Cyclone Nargis presented the humanitarian community with a number of challenges, particularly in relation to access. For many agencies, very limited access to the Delta area was a significant impediment to the response. Many staff remained stranded outside the country awaiting visas to enter, or in-country in Yangon, some distance from the disaster epicentre in Laputta. Agencies already present in Myanmar and with programmes and staff in the Delta were therefore perceived to be in a stronger position to respond immediately to the disaster. However, even for these agencies the movement of international staff was restricted, highlighting once again the importance of local response.
Merlin in Laputta
Laputta Township comprises over 500 difficult-to-reach island villages housing a total population of some 350,000 people. Prior to Cyclone Nargis, Merlin had been working in Laputta for three years as part of the tsunami response, supporting a Primary Health Care project. The programme was implemented with the agreement of the Myanmar Ministry of Health. A complementary programme was also under way aimed at improving access to safe drinking water and sanitation.
A primary goal of the programme was to reduce vulnerability to future shocks by strengthening the health system. The project addressed poor access to health care in the area through the renovation and refurbishment of health facilities and the supply of drugs and equipment, training health staff in the integrated management of maternal and childhood illnesses and improving family health practices. A key component of the programme was strengthening community-level institutions, including Village Health Committees, Village Tract Health Committees and Community Health Workers (CHWs). This latter group of volunteers is an established part of the national health system, providing first-line care at the village level, though at the start of Merlins programme it was non-functioning.
At the time of Cyclone Nargis, 540 CHWs in Laputta Township, covering all island villages, had been through a 21-day training programme and had received quarterly supplies of seven essential drugs. The training covered referral and drug management, hygiene education and prevention of STIs and HIV, with a primary focus on maternal and child health care, and basic first aid. All training was conducted in conjunction with the Ministry of Health and using Ministry of Health training manuals.
Figure 1 is a diagrammatic representation of the structure at community level, also showing links with the wider health system.
The response to Cyclone Nargis
Though the Delta area is prone to regular cyclones, the magnitude of Cyclone Nargis was far greater than previous experience and caused a level of destruction in excess of that seen following the 2004 tsunami. Merlins efforts to reduce vulnerability had highlighted the need for specific disaster preparedness arrangements, and at the time of Nargis these preparations were at an early stage. All CHWs had received training in disaster preparedness, covering floods, earthquakes and storms, though not in any depth. Merlin also had supplies of household water filters and chlorine solution in Laputta, which were available for immediate use following the cyclone, though not tanks, bladders or mass chlorination facilities.
Merlin staff in Laputta and Yangon (both national and international) were able to respond immediately. With the destruction of existing health facilities, the team in Laputta set up a first aid point which saw approximately 250 people a day. The majority of cases were trauma-related, including head wounds and bruising, and skin damage related to hail and wind exposure. The Merlin Response Team (MRT) arrived in the country a week after the cyclone. Merlin did not experience the delays other agencies encountered in getting approval for staff to enter Myanmar, perhaps because the organisation was already known to the authorities.
With the arrival of the MRT, preparations to scale up the response were put in hand. These included plans for the distribution of non-food items including water filters and purification solution, and in some areas water and food. Doctors and other health staff were recruited to expand the coverage of health services. Merlins national staff increased four-fold, from 44 to 160. There were problems in recruiting experienced staff: only two senior doctors could be recruited in-country and the majority were recently qualified without the level of experience with which Merlin usually works. Clinics were set up in temples and pagodas, which were being used as IDP camps, and gradually expanded across the Delta, ultimately providing six fixed clinics and ten mobile clinics, using boats, across Laputta Township. Over the following six weeks, health teams visited more than 350 villages.
Merlin was able to import supplies and clear them through customs without problems, though this was not the case for all agencies. Again this was probably due to Merlins previous presence in the country and the fact that it had an established Memorandum of Understanding (MoU) with the Ministry of Health. However, only two expatriates were allowed access to the Delta area, and they did not have the freedom to travel beyond Laputta. As a result, Merlin implemented a remote management arrangement, whereby MRT staff coordinated national teams in the villages, providing financial and logistical management in Laputta. National staff members and local people thus undertook all the assessment and distribution activities in the affected area outside Laputta. The level of responsibility and trust developed within the programme between Merlins local staff and community health workers before the cyclone ensured a degree of confidence that would not have been possible in a solely short-term response.
