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Report on Tsunami Research Feasibility Assessment Trip
Malaysia, India, Sri Lanka – May 4-9, 2005

Dr. Andy Johnson and Dr. Paula Palmer
Institute for Health Promotion and Disease Prevention Research,
USC Keck School of Medicine

May 16, 2005

We thank all of our APACPH colleagues for inviting us to the Kuala Lumpur meeting so that we could present our ideas to the Executive Committee. We appreciated your suggestions and comments. Special thanks to Walter Patrick for connecting us with research contacts in India and Sri Lanka, and for his graciousness as our host in Sri Lanka. Our visit to both countries proved to be personally rewarding as well as successful. The spirit and enthusiasm of our new colleagues and the affected people of India and Sri Lanka were inspirational.

Below is a summary of events from our fact finding visit.

MALAYSIA
May 4th, Kuala Lumpur - APACPH meeting, Day 2

The APACPH Executive Board meeting was attended by Anuar Zaini (President), Brian Oldenburg (Director, Brisbane Office), Colin Innes (Treasurer), Chalermchai Chaikittiporn (Director, Bangkok Office), Walter Patrick (Secretary General & Director, Hawaii Office), Tomiko Hokama (Vice President), Wen Ta Chiu (Vice President), Ian Rouse (Dean, Curtin University of Technology), Andy Johnson (Director, USC IPR), and Paula Palmer (USC IPR). Discussion centered on APACPH post-tsunami efforts in affected countries. APACPH’s central post-tsunami efforts, which are consistent with APACPH’s overall objectives, emphasize education and training for the medium and long term. The purpose of Dr. Johnson’s visit to KL was to solicit input for his research plan and garner possible research collaborations with APACPH members. Dr. Chaikittiporn reported that he would look into the possibility of carrying out the research in Thailand through Mahidol University but was not overly optimistic and noted that most areas in Thailand had already been over surveyed and that governmental restrictions on tsunami-based research were strict and unyielding. Dean Rouse expressed reservations about the feasibility of the proposed survey, especially the potential for securing cooperation of local collaborators and authorities. Drs. Johnson and Palmer were encouraged to consider scaling back the research to something perhaps less rigorous and demanding, with a view toward salvaging something useful should they meet insurmountable obstacles. Drs. Johnson and Palmer left KL in the late afternoon for Chennai, India to meet with other prospective research partners through arrangements made by Dr. Walter Patrick.

INDIA
May 5th, Chennai, India

Drs. Johnson and Palmer met with Dr. K. R. Thankappan (Additional Professor and Head, Achutha Menon Centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum,
The Achutha Menon Centre for Health Science Studies (AMCHSS) is the health sciences wing of the Sree Chitra Tirunal Institute for Medical Sciences and Technology. The main objective of AMCHSS is to train health professionals in health research and in formulation and implementation of health policies. The AMCHSS offers an international Master of Public Health (MPH) program, short courses and Ph.D. program catering to all South Asian countries. The Ministry of Health and Family Welfare, Government of India recognized the AMCHSS as a centre of excellence for Public Health Training and sponsors candidates for the MPH under the WHO fellowship program. Additionally, AMCHSS is the secretariat for the Public Health Schools Without Walls network, a network of Public Health Schools in Asia and Africa.

Dr. Thankappan received his MPH degree from Harvard, and has been involved in numerous international collaborations. Currently, he is co-investigator on a Fogarty grant aimed at building tobacco research capacity and promoting tobacco cessation in India and Indonesia in collaboration with the University of Minnesota. In January, he oversaw a tsunami Public Health Preparedness for Natural Disasters- Management Plan for Kerala and Tamil Nadu conducted by a group of his AMCHSS MPH students. Dr. Thankappan attended the Brisbane meeting last year and would like to become a member of APACPH; however, there is no mechanism at his institution to cover the annual fee.

Drs. Johnson, Palmer, and Thankappan met with M. D. Gupte, Director, National Institute of Epidemiology (NIE), part of the Indian Council of Medical Research (ICMR), and his colleague, Dr. M. Murhekar regarding possible tsunami research collaboration.

