Disasters and Disease
Cyclone Nargis struck Myanmar (let’s use the place names used by the World Food Programme) on 2 and 3 May, blasting the Ayeyarwady delta and the capital, Yangon. The population of the declared disaster areas – much of it the country’s granary – is about 13 million. About 1.5 million have been seriously affected. In many places houses, farming assets and food stores have been destroyed and the land ruined by saltwater.
Nargis has, for understandable reasons, been used as a stick to beat the heads of Myanmar’s military dictators, but so far, a good deal of the attack has been misplaced. What is so wrong is the notion that a second massive wave of victims – perhaps as many as those who were killed directly by the storm – will be carried off by ‘disease’. A recent exhaustive review by Nathalie Floret (a public health doctor at the University Hospital of Besançon) of the 516 earthquakes, 89 volcanic eruptions and 16 tsunamis recorded between 1985 and 2004 (including the one on Boxing Day 2004) found only three outbreaks that were related to any of these disasters. Malaria took off in the year after the 1991 Limon earthquake in Costa Rica; measles killed more than a hundred children in camps housing refugees from Mount Pinatubo following its eruption in 1991; and there was a significant increase in the number of cases of coccidioidomycosis (a fungal chest disease spread in dust) downwind of the Northridge earthquake near Los Angeles in 1994.
The idea that civil breakdown and disruption lead to disease is an old one. It was firmly believed by everyone in the late 1930s, for example, that epidemics would follow the bombing of cities. One response was the establishment, on a hill near Salisbury, of the American Red Cross-Harvard Hospital. Funded by Harvard and staffed with American volunteers, it was designed specifically to cope with infection. And a network of government funded laboratories, the Emergency Public Health Laboratory Service, was created in England and Wales in 1939 to deal with the expected surge of infectious diseases. Most of the laboratories were located away from the conurbations, in places such as Tavistock, Aberystwyth and Kirkby Lonsdale. The war did cause the patterns of infection to change. There was an upsurge in the number of cases of sexually transmitted diseases, and Salmonella increased markedly because of the importing of contaminated American dried egg. And there was an increase in tuberculosis, as in every other country in the world. But those were the only big changes. The Blitz did not cause epidemics.
That the unburied dead are a significant source of disease is another old idea. In fact the microbes that cause corpses to decompose are dedicated to this particular task – they find it very hard to infect the living. But the feeling that they must be dangerous, and constitute an imminent threat to health whatever the microbiologists may say, is a powerful one. And bloated corpses fit very well with the media’s need for strong, simple, dramatic images. Perhaps that is why on 15 May the BBC used a picture of floating bodies taken after the 2004 Boxing Day tsunami to illustrate a report from Myanmar, falsely claiming that the corpses were victims of Nargis. An apology was issued the following day, but it is too much to hope that this episode will change anything. Journalists appear to believe in the myth of the dangerous dead just as firmly as the Victorian miasmatists, who thought that disease was generated by bad smells. This is a great pity, because such beliefs cause bodies to be buried in haste, often without proper identification and in mass graves. Grieving survivors are deprived of the opportunity to conduct even the simplest funeral ceremonies.
The medical impact of a sudden disaster occurs in three phases. In the first phase, seconds or minutes after onset, people die from drowning or a mortal injury. In the second phase, the ‘golden 24-hour’ period following the disaster, evacuation and immediate first aid by local people are the key life-savers. In most disasters the majority of deaths occur at this time. In the third phase, days and weeks after onset, wound infections and psychological problems need urgent attention. The provision of food, water, fuel, shelter and the care of displaced persons are paramount. Whether these things are happening in Myanmar, it isn’t possible to say. Unsurprisingly, its government allows nothing to be said that might put it in a bad light. A good test is the communicable disease information that nations are supposed to provide to the World Health Organisation. Cholera occurs in Myanmar. The latest WHO Epidemic and Pandemic Alert and Response (22 April) reports that an outbreak is occurring in Vietnam, mostly in Hanoi. But the last time the Myanmar authorities provided cholera data to WHO was in 1995.
The most successful and least puffed part of the United Nations is the World Food Programme. More often than not it has to keep its head down because of the appallingly difficult political environments in which it operates. In Myanmar its pre-cyclone work focused on the starving landless labourers in the Northern Rakhine State, on the Central Dry Zone, and on the ex-opium growers of Shan State, whose loss of livelihood has driven them into chronic poverty. The WFP often works not by importing food but by moving it within a country from a surplus to a deficit area. The Ayeyarwady Division used to be a surplus area. Helping the WFP should be a top priority right now.
Nathalie Floret finished her search for disaster-associated epidemics at the end of 2004. However, eight months later there was a big one. When Hurricane Katrina hit New Orleans on 29 August 2005, many residents took shelter in the Superdome. From 31 August they were evacuated to an enormous ‘megashelter’, the Reliant Park Complex in Houston. Twenty-seven thousand people stayed there in the first three days of September. Between 2 and 11 September more than a thousand were struck down with norovirus gastroenteritis. No deaths were recorded. The evacuees had been provided with clean food, water and clothes, cots with linen, and lavatories and showers. But the characteristic symptom of the norovirus is sudden projectile vomiting, and the virus is in the vomit. Crowding did the rest. So ‘disease’ did follow that disaster. But its kind and its consequences were not as so often predicted by the media.