NAGAPATTINAM, India -- Six hours after the tsunami ravaged this coastal town, J. Radhakrishnan drove through the gates of the government hospital to lead the relief effort. He knew almost nothing about what was needed. Telephone lines and electrical facilities were destroyed, making it impossible to get reports. Fishing boats flung onto land blocked roads to many villages. Half the hospital was under water. The other half had become a morgue.
Radhakrishnan, an Indian health official, figured the hospital would be overwhelmed by hundreds more bodies and seriously injured people, whose care would absorb most of the attention. He was right about the bodies -- more than 6,000 people died in this district alone. But in what has emerged as a crucial factor in the success of the relief effort here and around the rim of the Indian Ocean, he was wrong about the injured. The tsunami was ruthlessly exact in its selection of victims: Most people either drowned or escaped unhurt.
Women in Nagapattinam, India, depend on a relief center for clean water more than a month after the tsunami struck. More than 6,000 died in the district.
(Peter S. Goodman -- The Washington Post)
"We saw very few serious injuries," Radhakrishnan said. "There was no in-between."
That goes a long way toward explaining how the global relief effort has managed to stave off disease and hunger following a natural disaster that left about 153,000 people dead, tens of thousands listed as missing and millions more homeless, according to official statistics. The Washington Post conducted a month-long examination in the four hardest-hit countries -- Indonesia, Sri Lanka, India and Thailand.
With relatively few injured people to attend to, relief officials turned almost immediately to disposing of bodies in a sanitary fashion, distributing clean water, digging latrines and immunizing children.
"There's been no waterborne disease, not a single case of cholera, malaria, dengue fever, typhoid," said J. Stanley Michael, a health officer from the city of Chennai sent here to head the local public health campaign. "If there had been more injured people, the public health and preventive medicine effort might have been retarded and we might have had an epidemic."
More Dead Than Injured
In most natural disasters, the number of injured is typically three to five times the number of dead, experts said. In this case, the ratios were reversed. Most people hurt by buildings that collapsed in the earthquake or by the force of the subsequent wave were washed away and drowned.
In Nagapattinam, India's hardest-hit district, the wave injured fewer than 2,000 people, less than one-third the number of those killed, area health officials said. The pattern was similar in Indonesia, where more than 105,000 are dead and more than 100,000 are listed as missing.
In the days after the tsunami, as the magnitude of the devastation began to emerge, World Health Organization officials warned that the death toll from disease could eventually dwarf the number of dead from the wave. This week, U.N. relief officials said great progress had been made in preventing that outcome, even as U.N. reports showed malnutrition in one in eight children housed in refugee camps in the Indonesian province of Aceh on Sumatra island, the area closest to the epicenter of the undersea quake.
"We believe we succeeded in abating this second wave of deaths," Jan Egeland, the U.N. emergency relief coordinator, said in New York.
Despite enormous transportation obstacles -- particularly along the western coast of Sumatra and in southern and eastern Sri Lanka -- emergency shipments of food, water and temporary shelter reached most affected areas in the first five days after the disaster.
The flow of aid that was generated by $7 billion in pledges, however, remains uneven, with food and medicine reaching remaining relief centers but failing to reach many people who have returned home.
With more than 300,000 people still living in camps, disease remains a concern -- particularly in Aceh, where latrines have yet to be dug in adequate numbers and people are defecating on open land, sometimes near streams.
Never in modern memory has a natural disaster delivered such a lethal blow to so many different places at once, posing enormous challenges to relief teams. The sea surge came a day after Christmas, when many aid officials were difficult to reach and out of position to respond. In Indonesia, early reports suggested that about 4,500 people were killed and that the worst-hit areas were in India and Sri Lanka. Many foreign aid teams went initially to those countries, then altered their plans as the extent of the damage in Aceh emerged.
In Thailand, where the tsunami ravaged beach resorts and fishing villages, tens of thousands of people spent the first night camped in forests, without shelter, food or water, waiting in vain for help to arrive. In the Andaman and Nicobar island chain, about 800 miles east of India in the Indian Ocean, and along the devastated west coast of Sumatra, villagers subsisted on coconuts and bananas for three or four days before aid arrived.
Once the relief effort got underway, bottlenecks emerged. The U.N. World Food Program flew more than 400,000 tons of supplies into Indonesia in the first two weeks. The U.S. Air Force used C-130 Hercules transport planes to bring goods from Thailand. But a shortage of forklifts at the airstrip in Medan -- Sumatra's hub for the relief shipments -- and in Banda Aceh, the Aceh provincial capital, substantially delayed offloading. The Banda Aceh airport was overwhelmed, forcing some relief planes to wait up to seven hours for permission to land.
