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2018 Sulawesi, Indonesia Earthquake and Tsunami Case Study

What caused the Sulawesi, Indonesian earthquake and what were the effects?

On Friday 28th September 2018 a magnitude 7.5 earthquake struck Palu, on the Indonesian island of Sulawesi, just before dusk wreaking havoc and destruction across the city and triggering a deadly tsunami on its coast. The 7.5 magnitude earthquake hit only six miles from the country’s coast.

A map to show the location of Palu

The shallow tremor was more powerful than a series of earthquakes that killed hundreds on the Indonesian island of Lombok this July and August.

Palu is located on the Indonesian island of Sulawesi, 1,650 kilometres northeast of Jakarta, at the mouth of the Palu River. It is the capital of the province of Central Sulawesi, situated on a long, narrow bay .

A satellite image to show the location of Palu – Source Google Earth

The coastal city of Palu is home to 350,000 people.

Small foreshocks had been happening throughout 28th September in Palu. However, in the early evening, the Palu-Koru fault suddenly slipped, a short distance offshore and only 10km (6 miles) below the surface. This generated the 7.5 magnitude earthquake.

The impact of the earthquake was magnified because of the thick layers of sediment on which the city lies. Whereas bedrock shakes in an earthquake, sediment moves a lot more, behaving like a liquid. Poorly constructed houses cannot withstand movement of this magnitude.

Scientists don’t pay much attention to the Palu-Koru fault line, as far as tsunamis are concerned. This is because the two plates are moving past each other, not with the vertical thrust required to form a tsunami.

Scientists are still trying to work out what happened to cause the tsunami. It is possible that the earthquake caused an underwater landslide which disturbed the water or there could be inaccuracies in the identification of the type of fault.

Once the wave started moving, Palu, at the end of a narrow 10km-long bay, was a sitting duck.

Tsunamis are no danger when out at sea. But when the waves come closer to land, their base drags on the seabed causing them to rise up.

Primary Effects

The quake destroyed thousands of homes in the city, as well as an eight-storey hotel, hospital and a large department store.

More before/after comparisons from around the #PaluTsunami and #PaluEarthquake captured by @planetlabs . Included rough lat/long. Keep an eye on https://t.co/Kz73HlYmGF as they often post the sat. imagery for responders, relief agencies et al. pic.twitter.com/1Vreovjt9b — Murray Ford (@mfordNZ) October 1, 2018

At least 2256 people have been confirmed dead, with more than 10,679 injured and 1075 missing. 200,000 people were in urgent need of assistance, about a quarter of them children.

The earthquake caused widespread liquefaction , which is when soil and groundwater mix. The ground becomes very soft, similar to quicksand. It causes foundations of buildings and other structures to sink into the ground.

In the case of Palu, buildings not only collapsed but some were moved by the liquefaction. This is why it is better to build on bedrock rather than on top of the soil.

The control tower and runway at Palu’s airport also sustained damage. Commercial flights were cancelled with only humanitarian and search and rescue flights permitted.

Secondary Effects

The earthquake triggered a tsunami reaching 6 metres in height. As the tsunami approached the coast it was reported to be travelling 250mph. The damage was as extensive: the main highway was cut off by a landslide and a large bridge washed away by the tsunami wave, which hit Palu’s Talise beach and the coastal town of Donggala.

Landslides, downed communications networks and collapsed bridges have made it hard for aid workers and rescuers to reach rural areas.

Due to hospitals being damaged, people received medical treatment in the open.

Strong aftershocks hit the island the day after the earthquake.

Immediate (Short Term) Response

A tsunami warning was issued by Indonesia’s geophysics agency (BMKG) when the earthquake was detected. However, the agency lifted the warning 34 minutes after it was first issued. The closest tidal sensor to Palu is around 200km (125 miles) away. The decision to lift the tsunami warning was based on this data.

Search and rescue teams were deployed to the worst-affected areas. Around 700 army and police officers were dispatched to assist in the emergency response.

The military sent cargo planes with aid from Jakarta and other cities. However, this was slow to arrive.

A large number of charities set up appeals to raise funds to support people in the affected area. Buckingham Palace reported that the Queen had made a donation to the Disasters Emergency Committee (DEC) appeal for survivors, which raised £6m in a day when it was launched.

The RAF delivered thousands of shelter kits, solar lanterns and water purifiers to the disaster zone in addition to trucks and power generators to help get them to where they are needed.

At least 70,000 people gathered in evacuation sites across the island.

Long-term Response

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The 2004 tsunami: a survivor’s story, editor’s note: ari palawi is a graduate degree fellow in ethnomusicology at the east-west center and the university of hawai`i at manoa, funded by the ford foundation international fellowships program. during the tsunami in december 2004, he was a lecturer at syiah kuala university in aceh province, indonesia. special thanks go to terance bigalke and barbara andaya at the east-west center for obtaining this story., as recounted to terance w. bigalke.

My name is Ari Palawi, and I was born on November 10, 1974. I grew up in Banda Aceh, the capital of Nanggroe Aceh Darussalam (Aceh). Aceh (pronounced Ah-chay) is a special territory ( daerah istimewa ) of Indonesia, located on the northern tip of the island of Sumatra. I finished my elementary, junior high, and senior high school there. In 1993, I went to Java Island to pursue my undergraduate degree at the Yogyakarta Indonesian Institute of Arts where I graduated in 2000. I began working in 2002 as a lecturer at Syiah Kuala University, Banda Aceh. There I taught arts and some music courses.

The moment that changed my life was on the Sunday morning of December 26, 2004. At that time, I still lived in my parents’ house at Peurada, about three kilometers from the sea. My room was on the second floor, and my mother’s and sister’s rooms were on the first floor. Suddenly, a powerful earthquake shook us, and we panicked. Spontaneously, I grabbed my cousin, while shouting to my sister to get out of the house quickly. After getting away from the house, we stood on the street. My mother was still in the garden. I could not reach her immediately because the earth was still shaking. When the shaking stopped for a moment, I was able to get to my mother.

After about thirty minutes, the earthquake stopped. We thought the disaster had ended. All our neighbors and my family returned to our houses. Then, mysteriously, my mother suddenly asked my sister and me to take all of the important documents and move them into my room on the second floor. My confusion about why my mother wanted us to do this was answered within thirty minutes. Hundreds of people were rushing by the street in front of our house, yelling “ Air naik! Air naik! Allahuakbar! Allahuakbar! Laillahaillallah! ” (“The water is rising, the water is rising! God is Great! God is Great! There is no God but God!”) These people yelled the phrases over and over, with panic, fear, and terror in their faces.

