Emergency on the Subcontinent

This article was written with assistance from Beth MacNairn and Lea Radick 

John Lancaster is a member of the Board of Handicap International’s U.S. national association and serves as the Treasurer of the newly formed Handicap International Federation. He recently served as the executive director of the National Council on Independent Living in Washington, D.C.  John was the executive director of the President’s Committee on Employment of People with Disabilities under the Clinton administration. He spent four years in Vietnam working with the Government and National Assembly to develop laws to protect the rights of persons with disabilities. He and his wife, Christine, live in Potsdam, New York. 

On December 26, 2004, at 6:58 am, an earthquake measuring 9.0 on the Richter scale struck Indonesia off the west coast of northern Sumatra. The earthquake triggered a tsunami, which caused extensive damage in Indonesia, Sri Lanka, Thailand, India, the Maldives, some parts of Malaysia, as well as Myanmar, the Seychelles, Somalia and Tanzania. In total, 12 countries were affected by the disaster, according to the United Nations Office for the Coordination of Humanitarian Affairs, with Indonesia and Sri Lanka suffering the highest casualties and the greatest devastation. In the Aceh province of Indonesia along the archipelago’s Indian Ocean coastline, an estimated 200,000 people died and 400,000 were left homeless, according to Handicap International.

The international humanitarian aid community quickly launched a massive and, at times, poorly coordinated emergency response to support the victims and help the most affected regions rebuild and recover. UNICEF’s 2008 Humanitarian Action Report highlighted the unprecedented challenges faced by the international humanitarian assistance community in response to the 2004 Indian Ocean earthquake and tsunami and the resulting lessons learned, such as the need for “greater predictability, accountability and leadership in humanitarian action.” A report completed in May 2006 by the United Nations General Assembly Economic and Social Council confirmed the coordination challenges faced by governments and humanitarian actors, but characterized the relief response as disjointed given that it was “not predicated on joint needs assessments by agencies, bilateral donors, and governments.”

Although a massive humanitarian crisis, such as the Indian Ocean tsunami or Haiti’s January 12 earthquake, results in suffering and loss of life, infrastructure and livelihoods, the scale and scope of such crises are also opportunities for the international relief community to analyze the weaknesses of previous responses and to apply the lessons learned to current and future crises. 

Eleven days after the tsunami struck, Handicap International’s assessment team arrived in Aceh on a fact-finding mission.  Ten days later, other professionals joined the effort to launch an urgent medical response for the injured. Initially, activities were conducted in the main hospitals of the province with some later follow-up in the first provisory camps and settlements. The initial objective was to provide physical rehabilitation to people who were most in need of post-medical rehabilitation and to strengthen the local capacity to meet these specific needs. Part of the objective was also to assist persons with disabilities who were affected disproportionately by the disaster. 

Over the course of 2005, Handicap International’s activities changed from direct intervention by expatriate physical rehabilitators in hospitals to decentralized health care in camps, community health care centers or “puskemas” and even in homes.  The organization’s focus shifted to providing training to reinforce the skills of local personnel. This transition from direct intervention to decentralized health care occurred over the duration of three distinct, yet interconnected, phases of intervention: An emergency phase (January 2005 through February 2005); a post-emergency phase (March 2005 through early October 2005); and a longer-term development phase, which began in October 2005 and continues today.

After the tsunami, health authorities in Banda Aceh were unable to cope with the large number of people affected and injured by the tsunami because of their own human and material losses. Handicap International’s first assessment missions in early January 2005 identified a significant need for physical rehabilitation in the hospitals the staff visited for patients suffering from lower-limb wounds, hand injuries, fractures, severe infections with a high risk of further amputation and respiratory infections. National and international medical staff confirmed this need. During this part of the emergency response, Handicap International was the only nongovernmental organization (NGO) providing rehabilitation.

Capacity building of local physical rehabilitation providers began in July 2005, during the post-emergency phase of Handicap International’s intervention in Indonesia, and continued throughout 2006 and 2007. Training sessions were conducted for teachers, clinical physical rehabilitators, and physical rehabilitation students. Paradoxically, the devastation inflicted by the tsunami offered a unique opportunity to ensure that renovated or new buildings conformed to international accessibility standards. This was a huge advantage not only for people with disabilities, but also for people with reduced mobility, such as the elderly or persons with chronic diseases.

Four major lessons emerged from external and internal evaluations of Handicap International’s emergency and post-emergency response December 2004 tsunami in Indonesia. Two of the lessons point to the need for rapid mobilization of (1) appropriate staff and (2) funds in the event of a disaster. Time matters in an emergency, in terms of the ability to both saves lives and lessen disabilities.  The other two lessons are (3) the importance of anticipating an appropriate immediate intervention, including community-based care and meeting the basic needs of those affected, and (4) the importance of transitioning to a longer-term development perspective.  All four of these “lessons” have now been applied to the organization’s current emergency response efforts in Haiti.  Below, is a fuller explanation of each.

Rapid mobilization of appropriate emergency response personnel

Before the tsunami, Handicap International had no staff on the ground in Indonesia.”The tsunami caught all of us off guard and we were really not prepared to respond to a disaster of this magnitude,” said Thomas Calvot, a physical rehabilitator and disability and emergency advisor for Handicap International.  “In retrospect, we could have used the three initial weeks following the disaster in more proactive way as this is the key time period in terms of life saving interventions,” added Calvot, who was part of Handicap International’s 2005 emergency response team in Indonesia.   

 Indeed, 11 days after the tsunami Handicap International’s emergency assessment team reached Aceh province. Six days later, the first emergency response team of physical rehabilitators arrived on January 16. Most of these expatriates were professionals drawn from the private sector in France, Belgium and Switzerland.