Above all, what the relief effort confronted was an unimaginable scale of death and devastation.
But what continued to astonish aid workers was the comparatively small number of injured.
When a team of 11 doctors from Singapore arrived in the Sumatran city of Meulaboh -- where 35,000 of 100,000 residents are estimated to have died -- they found only 20 people waiting for treatment at the lone surviving hospital, most of them with infected wounds and broken bones.
When Radhakrishnan, the Indian health officer, pulled in to the hospital in Nagapattinam with a convoy of 32 ambulances, he quickly discovered that what he most needed were trucks to collect the dead. There were 1,922 people listed as injured that day, but most had relatively minor problems. Most were treated for broken bones, cuts and bruises, then released. Almost immediately, the rescue effort shifted its attention to staving off hunger and disease. Trucks delivered aid to places reachable by road, while navy helicopters dropped shipments to other communities. "By nightfall on the first day, everyone had food and water," Radhakrishnan said.
On the second day, volunteers hacked a footpath around washed-up boats blocking the roads to two villages where 3,000 people had died on a three-mile strip of coast. The following day, the army arrived with bulldozers and cranes. By the fifth day, electricity had been restored. The state government set up floodlights, allowing the overwhelming work of body collection to proceed round-the-clock.
Stanley Michael, 31, the Chennai health expert tasked with averting disease, was consumed by concerns that the drinking water would be contaminated by all the corpses -- particularly after learning that the water table is as high as six feet below the surface here. First and foremost, he was concerned about cholera, an often-fatal disease that is endemic in the area and is spread in part by drinking contaminated water.
"I knew I was sitting on a time bomb," he said. "Once we had one case of cholera, it would have been four, then 100, 200 within a day. Thousands within two or three days."
The World Health Organization was recommending the use of an injectable cholera vaccine, but Michael doubted its effectiveness. The day after the tsunami struck, he sat at a desk in the health office and sketched out an alternative. Bodies would be placed in mass grave pits lined with multiple layers of bleaching powder, lime and soil, which would purify whatever fluid leaked through. Pipes would be inserted, allowing disinfectant to be poured in.
Local officials built 73 mass graves, the largest holding as many 800 bodies. "This is what prevented the epidemic," Michael said.
To assure drinking water quality, he handed out chlorine testing kits to his health officers. Wherever chlorine levels were not adequate, he instructed them to dump in more. He gave simpler contamination testing kits to village leaders.
By the third day, his teams were conducting blood smears to check for malaria and were injecting children with measles vaccine. Crews sprayed villages with insecticides. They found huge stocks of dried fish that had been soaked by the tsunami and were now breeding maggots that would sprout into houseflies. The fishermen wanted to keep the stocks and sell them as poultry feed. Michael ordered them destroyed.
Government crews aided mostly by Indian aid groups erected a network of 82 relief camps and set up tents. UNICEF dug latrines, further limiting the potential for disease.
The Challenges Ahead
Formidable challenges still remain. Aid workers worry that communities that had been self-reliant are now dependent on outside aid and have lost their resilience.
During a recent distribution of cereal mix in the village of Pattanachery by the Indian aid group Eficor, people pushed, shoved and hollered at one another as they waited in line for more than two hours. "I'm afraid there won't be enough," Chella Amma, 45, said as she guarded her place by pressing directly against the woman in front of her.
People in the area generally praise the Indian government for its response, but they are looking ahead nervously, hoping for a resumption of normal life, for a chance to rebuild homes and cook their own food.
The state government has talked of making loans and grants to fishermen to help repair boats or buy new ones, but no money has yet been offered. Some people are still living in camps run by aid groups, though most have moved to temporary housing units.
"I'm a fishermen. I can't do anything else," Dharmalingam Rangasamy said as he dozed on a woven mat on the ground next to his shelter.
Battles are shaping up here and in Sri Lanka over the rebuilding, with some saying that development will be barred near the shore. The construction of temporary housing has been slowed by a shortage of materials and bureaucratic complications in the allocation of land.
That all lies ahead. As Radhakrishnan paused by the beach on a recent afternoon, a month after the water surged, he took stock of where things stood in relation to what might have happened. "Considering the circumstances, the unexpectedness, India should be proud of how quickly we were able to restore things," he said. "We have a model to replicate."
Special correspondent Rama Lakshmi in New Delhi contributed to this report.