I got my motorcycle and asked my sister to drive it with my mother and cousin. After that, I locked the doors of the house and the outside gate. I ran as directly as possible to the place my sister took my mother and cousin. We, and people from all over, reached and gathered in a big mosque one kilometer away from the surging seawater. Spontaneously, people recited the Koran and prayed, expecting the worst. Every time the earth shook, the more panic people felt. From the second floor, we could see the water rising higher and higher until it almost entered the yard of the mosque.

After waiting for about five hours, my mother strongly wanted to go back to our house. Our house was still there, but everything inside it had been damaged or was gone. The seawater depth was still about seventy-five centimeters. The mud was about thirty centimeters high. It seemed that the water had reached more than two meters before it went down. While we were in the house, a number of after-shocks occurred. Many times we ran to our neighbor’s house which we thought was built stronger and higher. Finally, before nightfall, we went to a mosque in another village. It was quite far from the first mosque where we had stayed during the tsunami.

As a result of the disaster, there was no electricity at all. Villagers around the mosque gave some food and water to hundreds of refuges that stayed in the mosque. Even so, every one patiently kept praying in the mosque during prayer times. No one had enough sleep on that night. Every one was in trauma.

Next day, in the morning, we went back to our house again. The water was not as high as the first day. People tried to identify the dead bodies on the street along the way home. We went back to our home for a whole day to collect any useful things that remained. After securing them in one place, I tried to convince my mother to evacuate to my older sister’s house in Blang Bintang, which is about twenty-three kilometers from our house. We stayed in my older sister’s house for about one month and half.

Even though I was still very tired and traumatized from the tsunami, on the third day at my sister’s house I drove the motorcycle back to our house in Peurada. By doing so, I could convince my mother not to go back to the house, as she wanted to do. It was very hard on me, being alone in our house in an empty village in such an unpredictable situation. Damage and death were still everywhere. My love for my mother drove me to overcome my fear, and three or four times a day I shuttled back and forth to my sister’s house carrying three large sacks of valuables. I was happy to keep my mother so busy cleaning these things that she did not go back to Peurada.

A few weeks before returning to live in our house, we tried to clean and repair it. Meanwhile, in the tsunami aftermath, I focused on organizing friends in my village to get some help for Aceh from government or non-government organizations. As my family did, other people in our village stayed there only during the day and went back to their temporary place at night for food and rest. We saw the mosque as the center to light up peoples’ spirits and get help from people— and we received some donations of food, drinks, and even building materials. In one month, relief efforts in our village made rapid progress.

When I was sure that my family’s situation was getting better, I refocused my concern on the department where I work. The first time I went back to campus after the tsunami, three of my students were living there temporarily because they had no other place to stay. I advised them to make sure that all their documents, musical instruments, and teaching media were safe and to protect things from being looted. I met some other university representatives to figure out our departmental priorities to enable teaching and learning activities. I was the only lecturer from my department there at the time and had to make the decisions since my other colleagues were not yet back on campus. We received some donations that we used to repair the buildings and buy some materials and equipment. Finally, after several months, the students were able to resume their study. However, the multiple demands we faced in this situation of depleted teaching staff, organizational disarray, and damage to facilities made progress very slow.

As ordinary people, the trauma of the tsunami remains in our memory. Our experience with the tsunami enriches us in the way we think about disasters. For a time, we panicked whenever we felt the aftershocks that continuously occurred during the first year after the disaster. Preparing to minimize the potential damages and trying to make the situation as good as before the disaster are the keys for our mental and psychological recovery. Although we lost a number of our relatives and material possessions, we retained our sense of dignity, social propriety, and our sanity. Compared to other people who lost their parents, their children, and everything they owned, our experience is nothing. I might say that most of the direct victims of the tsunami mentally can accept the realities resulting from the catastrophe. I assume that the revival of religious awareness has been a vital aspect of maintaining our spirit. The extraordinary response from the people around the world is the most significant motivation to keep us active and optimistic, particularly for my family and me. In general, people bounce back from their sadness in a relatively short time.

In the wider-ranging effects, the momentum of the peace agreement between the government of Indonesia and Free Aceh Movement ( Gerakan Aceh Merdeka , GAM) signed in Helsinki made the misery of war become history. The first priority for disaster reconstruction and rehabilitation needs to extend to all sufferers of the war between GAM and the central government. Nowadays, there are a lot of changes coming about through the relief program in Aceh. Although the program has not stayed on schedule, slowly but surely we see an increasing number of people with new houses to replace what they lost in the tsunami. The city has been cleaned up and the people are intensively working as usual. Welfare and education are two of the most important parts of the recovery program—and they are developing through a hundred local and international funding agencies and NGOs. The successful elections in Aceh, which many people see as a major achievement, especially considering that former GAM leaders were peacefully elected to the governorship and vice governorship, brings new hope for Acehnese that we have reached a solution that will advance Aceh civilization in the future through our own decision-making. We are fulfilling the true determination of the Acehnese struggle through fifty years of war and the great tsunami. However, the transition of shifting more control from Jakarta to the Aceh government is still in progress to reach a win-win solution, and this affects the pace of meeting recovery targets in the relief program in Aceh.

For instance, some recent cases of manipulation of the multi-billion dollar program put the success of the recovery at risk. There are concerns that expenditures are not sufficiently benefiting incomes in the local community, due to too much recruitment by employers from outside the region and an unbalanced focus on certain urban areas in Aceh. The goals of the recovery program are falling short of meeting local needs, particularly in the isolated areas of some Aceh districts. These shortcomings cause the Acehnese to doubt that the rebuilding effort will fully meet their hope to independently develop technology, science, and culture in Aceh.

Politically, the momentum of the peace agreement between the government of Indonesia and the Free Aceh Movement signed in Helsinki on August 15, 2005, has begun to change the way Aceh perceives the Indonesian national government. A larger portion of gas revenue going to Aceh makes an important difference in the provincial economy and improves the prosperity of Acehnese people. However, it will depend on the transparency and accountability of all the authorities and the integrity of people in Aceh. The progress on implementing the Helsinki agreement should be transparent and independently verified. The commitment is crucial to perpetuate the political trust between Aceh and Indonesian Republic authorities, as stated in portions of the agreements. There is also a need to anticipate the possibility of third-party internal or external interests working to undermine the agreement. By walking this path, we will not lose our goals and ideals of the peace agreement that emerged from the monumental history of the 8.9-point earthquake followed by the tsunami on December 26, 2004. Our awareness and responsibility to do this is our appreciation to those who died or are missing because of wars and disasters and who made their own significant contribution to a better Aceh.

