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The Relief Effort

Shifting Gears to Tackle a 'Complex' Emergency

U.S.-Based Group, Used to Dealing With Man-Made Disasters, Makes an Exception

By David Brown
Washington Post Staff Writer
Wednesday, January 5, 2005; Page A10

JAKARTA, Indonesia, Jan. 4 -- Richard Brennan was supposed to be in Afghanistan this week. Afghanistan can wait. Unfortunately the same can't be said for Indonesia, which is where the Australian physician woke up this morning.

Brennan, 45, directs health programs at the International Rescue Committee, a humanitarian organization headquartered in New York. Normally, the IRC doesn't respond to natural disasters. Its specialty is the relief of man-made suffering, such as that seen in Kosovo, Afghanistan, Congo and the Darfur region of Sudan -- all places where Brennan has worked in the past decade.


Richard Brennan, right, at the International Rescue Committee office with Franklin Broadhurst and Gillian Dunn, emergency coordinator for Indonesia. (David Brown -- The Washington Post)

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But the organization is making an exception for the South Asian disaster. The IRC has worked for years with victims of civil unrest in Indonesia's Aceh province, which was hit the hardest by the Dec. 26 undersea earthquake and resulting tsunami. The disaster is taking on the characteristics of a "complex humanitarian emergency," the term relief workers give to the manifold human miseries caused by civil war, genocide and forced displacement of large populations. It's a new expression in the vocabulary of a new science -- the science of disaster relief.

The Indonesian tsunami may prove to be an important milestone, and will certainly write a chapter in the manual of what to do when such events occur in the future.

The province of Aceh, the northwestern portion of the island of Sumatra, is now full of people trying to help the victims of the Dec. 26 disaster. Assistance is coming not only from international relief organizations such as the IRC, but from the Indonesian government, U.N. agencies and the civilians and militaries of many countries.

In practical terms, help means providing water and sanitation, medical care, shelter and food for possibly hundreds of thousands of people. Coordination among dozens of organizations will be a task almost as difficult as the relief effort itself.

The IRC will be part of that effort. The role it will play -- and the outcome -- are uncertain at this point. But few relief organizations can argue that they know better than the IRC, with its 71 years of experience and programs in 25 countries, what to do in complex emergencies.

'All Systems Go'

Rick Brennan first learned of the tsunami two days after Christmas while buying bagels in a coffee shop in Indianapolis, where he spent the holiday with his girlfriend. He saw a story on the front page of the newspaper.

"I didn't really have a good idea of the scale of the disaster," he recalled. But by the time he was back in his New York office a day later, one thing was clear. "It was all systems go" for a big response by his organization, he said.

The IRC already had 21 people in Aceh, nearly all of them Indonesian nationals. Miraculously, 20 were alive.

Like many nongovernmental organizations, or NGOs, doing relief work, the IRC relies heavily on people who are not direct employees. Those outsiders are paid if they work a month or longer, so they are not volunteers in the classical sense. However, many take leave from their usual jobs and work stints at the IRC for far less than they normally earn.

It was through such an arrangement that Brennan saw his medical career change from that of an up-and-coming academic physician to one in which, he says, "I'm more likely to bump into someone on the streets of Kabul that I know than on the streets of New York, where I live."

Brennan, who has an open face that puts people at ease and seems to be the kind of person who is patient at times of stress, grew up in Sydney. His mother was a housewife and his father a disc jockey at a popular AM station who later became a talk-radio host and program manager. Brennan went to medical school at the University of Sydney, trained as an emergency physician, then did a two-year research fellowship at a medical school in upstate New York. Back in Australia in 1993, he saw an advertisement seeking emergency room doctors willing to work in Bosnia.

He went for four weeks that year and six weeks in 1994, helping to set up an emergency room and ER residency at a hospital in Zenica. He recalled the work as being both difficult and gratifying. After one chaotic, translation-clogged trauma case with a bad outcome, he set up daily mass-casualty practice sessions with mannequins for his team of an intern and two nurses.