National Institute of Epidemiology (NIE). The broad objectives of the NIE cover development of human resources in epidemiology and bio-statistics, networking of the various ICMR and non-ICMR Institutes at the national level for epidemiological purposes, and consultant services. The NIE has the distinction of being the WHO Collaborating Centre for Epidemiology of Leprosy and provides technical assistance for HIV epidemiology for India’s National AIDS Control Organization. The NIE carries out a variety of research activities, including, intervention studies, disease modeling, health systems research, evaluation of health schemes and disease control programs, research methodology, epidemiological investigations and clinical trials of traditional remedies. The NIE’s field practice area covers a population of roughly 5,000,000 people in southeast India. The NIE is recognized by the Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram for a two-year field epidemiology Training Program (FETP-INDIA) leading to Master of Applied Epidemiology (MAE) degree. The Institute has been conducting training programs annually in biostatistics, controlled clinical trials and basic epidemiology for medical doctors, medical students and para-medical workers. It also conducts WHO-SEARO 10 day regional workshops on surveillance, epidemic preparedness and response periodically.

Summary of research possibilities
During the visit Drs. Gupte and Murmekar presented some preliminary data from a tsunami study they conducted that included an assessment of Post Traumatic Stress Disorder (PTSD), depression, anxiety among 155 families, about 375 interviewed participants. The study was conducted among all surviving residents in a fishing village in Pondicherry roughly 175 km south of Chennai. The village, which was situated directly on the coast suffered severe damage and loss of life. Survivors have been relocated to a camp just across a lagoon from their former home. In-home, face-to-face interviews were utilized for data collection. Findings from the study conducted two months post-tsunami with adults from 19+ years indicated the following: Major depression 48.6%, PTSD 20%, low rates of anxiety, all according to DSM-IV criteria. Women were more affected than men, some participants rated high on suicidal ideation, communicable/infectious disease was minimal. Study staff included a psychiatric team that provided antidepressant meds to severely depressed patients and those exhibiting suicidal ideation. The results will be published shortly.

Drs. Johnson and Palmer presented the rationale for a population-based, longitudinal survey of more and less affected tsunami victims to study mid- to long-term effects of the tsunami on youth and families, including mention of research gaps that our collaborative research might fill. Dr. Gupte recognized the importance of such a study based on his own research, and has agreed to collaborate with USC. Dr. Gupte will oversee operations in Tamil Nadu (southeast) and Dr. Thankappan will do the same in Kerala (southwest). A survey (potentially census) will be carried out among adults and children in the families of the village previously assessed and additional fishing villages selected from among villages stratified for degree of tsunami impact and socioeconomic characteristics. Data will be collected in late summer, with plans for follow up data collection on the cohort in 2006 and 2007. Plans call for collecting data in 6 villages, 3 in each state. Collecting data from affected areas in two different Indian states separated by 500 miles provides a unique opportunity for cross-cultural, intra-country comparisons.

Following the meeting, Dr. Gupte suggested a trip to the Pondicherry site and sent along Dr. Murmekar, who was an investigator on the project and his statistician. In Pondicherry, we spent time in the re-location camp visiting with adults and children, who approached us to share their accounts of the tsunami. Just about all men in the village had gone out at 5am with the fishing fleet the morning of the tsunami. When they returned at 11am their homes were destroyed and over 70 women and children had been killed or were missing. Seven children are still unaccounted for.

Our Indian colleagues are well trained researchers, aware of gaps in the disaster literature, and were quick to recognize the opportunity to produce unique contributions to the literature. Drs. Gupte and Thankappan are well positioned to facilitate fairly swift movement in setting up and implementing our collaborative projects. Southern India offers the possibility for various research collaborations beyond our tsunami work. Its economic growth parallels that of China and offers interesting opportunities for cross-cultural comparative studies. The plan is for USC to finalize details of the research plan we discussed during our visit to Drs. Gupte and Thankappan within the next week for their input. Both were extremely enthusiastic about this and other future collaborations and the possibility of student training exchanges.


SRI LANKA
May 6th – 9th, Batticaloa, Sri Lanka

Drs. Johnson and Palmer and members of the APACPH group led by Walter Patrick met with the Chancellor, Professor T. Varagunam MD; FRCP, Eastern University, Sri Lanka, Batticaloa, in Kandy on the evening of the 6th and traveled to Batticaloa on May 7th. The group visited Eastern University for a short meeting with administrators to introduce the purpose of our visit, namely, to assess opportunities for and interest in training and research collaboration. Over the next two days, the group toured tsunami-ravage sites and met with various university, hospital, and psychological counseling staff.