Case Study: Sumatra and Thailand and the 2004 Tsunami

The Importance of Tsunami Warning Systems and the challenges of warning communication.

Think back to the video you watched in Module 7 – which included scenes of the 2004 tsunami event in Indonesia. The beginning of the video focused on the Banda Aceh area of Sumatra, where fishing communities and small coastal cities were completely destroyed, and the end of the video featured the Phuket area, where more tourist beaches were affected.

Through your reading and watching the videos, you hopefully gained an idea of what it is like to be caught in a tsunami with no advanced warning, and how frantic the attempts to get out of the way must be. Imagine what it would be like to try to move small children, sick or elderly people out of the way of a tsunami with before the wave strikes and with no time to spare!

In Module 7, the events in Phuket, Thailand, are described, with tourists enjoying their vacation on the beach at Christmas 2004. Many are oblivious to the dangers of the approaching tsunami. What could have been done differently? If this were to happen again, would these communities be better informed and prepared?

In Module 7 we also mentioned that early warning systems are very tricky because of the challenges of getting the message out soon enough after the earthquake and before the tsunami waves arrive at a particular shoreline. For example, the towns on the west coast of Sumatra are so close to the Andaman fault that they had almost no time to react, so a warning may not have worked, regardless of how well it was transmitted. Banda Aceh, on the northern tip of Sumatra, was devastated in 2004 because people did not have time to react, while there is evidence that some small nearby island communities fared better where traditional knowledge of the natural warning signs such as the sudden receding of the tidal waters was employed, and residents were able to flee to higher ground. Meanwhile, the tourist destinations of Phuket and Phi Phi, and nearby locations in Thailand had 2 hours, but the warnings were lacking. Visitors lacked necessary knowledge of nature’s warning signs and how to react, and may not have felt the earthquake, so many lives were lost.

In response to the enormous loss of life in the 2004 Indian Ocean tsunami, the Global Tsunami Warning and Mitigation System was put in place. The Indian Ocean tsunami warning system now integrates the signals from seismographs and DART Buoys and transmits data to 26 national centers. Warnings at the local level are generated in the form of SMS messages, mosque loudspeakers, sirens, and other methods to warn citizens. How well the warnings translate into lives saved due to rapid response and appropriate behaviors by the citizens depends on each step working properly. The failure of one of the steps can lead to disaster. If the citizens do not have the knowledge needed to take effective action, then the process will not work, and lives will be lost.

In 2012 another earthquake occurred near Banda Aceh in the Indian Ocean, so the newly implemented warning systems were put to the test. In this case, no tsunami was generated by the earthquake, but unfortunately, the weaknesses in the system were revealed. Despite the efforts expended to increase levels of tsunami preparedness since 2004, including new tsunami evacuation shelters and education programs, chaos ensued. Hearing the tsunami warning, people panicked and tried to flee by car, resulting in gridlock on the roads. It was clear that better guidance from the local government was needed, including clear evacuation route signage and regular drills. For more detail on this topic, read the National Geographic article Will Indonesia Be Ready for the Next Tsunami? Clearly, more work is still needed and ongoing to address these weaknesses.

Rubble and debris amidst sand, mud, and standing water.

Learning Check Point

We will spend a few minutes also revisiting the accounts of historic tsunami events – in particular, the 1960 event and its effects in Chile and Hilo, Hawaii, and the important messages about how to survive a tsunami. Please re-read some of the accounts of survival during tsunami events in Heed Natural Warnings .

For the Instructor

2004 Asian Tsunami

On December 26, 2004, while many westerners vacationed on South Asian beaches during the Christmas holidays, an earthquake with an epicenter in the Indian Ocean struck with an estimated magnitude greater than 9.0. This earthquake generated enormous tsunami around the Indian Ocean, heavily affecting the coastal zones of many countries including Indonesia, Sri Lanka, India, Thailand, the Maldives, and Somalia. More than 230,000 people lost their lives, including many westerners.

Two images show impact of 2004 Asian Tsunami at Banda Aceh, Indonesia, befoe and after.

Although earthquakes and tsunami are natural events, human factors contributed to the losses from the hazard. One factor was the economic development of South Asian coasts, including tourist developments and shrimp farms, which reduced or eliminated coral reefs and mangroves that otherwise might have diminished the intensity and inland reach of the tsunami. This development limited local livelihood options to tourism-related or fishery-related jobs, instead of traditional, diversified livelihood strategies. Consequently, it has been harder for local people to recover from the tsunami because of damages to tourism industries and export fisheries and the lack of other livelihood options.

Despite the widespread damage, some communities suffered less or recovered more quickly because they possessed higher adaptive capacities to this hazard event. One study found that fishing communities on Simeulue Island, Indonesia, and Surin Island, Thailand had fewer losses from the tsunami because they possessed traditional knowledge of tsunamis and had institutions in place that helped them prepare for and respond to the disaster.

Around the Indian Ocean basin, there were no early warning systems when the tsunami struck. In response to the disaster, governments almost immediately collaborated to develop the Indian Ocean Tsunami Warning and Mitigation System to reduce exposure to tsunami.

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This Collection is part of the 'Tsunami Disaster Channel' containing a number of case studies and reports relevant to tsunami disasters, where we try to find out what we have learnt from the past and how we can best reduce risk in future natural disasters. Current guidance comes from leading global organizations: Foreign - Commonwealth & Development Office (FCDO) , Swiss Resource Centre and Consultancies for Development Foundation (SKAT) , Office of the UN Secretary General Special Envoy for Tsunami Recovery , United Nations Children's Fund (UNICEF) , United Nations Environment Programme (UNEP) , United Nations International Strategy for Disaster Reduction (UNISDR) . Please send suggestions for additional content for this Collection to [email protected] . You might find other helpful collections on tsunami disasters below."