Mobile teams deployed from Laputta to the villages reported that communities were immediately assisted by their CHWs using the basic skills and supplies they had to hand. Of the 540 CHWs trained and functional on 2 May, 94 lost their lives in the cyclone. Many of the surviving CHWs had to deal with their own family situations including the loss of shelter and psychological trauma. Despite this, over the days following the disaster CHWs made their way to the Merlin office in Laputta, while others were contacted by Merlin staff. These CHWs became a central part of the response effort, assessing the needs of dispersed communities and ensuring the effective and equitable distribution of aid based on their local knowledge and positions within their communities. Anecdotal evidence suggests that communities considered the CHWs response effective, though no formal assessment has as yet been done.
Issues of quality and accountability within the programme were considered at an early stage. At the start of the scale-up response the teams covering food security, livelihoods and village rehabilitation all received Sphere training. All medical teams were provided with treatment protocols and prescriptions were reviewed by supervisors to ensure rational drug use. All Merlin assessments were designed to identify community priorities, and teams were asked to develop selection criteria for their respective sectors. The programme also began to develop tools for patient accountability. These initiatives are being taken further in the on-going programme.
What we have learnt
The on-going programme in Laputta was clearly critical to Merlins response, providing the community structures and staff on which to build and guaranteeing a high level of acceptance for Merlins work within the Delta. At the same time, however, access restrictions for international staff highlighted the importance of a locally prepared workforce with response systems and structures in place. The fact that national staff and local people were able to respond and utilise the skills and equipment available to them presents a strong case for making capacity-building and institutional strengthening in disaster response key components of on-going programmes in this and other contexts.
Merlins experience from a number of countries, including Ethiopia and Somalia, suggests that the health impact of disasters can be substantially reduced if national and local authorities in high-risk areas are well-prepared, such as through strengthened disease surveillance and effective epidemic preparedness. This also includes training health workers and enabling critical infrastructure such as health facilities to remain functional. However, in many resource- or governance-poor settings, disaster risk reduction may not be considered a priority by local authorities. While a number of donors and NGOs are increasingly viewing this area as an important aspect of work, more needs to be done to actively promote this, especially with the predicted increase in disasters in the future.
For Merlin, Nargis has highlighted areas that the programme can strengthen immediately. These include an expanded role for CHWs, with more detailed and specific training in disaster response management (to be conducted with the Myanmar Red Cross), and greater availability of supplies. A new training module on psycho-social support skills conducted by the Myanmar Red Cross has been built into the new programme.
None of this precludes the need for an effective and timely international response to disasters such as Nargis. The fact that Merlin had only two MRT staff in Laputta not only meant that a considerable burden was placed on these individuals in terms of administrative obligations, but also that they were unable to provide the usual front-line inputs into the response outside the town.
Lessons for the wider humanitarian community
In terms of lessons for the wider humanitarian community, it seems clear that the capacity to respond in Myanmar was based on the ability to employ or engage those already on the ground. In Merlins case, this predominately involved Merlin staff and CHWs previously trained by Merlin. In addition, however, Merlin needed to employ local medical and other specialist staff. This was challenging, both in terms of the quantity and quality of staff available. Problems were compounded by the lack of back-up from specialist internationals able to quickly skill-up recruits.
Given the restrictions on travel outside Laputta, remote management approaches were needed, in terms of the coordination of national staff and community partnership arrangements. This proved effective, utilising the combined inputs of international and national players and ensuring that supplies were distributed effectively within the Delta region. However, the speed of the scale up was undoubtedly reduced. For this reason, Merlin continues to advocate for the humanitarian space to ensure the international support needed to scale up, save lives and ensure every individuals right to assistance, while at the same time emphasising support to and strengthening of the local systems and structures vital to the response.
Fiona Campbell is Head of Policy at Merlin. Muhammad Shafique is Behaviour Change Communication Specialist, Merlin Myanmar. Paula Sansom is Emergency Response Manager (Health), Merlin. The authors acknowledge the considerable inputs to this article from Jacob Asens and Dr Panna Erasmus, Health Advisers, Merlin, Yves-Kim Creach, Merlin Response Team Manager, and Dr Paul Sender, Country Director, Merlin Myanmar. Correspondence on this article should be sent to: Fiona.firstname.lastname@example.org.