Sri Lanka]”, said Borra. Loss of health professionals, facilities, and infrastructure in the tsunami has made it difficult for Sri Lanka to manage existing health problems. However, says Borra, the tsunami provided an opportunity to create new systems to deal with old problems. Working with WHO in the months after the tsunami, the Sri Lankan government developed a mental health strategy. And the policy has gone a lot further than words and documents. In each district, a hospital ward has been designated for people with acute psychosis (in many areas none existed before) and community support officers have been trained to identify people with signs of serious mental illness, support those on treatment, provide information to the community, and help people get access to resources. “Mental health became a national programme, a national strategy because the psychological impact when the world turns upside down in 20 seconds and you have lost everything, was recognised”, said Borra. “We have taken maximum advantage of this and have done something that should have been done 10 years ago. Even if it looks like such a happy island, it is the opposite. The levels of social stress in this island are just appalling.”
Some of the factors slowing down construction in Aceh were specific choices made by agencies such as Oxfam and the different Red Cross societies that use environmentally friendly building materials like plantation timber from proven, legal sources, such as New Zealand. Oxfam also suspended activities in Aceh for a period because an internal audit revealed governance problems. But many of the problems have been beyond the control of individual agencies, such as the lack of skilled local labour, particularly water and sanitation engineers. The combination of massive losses inflicted by the tsunami and the long-term loss of young men to conflict meant there have been few skilled workers available. Costs rose rapidly because many projects started at the same time and were in competition for scarce materials and labour. Superimposed on these problems was the slow and difficult process of establishing land title. In some ways, says Burnaby, it has been a good thing that the Hong Kong Red Cross projects have been able to take their time because “it has given us a chance to learn from the mistakes of others”. Construction of the 780 permanent houses they plan to build got underway in April and they expect to finish by September of this year. Each house will have a septic tank and a 2067
Special Report
AP Photos
The printed journal includes an image merely for illustration
Thousands of people are still living in temporary shelters
wetland system, in which grey water first runs into the septic tank, then on into a second tank containing plants able to extract nutrients, and into a soak pit. All the newly built villages will also have electricity and piped water. If, as seems to be a recurring problem in Aceh, the pipes have not been laid in time, “the American Red Cross has committed to trucking water in”, said Burnaby. In some parts of Sri Lanka, reconstruction has gone ahead remarkably quickly. In fact, according to a housing progress update provided by the Sri Lankan government’s Reconstruction and Development Agency (RADA), in some southern Sinhalese provinces more houses than are actually needed have been, or are being, built. But in the north and east of the country, which are mainly Tamil areas, where the pain wrought by both the tsunamis and the conflict is most acute, far fewer homes have been built. Of the 37 223 new homes the Sri Lankan government has estimated need building, 11 108 or less than a third have been completed and handed over to beneficiaries, according to RADA. The numbers are better in the south and west, with 44% of houses needed now completed and handed over, compared with 17% in the north and east of the country. Province by province the disparities are even greater. In Hambantota, a coastal 2068
town in the south of the island, an area so ravaged by the tsunamis that bodies and boats filled the harbour in the days that followed, 64% of the planned 5476 new homes have been completed. However, Hambantota’s success has attracted plenty of finger pointing because it also happens to have been the parliamentary seat of Sri Lanka’s current president Mahinda Rajapaksa since 1989. The housing reconstruction in Sri Lanka differs from other tsunamiaffected places not only in pace and politically drawn maps but also in policy. Instead of simply building new settlements to rehouse those displaced by the tsunami (known as donor-driven houses), many agencies now favour what they call owner-driven housing: providing a sum of money, expertise, supervision, and planning assistance but essentially letting the beneficiary build the house him or herself. The need for owner-driven housing became apparent when the Sri Lankan government relaxed a buffer zone that banned any building close to the water’s edge. People who had been displaced by the buffer zone rule suddenly had land to go back to but, in many cases, found just a pile of rubble where their homes once stood. “I couldn’t even work out where my house had been”, said DS Hemani Mallika, still tearful as she recollected seeing what was left
of her village on television. “There seemed to be no houses”, she said. She had been in Colombo visiting her sister for Christmas when the tsunami wiped out her house. Seated in the living room of the nearly finished two-bedroom house, the 61-year-old widow explained how she and her daughter carried bricks and mixed cement every day while her sons built their new house. Arjan Blanken, of the Netherlands Red Cross, the agency managing the owner-driven housing scheme under which Mrs Mallika’s house is being built said that they decided quite early, in April, 2005, to move toward owner-driven housing. “We wanted to support people in their development… its more about empowering people to build their own houses.” Donor-driven housing projects are totally new settlements set on land provided by the government. The land is wherever it can be found—not always close to the coast and sometimes in the middle of other communities. But, as in Aceh, putting the houses up is often a lot easier than making sure they have a good water supply. Locating a good source of water near new housing settlements may take donors onto private land where the landlord needs to be persuaded to allow a well on his land. Sometimes it is not only the landlord but also host communities who need persuading, said Hasan Hamou, who is supervising the 26 water and sanitation projects being run by the International Red Cross in partnership with Sri Lanka’s national water board. When his team went to check a potential well site, the villagers came out “and demonstrated against them…it was a little bit aggressive”. “They were convinced it [the well] would suck out the water from their shallow well… still the negotiation is going on”, he said. Overcoming these attitudes is yet another hurdle for the agencies involved in reconstruction.
Margaret Harris Cheng www.thelancet.com Vol 369 June 23, 2007