Resources on this Collection

10 Lessons Learned from the South Asia Tsunami of 26th December 2004

Approaches to Equity in Post-Tsunami Assistance - Sri Lanka: A Case Study

Environment and Reconstruction in Aceh: two years after the tsunami

Evolving Strategies For Long-term Rehabilitation On Shelter and Development in the Tsunami Affected Areas of Tamil Nadu

Impact of the tsunami response on local and national capacities: Maldives country report

Indian Ocean Earthquake and Tsunami UNICEF response at six months update

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Tsunami in the last 15 years: a bibliometric analysis with a detailed overview and future directions

Original Paper
Published: 02 January 2021
Volume 106 , pages 139–172, ( 2021 )

Cite this article

Nikita Jain 1 , 2 ,
Deepali Virmani 3 &
Ajith Abraham 4

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In the last fifteen years, tsunami science has progressed at a rapid pace. Three major tsunamis: The Indian Ocean in 2004, the 2011 Tohoku tsunami, and the 2018 Palu tsunami were significant landmarks in the history of tsunami science. All the three tsunamis, as mentioned, suffered from either no warning or poor reception of the alerts issued. Various lessons learned, consequent numerical models proposed, post-2004 tsunami damage findings manifested into solutions. However, the misperceived solutions led to a disastrous impact of the 2011 Tohoku event. In the following years, numerous improvements in warning systems and community preparedness frameworks were proposed and implemented. The contributions and new findings have added multi-fold advancements to tsunami science progress. Later, the 2018 Palu tsunami happened and again led to a massive loss of life and property. The warning systems and community seemed un-prepared for this non-seismic tsunami. A significant change is to take place in tsunami science practices and solutions. The 2018 tsunami is one of the most discussed and researched events concerning the palaeotsunami records, damage assessment, and source findings. In the new era, using machine learning and deep learning prevails in all the fields related to tsunami science. This article presents a complete 15-year bibliometric analysis of tsunami research from Scopus and Web of Science (WoS). The review of majorly cited documents in the form of a progressing storyline has highlighted the need for multidisciplinary research to design and propose practical solutions.

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Hard Lessons of the 2018 Indonesian Tsunamis

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Tsunami hazard assessment in the South China Sea: A review of recent progress and research gaps

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Nikita Jain

Department of Computer Science & Engineering, Bharati Vidyapeeth‘s College of Engineering, New Delhi, India

Department of Computer Science & Engineering, Bhagwan Parshuram Institute of Technology, GGSIPU, New Delhi, India

Deepali Virmani

Machine Intelligence Research Labs (MIR Labs), Scientific Network for Innovation and Research Excellence, P.O. Box 2259, Auburn, Washington, 98071, USA

Ajith Abraham

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Correspondence to Nikita Jain .

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Jain, N., Virmani, D. & Abraham, A. Tsunami in the last 15 years: a bibliometric analysis with a detailed overview and future directions. Nat Hazards 106 , 139–172 (2021). https://doi.org/10.1007/s11069-020-04454-2

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DOI : https://doi.org/10.1007/s11069-020-04454-2

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v.3(6); 2006 Jun

Mass Fatality Management following the South Asian Tsunami Disaster: Case Studies in Thailand, Indonesia, and Sri Lanka

Oliver w morgan.

1 Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom

Pongruk Sribanditmongkol

2 Department of Forensic Medicine, Faculty of Medicine, Chiang Mai University, Chaing Mai, Thailand

Clifford Perera

3 Department of Forensic Medicine, University of Ruhuna, Galle, Sri Lanka

Yeddi Sulasmi

4 World Health Organization, Banda Aceh, Indonesia

Dana Van Alphen

5 Pan American Health Organization, Washington, District of Columbia, United States of America

Egbert Sondorp

Following natural disasters, mismanagement of the dead has consequences for the psychological well-being of survivors. However, no technical guidelines currently exist for managing mass fatalities following large natural disasters. Existing methods of mass fatality management are not directly transferable as they are designed for transport accidents and acts of terrorism. Furthermore, no information is currently available about post-disaster management of the dead following previous large natural disasters.

Methods and Findings

After the tsunami disaster on 26 December 2004, we conducted three descriptive case studies to systematically document how the dead were managed in Thailand, Indonesia, and Sri Lanka. We considered the following parameters: body recovery and storage, identification, disposal of human remains, and health risks from dead bodies. We used participant observations as members of post-tsunami response teams, conducted semi-structured interviews with key informants, and collected information from published and unpublished documents.

Refrigeration for preserving human remains was not available soon enough after the disaster, necessitating the use of other methods such as dry ice or temporary burial. No country had sufficient forensic capacity to identify thousands of victims. Rapid decomposition made visual identification almost impossible after 24–48 h. In Thailand, most forensic identification was made using dental and fingerprint data. Few victims were identified from DNA. Lack of national or local mass fatality plans further limited the quality and timeliness of response, a problem which was exacerbated by the absence of practical field guidelines or an international agency providing technical support.

Conclusions

Emergency response should not add to the distress of affected communities by inappropriately disposing of the victims. The rights of survivors to see their dead treated with dignity and respect requires practical guidelines and technical support. Mass fatality management following natural disasters needs to be informed by further field research and supported by a network of regional and international forensic institutes and agencies.

Case studies were conducted to systematically document how the bodies of those killed in the tsunami were managed in Thailand, Indonesia, and Sri Lanka. Many lessons can be learned, though more research is needed.

Editors' Summary

Background..

Some 226,408 people died in the tsunami that hit countries across South Asia on 26 December 2004. As well as providing assistance to the living, a crucially important part of the disaster relief effort was the recovery, identification, and disposal of the dead. However, there is very little consensus about the best way to handle and identify large numbers of bodies. Although natural disasters that kill many people occur frequently, most guidelines for the management of large numbers of dead bodies have come out of the experience gained from transport accidents and from terrorist incidents, and these guidelines are not directly relevant; for example, natural disasters often cause many more deaths than transport accidents or terrorist attacks. It is important for survivors that the bodies of the dead are handled with respect and that the dead are identified so that survivors know what has happened to missing relatives. However, at the same time many people are afraid of what the effect of many dead bodies might be on the living; one belief is that dead bodies are a source of disease. Such a belief can lead to the inappropriately rapid burial of bodies before identification has been done.

Why Was This Study Done?

The tsunami of 2004 provided an opportunity to study four different aspects of how the dead were handled in a number of different countries: how the bodies were recovered, how the bodies were identified, how the bodies were disposed of, and what, if any, were the health effects of the large number of bodies on survivors. The authors wanted to then use the results to make recommendations for use in future natural disasters.

What Did the Researchers Do and Find?

The authors interviewed in person, in writing, and by E-mail key people involved in the handling of the dead in three of the countries affected by the tsunami: Thailand (where 8,345 people died), Indonesia (where 165,708 people died), and Sri Lanka (where 35,399 people died). The authors discovered that there were a huge number of people and agencies involved in the handling of the dead; for example, in Indonesia 42 different organizations were involved in recovering bodies.