"They complained about it, but each day they got better," he recalled. "About a month later we had six people come in at once who'd been wounded by a mortar shell. They responded like clockwork -- evaluation, triage, resuscitation, everything. I was amazed by what they did."

After a third tour in 1995, he quit his job at Westmead Hospital, an 800-bed medical center in Sydney where he was the director of the emergency medicine residency. He got a master's degree in public health after a year of study at the Johns Hopkins School of Public Health.

Over the next few years, he helped in the mass-casualty planning for the Summer Olympics in Atlanta, evaluated the International Red Cross's program in Tajikistan and trained military doctors in the response to complex emergencies under the auspices of Tripler Army Medical Center in Hawaii. After he spent several months evaluating the IRC's medical activities, the organization hired him in 1999 to run its health unit.

It's the longest job he's ever held. It also has taken him out of clinical medicine. Except for two intravenous lines he started on collapsed passengers on his ceaseless air travels, he hasn't put hands on patients in several years. However, what he and people like him do is emergency medicine -- writ very large, with an entire population as the patient.

Like work in the emergency room, disaster relief balances the desire to collect information thoroughly against the need to treat the patient quickly. A practitioner's most important skill is setting priorities. The work also requires guidelines and protocols, and many who work in the field say that no matter how important the moment's intervention is, the patient has a past and, in most cases, also a future -- and both need to be respected.

Mobilizing the Team

Brennan called or e-mailed about 20 people in the three days after he learned of the tsunami. He recruited a post-graduate fellow from Johns Hopkins, a private practitioner, an Australian surgeon, an ER physician from New York-Presbyterian, a public health physician in graduate school and a nurse recently back from two years in Afghanistan. The Centers for Disease Control and Prevention may lend the IRC an epidemiologist. Three other nurses and five physicians told him they might be able to go in a month or so.

The offers were so good that Brennan thought he would "hang back, do some more recruitment and keep an eye on other things," including work in Afghanistan, where he planned to go this week. "But my bosses said, 'You should go, just to help kick-start the process,' " he said.

A budget drawn up in less than a week estimates the organization will need about $7 million for the next six months in Indonesia. It has raised $2 million so far. It expects to get some of the rest from the U.S. government, which will spend much of its $350 million pledge by paying NGOs to provide relief.

Everyone coming in from overseas -- not only the medical professionals, but the logistics chief who will hire cars and rent houses and the administrator who will manage the whole operation -- has experience in complex emergencies.

"The science and practice of what we do has really advanced in recent years," Brennan said as he waited at John F. Kennedy International Airport in New York to take off with Franklin Broadhurst, IRC's chief water and sanitation engineer. "It's gone beyond people showing up and saying, 'Can I help?' We are no longer throwing food parcels off the back of the boat."

Five hours after arriving in the Indonesian capital, Brennan sat in the IRC office for the nightly 6 o'clock staff meeting. His brown canvas shirt, professionally laundered and lightly frayed at the neck and cuffs, still looked good after a day and a half of travel. Around a square of tables were members of the organization's rapidly expanding team -- Indonesian, Norwegian, American, Australian.

Midway through, Aitor Lacomba, an ethnic Basque who has directed the IRC's work in Indonesia for three years, joined the meeting. He had just flown back from Aceh.

"Today we recovered the body of one of our staff," he said. "Rosemary is dead." She cleaned the group's office in Aceh, which is currently surrounded by debris nine feet high that contains numerous corpses.

Many relief organizations are starting work in Banda Aceh, the provincial capital, Lacomba said, holding up a map of Sumatra. Some, such as Doctors Without Borders, already had clinics operating. But much of the central western coast remained unexplored since the tsunami, he said, as was the highland interior, which may have suffered earthquake damage.

Earlier, on the flight, Brennan acknowledged that inevitably "there is a bit of flag-planting" in the freewheeling, unregulated world of disaster relief. But he said he thought the IRC kept that to a minimum, and never forgot that "our primary objective is to meet unmet needs and to support local structures."

In that spirit -- and in the spirit of footprint-making if not flag-planting -- the group agreed that as soon as it got a few more experts in Aceh, it would direct its attention to those unclaimed places.


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