Batticaloa is the regional capital of eastern Sri Lanka and is located about 190 miles (340 km) from Colombo. It’s located on a long sandy strip of land separated from the mainland by a brackish lagoon. Lagoon and coastal fishing and rice growing are the two main industries; both were adversely affected by the tsunami. The fishing fleet was washed out and a significant proportion of the rice paddies were flooded by sea water. Batticaloa was a stronghold of the Tamil resistance; militia remain stationed throughout the area. The area is severely depressed economically due to 20 years of civil war.

Navaladi:
(See map)
We visited Navaladi, a fishing village located on a sliver of sand between the Indian Ocean and a saltwater lagoon, on May 8th. One-lane roads connect the village of one-story brick homes and shanties with the mainland. The entire sandy strip is roughly three-quarters of a mile wide from ocean to lagoon at its widest. There are shattered brick and concrete house foundations and exposed circles of concrete; some palm tree and a few other shrubs are still standing. We spoke with survivors who told us stories of their personal experiences of loss and how they are rebuilding their homes and lives. The water rose to about 20 feet very suddenly, people were lifted over homes and the tops of palm trees. Of the 10,000 residents, roughly 2,000 were killed; 20% of the population, at least 1/3 of those were children. Rebuilding is underway but the government prohibits any re-building closer than 200 meters from the water (same is true for areas we visited in India). Navaladi citizens, as is the case with people in all stricken areas we visited, do not want to re-locate out of the area. Family, community, and religious ties run deep.

Navaladi


Eastern University, Sri Lanka (EUSL) is located in Vantharumoolai, Chenkalady, about 10 miles north of Batticaloa. At present EUSL has four faculties of study: Faculty of Agriculture, Faculty of Arts and Cultural Studies, Faculty of Management and Commerce, Faculty of Science. The university offers undergraduate and postgraduate (research MPhil) degrees. A medical school is under development and will be situated in the future Health Sciences Center. University operated tsunami website: http://www.eusl.info/index.htm EUSL post-tsunami projects have included testing water quality, assessing environmental impact, impact on local fishing industry, economic impact, including monitoring unemployment.

Summary of research possibilities
There is enthusiasm for collaborating in a longitudinal population-based study of youth, families, and communities in conjunction with Eastern University faculty. We were able to obtain a dataset from a post tsunami survey of 28,000 mostly in 120 relocation camps (representing an estimated 80% of affected people). Information was collected from people 19 years + Sri Lankans with oversight by Dr. T. Sritharan, Director, and Center for Information & Communication Technology & Head of the Mathematics Department, EUSL. This dataset will be helpful in determining the effect of the tsunami, including property and family loss and will aid sampling and stratification of the proposed USC study. Dir. Sritharan will serve as our primary research partner. He was instrumental in the organization and administration of the Batticaloa dataset, and can assist with arranging for data collectors, data entry, and analysis. David Harris, EUSL Registrar, may also be helpful in research logistics. Other faculty may join once the study design is in place. That our colleagues and many citizens in both India and Sri Lanka are fluent in English is a real plus for our research. It facilitates our ability to participate fully through direct interaction with tsunami victims.

Special attention to cultural considerations will be important in any assessment done in Sri Lanka. Past research and post-tsunami NGO activity has typically been well meaning but culturally insensitive and inappropriate according to reports from our Sri Lankan collaborators. Community input and that of local experts will be involved in study and measurement design and administration.

Special needs of Sri Lankan children have resulted from ethnic strife, civil war, floods, and the tsunami. Multi stressors need to be taken into consideration. Programs and psychological counseling and play therapy have been helpful in building resilience in affected youth. The Mangrove Psychological Counseling Centre (leadership in flux) and Butterfly Peace Garden (Father Paul Satkunanayagam, Director) are two examples.

As with the proposed Chennai research, time is of the essence in setting up and implementing the research plan and pilot. We will proceed with the same time line presented at the KL meeting with data collection to be completed by September at the very latest. The sampling plan as presented in KL will be slightly modified. Survey items will be expanded based on input from our research colleagues.

Note:
A memorial fund will be established in the name of Bala Sugumar’s 14 year-old daughter and only child who was swept away by the tsunami. Sugumar is the Dean of Faculty of Arts & Culture at EUSL. Vice chancellor, Prof. S. Raveendranath, provided a disk with names of students who could benefit from monetary support. Dr. Palmer will continue to work on this with Walter Patrick and our colleagues at EUSL.