None of the countries had sufficient refrigerated storage available to store bodies until they could be identified. Some effective alternatives were used, such as temporary burial in shallow graves—where the temperature is lower than in the ambient air—with the intention of exhuming the bodies later for identification. However, many bodies were hurriedly buried in mass graves because they were decomposing; these bodies were almost impossible to identify.

Methods and efficiency of identification varied between and within countries. One hospital in Sri Lanka excelled by systematically photographing all bodies brought in and recording sex, height, and personal effects: 87% of the bodies brought here were identified. But in most areas rates of identification were much lower. It seemed that simple methods of identification were the most useful: photographs taken quickly before the bodies started to decompose, dental records, and personal effects found on the bodies. DNA analysis was only useful for a small number of bodies.

When it came to disposal of the bodies, again procedures differed widely, and in some cases were dictated by religious needs—for example, in some Muslim communities all bodies were buried within 24 hours, making counting and identification of the dead very difficult. Mass graves were often used, but these caused problems; for example, haphazard arrangement of the bodies meant that later exhumation and identification would be impossible.

The authors concluded that there was virtually no health impact of the dead bodies on survivors. Other studies found that there were no epidemics among the surviving population, and that most effects were on those who handled bodies in temporary morgues, where there were the expected variety of sharp-implement injuries and mucosal splashes with body fluids, along with heat stress and dehydration due to overuse of personal protective equipment such as respirators.

What Do These Findings Mean?

How efficiently bodies were handled after the tsunami varied widely across and even within countries. The authors conclude that much of this variety was because of a lack of national or local plans for such mass fatalities, along with a lack of practical field guidelines. There was little coordination of all of the different organizations involved. However, in some places bodies were handled very well. The authors drew on their findings to suggest guidelines for the possible future management of large numbers of bodies, and also suggested that further research should be done. Reassuringly, the large numbers of bodies did not cause problems for the survivors, so in the future survivors should be encouraged to systematically identify the dead rather than rushing to bury them because of fear of disease.

Additional Information.

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030195 .

• The World Heath Organization has a Web page that brings together much information on the tsunami and its aftermath

• News from the United Nations special envoy for the tsunami can be found on its Web site

• An article published by the Pan American Health Organization called “Disaster Myths That Just Won't Die”

• Field guidelines for managing mass fatality natural disasters developed by an international workshop following the tsunami

Introduction

Globally, there are at least six natural disasters every year that kill more than 500 people [ 1 ]. Although management of human remains is one of the most difficult aspects of disaster response, there are currently no technical guidelines for dealing with large numbers of dead bodies following natural disasters. Existing methods developed for transport accidents and acts of terrorism are not directly transferable as they are designed for a smaller number of victims within a criminal or international medico-legal framework [ 2 – 4 ]. Developing appropriate guidelines for natural disasters is further complicated by the absence of information about post-disaster management of the dead following previous disasters.

Experience from the last 25 y suggests that a common reaction following mass fatality natural disasters is fear that dead bodies will cause epidemics [ 5 , 6 ]. This fear has frequently been used to justify rapid burial of human remains in mass graves with no identification [ 7 ]. Consequences of such mismanagement include increased psychological distress for survivors and legal problems affecting inheritance, compensation, insurance, and re-marriage of spouses [ 7 – 9 ]. Diplomatic tensions may also occur when foreign tourists are involved.

The tsunami disaster in South Asia on 26 December 2004 was one of the largest natural disasters in recent times ( Table 1 ). Management of the dead varied remarkably between affected countries, with the biggest international forensic investigation in history following a natural disaster mounted in Thailand, while in other countries, local authorities were left to cope as best they could. The size of the disaster and the different responses provided an important opportunity to systematically document and learn about methods for managing human remains following large natural disasters. In this paper we present our findings from three case studies in Indonesia, Sri Lanka, and Thailand, and make recommendations for future disasters.

Natural Disasters That Have Caused at Least 100,000 Deaths between 1900 and 2005

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We used a descriptive multiple-case study design [ 10 ]. The study was deliberately designed to compare and contrast the management of a large number of fatalities in different countries affected by the tsunami. Each case was a different country. Our resources enabled us to select three countries. We therefore selected countries with (1) a large number of fatalities caused by the tsunami and (2) different levels of sophistication used to manage the dead.

At the beginning of the study we determined to examine four parameters: (1) methods of body recovery and storage, (2) methods of victim identification, (3) methods of disposal of human remains, and (4) public health issues associated with the management of a large number of dead bodies. Where possible, we used triangulation, whereby data were sought from different sources to supplement and validate observations. Several authors (P. S., C. P., Y. S., and D. V. A.) made participant observations while working as members of post-tsunami response teams in the affected countries. Semi-structured interviews using a checklist/question prompt were conducted with key informants by one of the authors (O. W. M.) between 18 February and 4 March 2005. Purposive sampling [ 11 ] was used to select individuals with operational and managerial responsibility for the management of the dead. Where face-to-face interviews were not possible, interviews were conducted by telephone or E-mail. Interviews were conducted in English or with the aid of an interpreter recruited in each country specifically for the study. In each country we sought published and unpublished documents (situation reports, official statistics, evaluation reports, technical documents, guidelines for victim identification, and public health reports) from national ministries of health and government offices, the World Health Organization (WHO), non-governmental organisations, and voluntary groups. We analysed field and interview notes thematically and inductively (generating ideas from the data), using the study parameters as a framework for analysis [ 10 , 11 ].

We selected Thailand, Sri Lanka, and Indonesia for this study. The number of fatalities in each of these countries has been estimated as 8,345, 35,399, and 165,708, respectively [ 1 ]. Participant observers (P. S., C. P., Y. S., and D. V. A.) spent at least 4 wk working in affected areas. Interviews were conducted with 40 key informants from the voluntary sector ( n = 9), ministries of health ( n = 8), military ( n = 6), WHO ( n = 5), police ( n = 5), hospital staff ( n = 4), and government officials ( n = 3). Reviewed documents included WHO situation reports ( n = 37) [ 12 ], evaluation or surveillance reports ( n = 4), and technical documents ( n = 4).

