Originally published in The Ottawa Citizen January 09, 2005
Original Title: Toxic Soup

All the ingredients for a potential health calamity are present

The tsunami survivors face great health challenges. To date there have not been reports of epidemics of cholera or other infectious diseases. However, the massive aid pouring into the affected regions is designed to address the health risks that have the potential to cause further harm.

All the ingredients for a potential health calamity are present: a contaminated water supply, lack of sanitation infrastructures, overcrowding, malnutrition, and endemic infectious diseases.

Human waste and decaying corpses contribute to the massive contamination. In effect, some of the survivors are living amongst a biologic toxic soup containing myriad pathogenic micro-organisms.

It is the children who will suffer most. Their weakened state impairs their ability to resist disease. Many can live without food for a week or more, but survival time is measured in days without clean water; they will rapidly succumb to dehydration, especially within the hot tropical environment.

With weakened immune systems comes an increased incidence of diarrheal illnesses, pneumonia, urinary tract infections and skin infections, among others. The severity of the illness and the survival rate is usually proportional to the time it takes to diagnose and treat it.

Indeed, bacterial diseases such as typhoid (Salmonella typhii), cholera (Vibrio cholerae), and enterotoxigenic E. coli are a major cause of dehydration, and are endemic in developing countries in Asia and Africa. All these organisms are found in contaminated food and water. They will also pass from person to person. Lack of adequate shelter makes it impossible to isolate the sick from the uninfected population.

Although the manner in which they cause disease (pathogenesis) differs, the end result is similar: They will infect and damage the intestines (enteric disease).

The small intestine absorbs most of the nutrients from food while the large intestine absorbs about 99 per cent of all water that flows through it. Damage to these structures can lead to bleeding and reduced absorptive capacity causing massive diarrhea.

Children and the elderly do not have as great a fluid reserve as do younger adults. In many instances, they must receive intravenous fluid replacement to compensate for their losses from diarrhea. The availability of clean water to drink will not help them in this case because the large intestine has lost its ability to absorb it.

The supportive care to treat cholera and other enteric diseases requires many litres of intravenous fluid replacement per patient. Some may need between 10 and 20 litres during the course of disease. Given the thousands of people that will contract these diseases, the resources alone for this one condition can strain available medical resources and supplies.

Contaminated pools of water attract disease-carrying flies, malaria and dengue fever-laden mosquitoes, and also harbour hepatitis A.

Without adequate shelter and netting for nighttime protection, the survivors are at risk for malaria and dengue fever. Left untreated, many will die. Waterborne parasites can also cause intestinal infection leading to cramps, bleeding and diarrhea. Most healthy people will recover from hepatitis A without any major consequences. However, the survivors of the tsunami have a greater risk of complications because of their weakened state.

Tuberculosis, a disease that affects two billion people worldwide — roughly one-third of the world’s population, most in developing countries — will claim more victims. This highly contagious person-to-person disease will have the opportunity to infect many others because of the living conditions and migration of people to temporary shelters or camps.

Some will have physical injuries that require proper wound care. Without treatment, these wounds will fester and infections will develop. Cellulitis is a common and potentially serious skin infection that normally starts in areas where there is pre-existing skin damage. The skin becomes swollen, red and hot and has a poorly defined border. The area of redness (erythema) rapidly expands and creeps along the skin within hours.

If diagnosed early, treatment consists of an oral antibiotic. Intravenous antibiotics are used if oral treatment fails or if there is an initial extensive spread of the infection. However, many of the survivors will not have access to prompt medical treatment. The end result is that a readily treatable infection will spread and increase the risk of septic shock and death.

The relief efforts are designed to counter the problems outlined, here. Setting up proper sewage and waste management systems will take time. Burying the dead, decontaminating water supplies, providing food and shelter and tending to the sick and injured are the initial focus of the recovery program. This in turn will slowly introduce order into a chaotic situation, but it will take months or years to remedy.

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© Dr. Barry Dworkin 2005