Quotes of the Day

The death toll from the Asian tsunami rose sharply last week when Indonesia's Health Ministry moved 50,000 of the people on its missing list to the fatalities column, bringing the total there to 166,320. Although the waves have long receded, the tsunami still threatens. For survivors in crowded, unsanitary refugee camps, normally treatable illnesses such as cholera, dysentery, malaria and measles can quickly become mass murderers. So great is the danger that Dr. David Nabarro, the World Health Organization's (WHO) head of crisis operations, initially warned that the death toll from disease could rival that of the tsunami itself.

Yet almost a month after the tsunami hit, those feared epidemics have yet to strike. Waterborne diarrheal diseases have been staved off through good sanitation and hygiene, aggressive insecticide use has kept malaria and dengue fever to a minimum, and meticulous surveillance has contained contagious illnesses. The battle against disease isn't over, but the medical response to the tsunami is shaping up to be a surprising success story for the field of emergency public health. "The situation is still evolving, still dynamic, but I think we are well prepared," says Dr. Jai Narain, the WHO's Southeast Asia regional adviser for communicable disease. "Even if an outbreak occurs, we would be able to respond to it very effectively."

In the heroic world of disaster relief, public-health workers are the plumbers. But their line of unglamorous pipe work has saved an untold number of lives. The waves that destroyed entire towns also fractured sewage pipes and fouled drinking water wells, leaving the water supply of tsunami-affected areas contaminated with seawater, garbage and human waste. The first order of business was to ensure a steady supply of clean drinking water, at least 18 liters a day per person, and to create a passable sanitation system—building latrines away from refugee camps, and promoting proper hygiene among survivors—to prevent illnesses like cholera. The disease is transmitted through water contaminated with cholera-carrying human feces. If a refugee camp's water becomes tainted, the disease can spread geometrically, making it one of the great killers of disaster survivors. In the 1994 Rwanda refugee crisis, cholera took some 45,000 lives in less than three weeks. "Water sanitation is and remains priority number one," says Dr. Dana Van Alphen, the WHO's team leader in Banda Aceh. In Aceh, much of which remained partially flooded after the tsunami, teams built raised latrines to prevent waste from contaminating the water used by refugee camps. Medical workers were also quick to spray camps for mosquitoes, which transmit malaria and dengue fever. These diseases are endemic to the region, especially at this time of the year, and the brackish pools of water left by the tsunami are perfect breeding grounds for the insects.

Beyond simple sanitation, the essence of good public health is meticulous data collection—finding and snuffing out the sparks of disease before they become the fire of an epidemic. "You have a heightened need for information," says Dr. Ronald Waldman, an emergency public-health expert at Columbia University who helped set up the WHO's disease surveillance program in Indonesia. Waldman and his team quickly passed out detailed surveillance forms to all health agencies working in Aceh, asking them to report any cases they found of diseases that could turn into epidemics. The morning after the early warning system was set up, Waldman received a report of measles in a refugee camp near Banda Aceh. A highly contagious disease that can spread rapidly, measles was responsible for more than half of the deaths in the Sudan refugee crisis in 1985. Waldman's team confirmed the cases and had scores vaccinated before the end of the day. "We were on top of the trends occurring beneath the radar screen," he says. "The cooperation we got was terrific."

Every public-health victory is precarious; the slightest drop in watchfulness can open the door tomorrow for the epidemic that was stymied today. "We don't have measures for success," says Van Alphen. "We only have measures for failure." But for the thousands of survivors still alive today because of those efforts, even a temporary victory is a kind of miracle. Says Waldman: "The fact that nothing has happened so far to worsen the plight of this population that has been so extraordinarily traumatized is something that people should take real pride in." If vigilance is maintained until villages are rebuilt and the camps are emptied, the wave of death will at last recede.

• Bryan Walsh
• Public-health workers have done a remarkable job of averting epidemics since the tsunami struck