Body Recovery and Storage

Body recovery is the first phase of the management of dead bodies. In all countries it was characterised as being initially chaotic and uncoordinated, involving a large number of different actors. In Thailand, body recovery was done by foreign tourists, local volunteers, Thai non-governmental organisations that specialise in body recovery following disasters (Po-Tek-Tung Foundation and Ruam-Ka-Tan-Yu Foundation), the military, and the police. In Indonesia, the body recovery phase lasted several months ( Figure 1 ), and, under the coordination of the military, 42 different organisations were involved. In Sri Lanka, body recovery was done almost exclusively by the affected communities themselves. In all cases, bodies were taken to multiple locations, and relatives did not know where their family members had been taken.

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Districts include Pantai Barat, Pantai Timur, Aceh Besar, and Band Aceh.

(Source: Badan Koordinasi Nasional Penanggulangan Bencana Dan Penanganan Pengungsi—BAKORNAS PBP)

None of the countries had sufficient refrigerated storage immediately available. In Thailand, the only country able to mobilise large numbers of refrigerated containers, it took about 2 wk to provide about 100 containers needed to store around 3,600 bodies. Temporary burial in shallow trench graves (about 1 m deep) was used effectively to store about 600 bodies. Effective use of dry ice proved difficult: when placed on top of the bodies it damaged them because of its low temperature, while not providing sufficient overall cooling to stop decomposition. Handling large quantities of dry ice also caused many skin burns among individuals handling it [ 13 ]. However, it was found that an effective method was to build a small wall of dry ice surrounding a group of bodies, and then to cover the group with a tent or tarpaulin.

Identification

Victim identification differed considerably between the three countries. In Indonesia, simple visual identification was attempted in the first few days. However the sheer number of bodies meant that it was impossible to arrange viewing for all bodies or store the bodies for later identification. Nevertheless, the body recovery teams successfully identified over 500 victims using personal effects such as identity cards and jewellery, and even mobile telephone SIM cards.

In Sri Lanka, the Centre for National Operations (an ad hoc governmental disaster management committee) mandated that local authorities take photographs and collect fingerprints of all the victims. However, because of damaged communications infrastructure, these instructions only arrived after 2 or 3 d, by which time decomposition had distorted facial features. In all, many hundreds of photographs were taken by police photographers, medical staff, journalists, and freelance photographers. In some cases, the films were not developed as there were insufficient funds to pay either the developer or freelance photographers. There were, however, outstanding examples, such as the hospital at Matara, where digital photographs were taken and basic information recorded (sex, height, and personal effects) for each body as it was brought into the hospital. Over 87% of the 547 victims handled by the hospital were identified [ 14 ]. Foreign victims, largely found in the eastern part of the country, were sent directly to the capital city Colombo, where an Identification Centre was established with support from the British government. During 2005, the Identification Centre also supervised six major exhumations to search for missing foreigners who were buried along with Sri Lankan nationals. A total of 155 bodies were examined by the disaster victim identification team. Analysis of DNA and dental records was used to successfully identify these individuals, who came from 18 different countries.

On 27 December, the first Thai forensic teams, many travelling independently under their institutes, started arriving in the affected areas of southern Thailand. They rapidly set up basic identification facilities in local temples. During the first 7–10 d of operations, Thai forensic teams examined around 3,600 bodies. The examination included external examination, photography, and recording of all personal effects. Fingerprints were taken from about 600 cadavers. DNA samples were collected from almost all bodies during the first few days, and included hair and soft tissues and, later, ribs and teeth. During this initial phase, Thai forensic teams identified about 1,100 human remains and released them to the families. In addition, about 500 bodies were identified and released to relatives by local physicians and police without the support of forensic specialists.

After the first week, forensic teams from other countries started to arrive in Thailand. They formed an international disaster victim identification committee to work in collaboration with the Royal Thai Police [ 15 ]. In Phuket, the committee's information centre was established with the financial support of the Australian government. The Thai government decided to combine the efforts of the Thai forensic experts, the Thai Royal Police, and international disaster victim identification committee teams, and on 13 January the Thai Tsunami Victim Identification (TTVI) centre was established in Phuket [ 16 ]. In collaboration with Interpol, the TTVI established a central mortuary in Phuket, sponsored by the Norwegian government. It was decided to examine or re-examine all 3,777 remaining victims using Interpol's standard protocol [ 17 ]. This included external examination, personal effects, photographs, fingerprints, forensic pathological examination, dental examination, and DNA sampling from bone and teeth. As of 27 July 2005, 7 mo after the disaster, TTVI had identified 2,010 victims, with over 1,800 cadavers remaining unidentified [ 18 ]. Sixty-one percent of victims were identified by TTVI using dental examinations ( n = 1,235), 19% using fingerprint records ( n = 378), 1.3% using DNA analysis ( n = 26), and 0.3% using physical evidence ( n = 6). In a further 18% of cases ( n = 365), more than one type of evidence was used [ 19 ].

Disposal of Human Remains

In Thailand, unidentified victims were stored in refrigerated containers during identification activities. Bodies that were identified were disposed of by cremation or burial according to local custom. Bodies of foreign victims were repatriated by their respective embassies. Around Banda Aceh, Indonesia, there were 14 mass graves, the largest, at Lambarro, reportedly containing 60,000–70,000 victims. Finding suitable government land for these large graves was difficult, and in some instances graves were sited very close to communities. In the areas surrounding Banda Aceh, smaller village-level graves were often used. Many were constructed rapidly, sometimes within the village itself. This has caused difficulty for returning survivors wanting to exhume and re-locate the graves to outside the village. In many rural areas, there was no formal body recovery and disposal of remains. In Sri Lanka, most human remains were buried after 3 or 4 d. Common graves, in which bodies were buried haphazardly in several layers, were sited largely within existing cemeteries. However, within some Muslim communities the deceased were buried within the first 24 h according to custom, making it difficult for the local authorities to identify and count the dead. Additionally, there were concerns that some of the deceased, who were buried as Muslims, may have been from other religious groups.

Health Impact from Dead Bodies

Shortly after the tsunami, WHO and national governments established early warning disease surveillance. No epidemics among the surviving populations were identified in the weeks after the tsunami [ 20 ]. In Banda Aceh, Indonesia, it took some 2 mo to bury the thousands of bodies ( Figure 1 ). In spite of the prolonged presence of dead bodies, no epidemics occurred [ 21 ]. Among individuals handling human remains (recovery, identification, and disposal), we did not identify any reports of “occupational” infections. A health and safety assessment of temporary morgues in Thailand by the United States Centers for Disease Control and Prevention and the Thai Ministry of Public Health reported sharp-implement injuries and mucosal splashes with body fluids as well as heat stress and dehydration due to overuse of personal protective equipment such as respirators [ 13 ]. A questionnaire survey conducted by the Thai Ministry of Public Health of around 200 individuals involved in body recovery did not identify any reports of infectious disease (S. Sirituttanapruk, personal communication). Back injuries, caused by lifting bodies into trucks, were reported by Indonesian military. Body recovery teams faced potential injury risk from working among debris, especially from earthquake-damaged buildings. In Sri Lanka, most dead bodies were taken to local hospitals, which had an indirect health impact by disrupting the provision of medical assistance to survivors and threatening to close hospitals because of the smell of decomposition.

