Chapter 1
Box 1.5 Turkish earthquakes leave long-term legacy

The ground shook for just 45 seconds, but the damage was devastating: over 17,000 dead, 44,000 injured, millions psychologically affected. The massive earthquake which struck north-western Turkey at 3 a.m. on 17 August 1999 measured between 7.4 and 7.8 on the Richter scale. It damaged or destroyed around 340,000 buildings, hitting Izmit hardest – an industrial city of 1 million inhabitants. The floors of apartment blocks collapsed “like a loaf of sliced bread”, according to one observer, crushing thousands in their sleep. As the seabed dropped suddenly along the fault line, a tidal wave as high as six metres swamped the coast.

Over 1,300 aftershocks followed, culminating in a second major quake on 12 November around 100 km east of Izmit. Rated 7.2 on the Richter scale, it killed at least 845 people and injured nearly 5,000 more. A further 40,000 homes and buildings were destroyed.

The sheer scale of the first catastrophe caught everyone off guard, prompting the Turkish government to declare a state of emergency and request international assistance. Initial fears – widely publicized in local and international media – that epidemics of cholera would be spread by dead bodies beneath the rubble proved unfounded. Emergency public health activities focused on surveillance of communicable diseases; providing clean water and sanitation equipment for survivors living in tent cities and prefabricated settlements; and distributing medicines and medical equipment to hospitals, clinics and rehabilitation centres.

While the international media publicized the work of dozens of international search-and-rescue teams lifting injured survivors out of the rubble, these images disguised the reality that most of the rescue work, in the first crucial hours after the disaster, was done by neighbours, often digging with bare hands. And the spontaneous but professional action of Turkish health workers – many of whom had themselves lost homes and family members – undoubtedly saved lives.

Estimates of the survivability of victims buried under collapsed buildings in Turkey indicate that within six hours less than 50 per cent of those buried were still alive. With even the quickest international rescue teams taking 12 hours to reach the disaster zone, clearly it is local people and institutions that need to be strengthened and supported to cope whenever disaster strikes. An assessment team deployed by the International Federation shortly after the first earthquake was surprised to find few patients in the disaster area. Turkish health personnel had already evacuated seriously injured patients to Istanbul or Ankara, while ‘walking wounded’ had moved to safer areas.

Nevertheless, temporary clinics and hospitals were needed to meet the demands of non-earthquake-related patients. The pre-quake 5,000-bed capacity of the 25 hospitals in the most seriously affected provinces dropped to just 300 beds after the earthquake – and half of this capacity was in ‘buffer hospitals’ outside the immediate disaster zone. Tented, ‘container’ and, later, prefabricated hospitals provided temporary clinical health services in the earthquake area. But while international aid organizations focused on the epicentre of the earthquake, looking to support hospitals that suffered structural damage, the buffer hospitals received the bulk of patients – and hardly any international assistance. The Kandira State Hospital, to the north of the August epicentre, had a tenfold increase in admissions and operations. “I performed 11 caesarean sections within the first day after the earthquake and the midwife assisted in 35 births,” said hospital director Ismail Yilmaz. Hundreds of patients were admitted to his hospital, despite the lack of tele-communications, staff, medication, clean water or electricity. “Today, seven months later, we continue to face serious personnel, financial and structural constraints,” explained Yilmaz.

In the aftermath of disasters, international aid could make more difference if it were focused on ‘helping the helpers’. That means, within the health context, material support for the buffer hospitals bearing the brunt of treating patients, and physical and psychological support for local hospital and health personnel. Local and international health professionals considering the long-term public health implications of the two earthquakes agree that, .../ .../ besides widespread damage to health facilities, at least two other direct consequences of the disasters will be felt for years to come: the need for essential physical rehabilitation of severely disabled quake survivors; and the importance of addressing the psychosocial needs of the affected population.

Since August 1999, the International Federation’s health team in Turkey has visited many of the Istanbul hospitals to which most seriously injured patients were transferred. One 17-year-old boy, who lost his home and entire family, is now paralysed from the neck down and still waits for medical rehabilitation seven months later. An estimated 4,000 quake survivors are suffering from spinal-cord injuries, peripheral nerve lesions, multiple bone fractures and extremity amputations. The majority of these victims received emergency treatment immediately after the earthquakes. However, due to the limited capacity of local health institutions, many patients must wait up to a year for crucial, often lifesaving, physiotherapy and rehabilitation. The earthquakes and aftershocks caused severe psychological disturbances and many still suffer from post-traumatic stress symptoms, including sleep disorders, irritability, hyperarousal, anxiety, depression and psychosomatic disorders. In addition, the constant predictions, widely advertised by the Turkish media, that another strong earthquake could hit Istanbul at any time, have added to survivors’ distress. The International Federation has initiated a community-based psychosocial programme – starting in Avcilar, Istanbul – aimed at providing immediate support to quake survivors, medical personnel and relief workers.

Long-term efforts in the health sector will not only focus on psychosocial support, physiotherapy and rehabilitation for severely injured quake survivors, but also on public health issues, first-aid training and upgrading the Turkish Red Crescent Society’s nationwide blood programme. Other key areas for the Red Cross/Red Crescent include reconstruction of health, education and social facilities, social welfare and disaster preparedness. What has been learnt in the aftermath of disaster? A comprehensive disaster preparedness plan encompassing the government, non-governmental and civil society organizations, health institutions and individual families is needed. The following list highlights some of the important public health aspects to be taken into consideration when serious disasters strike:
- Assess the damage and consider the immediate needs of hospitals and clinics in the disaster zone. Main needs often include: clean water and food; staff; medicine and medical items; and electricity.
- Assess the needs of buffer hospitals and clinics surrounding the disaster area, which may receive a high number of victims in addition to their regular caseload and may quickly become overwhelmed.
- Helping the helpers: the basic needs of health personnel must be quickly met to enable them to perform their duties effectively.
- Swiftly organize psychological debriefing for both local and international health and aid personnel.
- Mobilize additional medical staff from outside the disaster area.
- Organize additional field hospitals/temporary clinics in the disaster area within 24 hours – not for lifesaving purposes, but for filling temporary gaps in the health service.
- Health personnel must be trained beforehand in triage and first aid, while the general public needs prior training in basic rescue and first-aid skills.
- Public health surveillance is crucial in a disaster-stricken area. Fast response must follow up any detected needs.
- A disaster preparedness plan must provide for sufficient relief items and medical stocks, availability of transport to evacuate patients quickly, good communication, generators for hospitals, and a database of available human resources.
- Recovery programmes should include the reconstruction of the health structure and facilities as well as the physical and psychological rehabilitation of the affected population.