Coordination and Preparedness

In each country, a large number of individuals and organisations were involved in managing the dead. Body recovery involved the affected community, voluntary organisations, the police, and the military. Doctors, medical staff, and forensic specialists were involved in death certification and collecting post-mortem data. National police forces and consulates or embassies were involved in collecting ante-mortem data (information about the deceased collected before death, such as dental or fingerprint records). Disposal of the bodies was done by the military or police, who also had legal responsibility for victim identification. No single person or organisation had a clear mandate to coordinate the process of collecting, identifying, and disposing of the dead, either nationally or locally. None of the countries had mass fatality plans.

The technical and logistical challenges of recovering and identifying victims after the tsunami were exceptional. The hot climate increased the rate of decomposition: bloating and discolouration of the human face rendered visual identification almost impossible after 24–48 h. Odours from decomposition caused concern about epidemics, and led local communities and national authorities to sanction mass (unplanned) burial without identification. Refrigeration for preserving human remains was not available soon enough, and no country had sufficient forensic capacity to identify thousands of victims. Lack of national or local mass fatality plans further limited the quality and timeliness of response, as did the absence of practical field guidelines or an international agency providing technical support.

Strengths and Limitations

Unlike study designs that make statistical inferences about a population, case study designs are suitable for describing and understanding why events occur and for generating hypotheses for future study. Therefore, rather than select cases to be “representative”, we selected cases to highlight a range of experience. A case study design was especially appropriate in this situation because we had no previous information about how the management of mass fatalities is undertaken following natural disasters (and hence no a priori hypotheses to test).

Conducting research during a humanitarian emergency presents many challenges. For example, individuals from relief agencies and governmental bodies have heavy workloads and are under considerable stress. Consequently, allocating time to participate in research activities may be of secondary importance. The stressful nature of disaster response leads to a high turnover of staff, and some of the key informants were no longer available for interview during our fieldwork. We attempted to contact these individuals by telephone and E-mail, but this was not always possible. Finally, we found that the management of dead bodies was politically very sensitive, both at local and national government levels. For these reasons, it is likely that some key informants were not included.

Storage, Identification, and Burial

Cold storage is vital for preserving evidence for identification. None of the countries could quickly mobilise sufficient refrigerated containers after the tsunami, and in Thailand, where refrigerated containers did eventually become available, most of the bodies had decomposed considerably by that time. The use of dry ice was reasonably effective, but it was difficult to manage, logistically intensive, and a significant cause of work-related injury. An alternative is normal ice (frozen water), as used after the Bali bombing in 2002 [ 22 ]. However, large quantities of melted water are produced that contain products of decomposition, which are likely to create additional management problems [ 22 , 23 ]. For large numbers of dead bodies, the most practical option is temporary burial in trench graves. The temperature underground is lower than at the surface, and burial acts as “natural refrigeration”. At 1.2 m depth, bodies have been well preserved for several months [ 24 ]. However, this approach must include careful recording of the location of each body and good communications with the public and media, who may mistakenly interpret this as disposal of victims without identification.

The simplest form of identification used after the tsunami was visual recognition and photographs of fresh bodies. In the absence of cold storage, this needs to be done rapidly. After 24–48 h without cooling, gases build up within the body, swelling the face and lips and forcing the tongue out of the mouth, making visual identification unreliable. The epidermis detaches from the body, leaving un-pigmented skin, giving the appearance of a white cadaver, even in dark-skinned individuals [ 25 ]. Further, while visual identification is relatively simple, it will result in some misidentification. Injuries to the body, or the presence of blood, fluids, or dirt, especially around the head, will reduce the chance of correct recognition. Following the Bali bombing, visual identification was incorrect in about one-third of victims [ 22 ]. The effectiveness of this method following natural disasters is unknown, although reports from one hospital in Sri Lanka suggest that it can have good results [ 14 ].

Forensic techniques such as dental, fingerprint, and DNA analysis are effective because they can identify decomposed or damaged bodies. However, for large disasters they require many trained specialists and are resource intensive. Most importantly, these methods are only useful if comparative data are available. While fingerprint data are recorded for Thai citizens when identity cards are issued, and many Western victims had dental records, comparative data may be scarce in many parts of the world. Few countries have the capacity for DNA collection and analysis following large natural disasters. DNA identification is expensive, technically demanding, and logistically difficult to implement on a large scale [ 2 ]. In the case of the tsunami in Thailand, it proved to be a relatively unimportant method of identification. DNA identification should not be considered as a first-line method of identification, but rather should only be implemented when physical, fingerprint, and dental methods have been unsuccessful [ 26 ].

Communal burial may be necessary when the number of human remains is large, as happened in Sri Lanka and Indonesia. Haphazard commingling of cadavers in mass graves makes future exhumations extremely difficult. Communal graves should be clearly marked, with bodies well organised and buried in one layer. All affected countries had difficulty finding locations for graves while considering the wishes of the local community, access for relatives, and land ownership. Although few cremations took place in the countries studied, they should be avoided because they make identification exceptionally difficult, require large amounts of fuel, and rarely achieve complete incineration, necessitating burial of partially burned cadavers.

Health Risks

The fear that dead bodies will cause epidemics among survivors, often encouraged by the media, prejudices proper handling and identification [ 6 , 27 ]. The unpredictable and chaotic nature of disasters means epidemiological evidence about associated infections is unavailable. A risk assessment suggests that the risk is small for members of the public and is primarily due to diarrhoea from drinking water contaminated with faecal matter from dead bodies [ 28 ]. This assessment of low risk, along with anecdotal observations over the last 20 y [ 6 ] and the absence of outbreaks in Banda Aceh despite the presence of several thousand bodies, should be considered the most convincing evidence to date that dead bodies pose a negligible threat to the general public after natural disasters.

Individuals who handle the dead (recovery, identification, and disposal) may be exposed to blood, body fluids, or faeces that contain chronic infections such as hepatitis B and C, HIV, tuberculosis, and gastrointestinal pathogens [ 28 ]. Simple precautions such as wearing gloves and washing hands will reduce transmission and hence reduce risks considerably. We did not identify any reports of “occupational” infections among body handlers. However, considering the relatively long incubation period for blood-borne infections and the low likelihood of testing among these individuals, it may have been too early to detect their incidence. Long term follow-up of this group is needed.

None of the countries had a single organisation with jurisdiction for recovery, identification, and disposal of bodies. Not only did this cause tension, but also added to the confusion and stress of relatives searching for family members. The lack of mass fatality plans meant that these issues had to be worked out during the response.

Recommendations and Conclusions

The South Asian tsunami in 2004 was an extreme natural event resulting in many thousands of fatalities. Several important lessons can be highlighted for future disasters ( Box 1 ). Until now, the failure to document and learn following mass fatality natural disasters means that similar mistakes occur time and time again. In May 2005, WHO, the Pan American Health Organization, and the International Committee of the Red Cross/Red Crescent convened an international workshop in the city of Lima, Peru, to share the experience of the tsunami and other previous disasters and to develop a first responders' manual for mass fatality natural disasters. These practical field guidelines were published in April 2006 [ 29 ].

Box 1. Recommendations for the Management of the Dead after Natural Disasters

Health Impacts

• The health risk to the general public of large numbers of dead bodies is negligible

• Drinking water must be treated to avoid possible diarrhoeal diseases

• Body handlers should follow universal precautions for blood and body fluids, wear gloves, and wash their hands

Body Storage

• Refrigerated containers provide the best storage, if available

• Temporary burial in trench graves can be used if refrigeration is not available

Body Identification

• Visual recognition or photographs of fresh bodies are the simplest forms of non-forensic identification and should be attempted after all natural disasters

• If resources and comparative data are available, simpler methods can be supplemented by forensic techniques (dental, fingerprint, and DNA analysis)

Body Disposal

• Communal graves may be necessary following large disasters

• Bodies should be buried in one layer to facilitate future exhumation

• Graves should be clearly marked

Coordination

• A named person/organisation should have an agreed mandate to coordinate the management of dead bodies

Preparedness

• Mass fatality plans should be included in national and local disaster preparedness activities

• Systematic documentation about how the dead are managed in future disasters is needed to learn from them

Communications

• Close working with the media is needed to avoid misinformation and to promote the rights of the survivors to see their dead treated with dignity and respect

Management of the dead has important socio-cultural implications, and emergency response should not add to the distress of affected communities through inappropriate handling and disposal of the victims. Promoting the rights of the survivors to see their dead treated with dignity and respect requires guidelines and technical support, which must be informed by further field research ( Box 2 ). Moreover it is important that the international community promotes the rights of victims and communities by including standards for the management of the dead in existing humanitarian Sphere Project guidelines [ 30 ] (the Sphere Project is a collaboration of over 400 organisations that agree on minimum standards in disaster relief). Finally, no country has sufficient capacity to respond to very large disasters, and networks of countries, forensic institutes, and international agencies such as Interpol and WHO are needed to provide assistance for the management of the dead following future disasters.

Box 2. Areas of Further Research in the Management of Dead Bodies following Natural Disasters

• Different methods of body storage where refrigeration is not available.

• Hydrological characteristics of mass communal burial and measures to avoid groundwater contamination.

• Epidemiological studies of infectious and non-infectious health risks for individuals recovering and identifying dead bodies.

• Methods for victim identification in situations where specialist forensic support is limited or unavailable, especially using visual and fingerprint identification.

• Strategies for developing regional and international forensic capacity and resources.

• Systems and protocols for managing information about the dead and missing.

• Social and cultural impacts of bereavement and the imperative to identify missing relatives and friends.

• Social and cultural acceptability of technical approaches for identification.

• Community-level approaches to disaster preparedness and response with regard to the management of the dead.

Acknowledgments

We would like to thank Jean Luc Poncelet and Ciro Ugarte at the Pan American Health Organization. Claude de Ville de Goyet provided valuable comments about the study protocol, facilitated the fieldwork, and provided comments on the paper. William Black at the Pan American Health Organization and Katri Jalava from the European Programme for Field Epidemiology Training provided comments on drafts of this paper.

Author contributions. OWM and ES designed the study. OWM conducted the interviews. PS, CP, YS, and DVA provided data from field observations. All authors contributed to the analysis and writing of the paper.

Abbreviations

Citation: Morgan OW, Sribanditmongkol P, Perera C, Sulasmi Y, Van Alphen D, et al. (2006) Mass fatality management following the South Asian tsunami disaster: Case studies in Thailand, Indonesia, and Sri Lanka. PLoS Med 3(6): e195. DOI: 10.1371/journal.pmed.0030195

Funding: This project was supported by a grant from the Pan American Health Organization. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Open Access

Peer-reviewed

Research Article

Mass Fatality Management following the South Asian Tsunami Disaster: Case Studies in Thailand, Indonesia, and Sri Lanka

* To whom correspondence should be addressed. E-mail: [email protected]

Affiliation Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom

Affiliation Department of Forensic Medicine, Faculty of Medicine, Chiang Mai University, Chaing Mai, Thailand

Affiliation Department of Forensic Medicine, University of Ruhuna, Galle, Sri Lanka

Affiliation World Health Organization, Banda Aceh, Indonesia

Affiliation Pan American Health Organization, Washington, District of Columbia, United States of America

Oliver W Morgan,
Pongruk Sribanditmongkol,
Clifford Perera,
Yeddi Sulasmi,
Dana Van Alphen,
Egbert Sondorp

Published: June 6, 2006
https://doi.org/10.1371/journal.pmed.0030195
Reader Comments

Methods and Findings

Conclusions

Citation: Morgan OW, Sribanditmongkol P, Perera C, Sulasmi Y, Van Alphen D, Sondorp E (2006) Mass Fatality Management following the South Asian Tsunami Disaster: Case Studies in Thailand, Indonesia, and Sri Lanka. PLoS Med 3(6): e195. https://doi.org/10.1371/journal.pmed.0030195

Academic Editor: Bala Balasubramaniam, Health Action International Asia Pacific, Sri Lanka

Received: November 23, 2005; Accepted: January 18, 2006; Published: June 6, 2006

Copyright: © 2006 Morgan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: TTVI, Thai Tsunami Victim Identification; WHO, World Health Organization