“While we were oriented toward quality interventions and mostly did very well, we were less focused on providing simple but immediate and efficient care and transferring practical care-giving skills to the families and caretakers of injured patients, who are instrumental in ensuring long-term follow-up,” Calvot said.  Handicap International recruited and sent 20 short-term expatriate physical rehabilitation staff for the emergency and post-emergency response in Indonesia.

However, the first assessment report in early January 2005 identified a significant need for physical rehabilitation in the hospitals visited — a need that was confirmed by national and international medical staff involved in emergency care management to the tsunami wounded, mainly lower limb and hands injuries, fractures, severe infections with high risk of further amputation and respiratory infections. The fact that Handicap International was the only international NGO providing rehabilitative support during the emergency phase demonstrates the advantages of including a disability specialist with experience in an emergency context in the first operational teams deployed.

To increase its capacity to intervene in natural and humanitarian disasters, Handicap International merged with Atlas Logistique, another international solidarity organization based in France, in 2006. At the time, Atlas Logistique had more than 13 years of experience in providing logistical solutions to humanitarian aid organizations. Handicap International’s emergency response division now has a four-person “flying team” of crisis specialists available at all times to respond to humanitarian emergencies, ideally within the first 72 hours. 

A roster of experienced, pre-validated short-term professionals allowed Handicap International to send a project manager specializing in the case-management of injured people in Haiti within 72 hours of the earthquake, as well as some of the first shipments of emergency supplies, including water and high-energy biscuits, to arrive in Haiti. The project manager was soon joined by a team of physical rehabilitation professionals and logisticians. Within eight weeks after the earthquake, Handicap International had sent 90 appropriate and experienced professionals to Haiti. By early May 2010, the team had grown to more than 400 staff members, including 70 expatriate staff.

For most humanitarian relief organizations, as well as the United Nations, the Indian Ocean tsunami was a pivotal experience that led to internal review of policies and procedures.  In a review of the literature produced on this topic, the principal factor cited was the need for mechanisms to improve both coordination and coherence amongst actors on the ground and more consolidated and predictable funding. In response, several mechanisms have been put in place over the intervening years, including humanitarian funding systems – the Consolidated Appeal Process (CAP) and Central Emergency Response Fund (CERF) – and, in 2005, the United Nations Cluster System with lead agencies covering needs in identified sectors, such as water sanitation and hygiene, health and shelter.

Rapid mobilization of funds for immediate crisis response 

Immediate funding that can be mobilized for the initiation of staffing, travel, procurement, and distribution of goods and materials is equally important and linked to the need for rapid mobilization of appropriate staff in an emergency. Before the tsunami response, Handicap International had enough internal funding to initiate a preliminary assessment and provide a limited response. However, activities were, for the most important part, delayed while the organization sought external funding from donors and the public. This further whittled away at the three-week target window critical for life-saving intervention.

Because of its experience in the tsunami, Handicap International now has in place an internal funding mechanism worth between US$250,000 to US$270,000 each year, for immediate and early emergency response. “We had more of a long-term development mind set then and the internal justification process took some time,” Calvot said of Handicap International’s establishment of an internal funding mechanism.

Having the organizational capacity to respond in the immediate aftermath of a disaster is critical in terms of saving lives. Equally important is knowing how to respond most effectively. A large part of the relevant and swift intervention following a disaster lies in the capacity to forecast future needs and to be able to anticipate the corresponding response without knowing exactly the type and extent of the needs.

The role of new or newer organizations and the power of individual giving are also potentially important factors in humanitarian response.  It is critical that their efforts be closely coordinated with the needs of the target population and the actions and efforts of the larger humanitarian response community.  Newer institutional actors should participate in the U.N. Cluster System to ensure their actions complement those of other organizations and are consistent with the goals and priorities of host country governments.

Although individuals are sometimes motivated to make in-kind donations of items, such as hygiene kits, blankets and food items, their goodwill is best directed toward cash contributions to organizations that have a presence in-country. By providing cash to support the activities of institutional actors, individuals can greatly multiply the impact of their giving by effectively combining it with other funding sources. Furthermore, organizations are more likely to purchase identified, appropriate and needed items, have the capacity to make larger scale and therefore less expensive procurement decisions and have the logistical capacity to ensure the timely shipping and delivery of needed items directly to beneficiary communities in the disaster zone.

Programming: Community-based care and provision of basic needs

Handicap International’s response to the injured victims of the tsunami in Aceh was initially focused on hospital-based care and the prevention of secondary disabilities. The organization did not have community focal persons or mechanisms identified that could provide a continuum of care and services for the injured and disabled after hospital discharge. Eventually, as the patient load in hospitals decreased, Handicap International began follow-up care in the communities. 

“After the tsunami, there weren’t that many injured people,” Calvot said. “Many had died and, yes, some were injured, but not as many as in Haiti, for example. In Indonesia, post-tsunami, the true medical emergency was a matter of three to four weeks,” he added. Handicap International’s intervention was primarily focused on assisting people with disabilities affected directly or indirectly by disaster. Therefore, people with chronic disease and the elderly were helped, but were considered less of a priority.  

Through the two assessments and a process of internal reflection on the organizational response, Handicap International now believes that its initial response in Banda Aceh could have more directly taken into account the basic needs of the most vulnerable populations and to ensure that protection measures were in place, such that these populations received the assistance needed. These observations have led to a greater and broader emphasis on a “basic needs approach” in emergency response programming.

“Initially, our intervention was specific-needs oriented, related to the treatment of injury and support in the field of disability, and, in retrospect, lacked focus on other vulnerable population like the elderly and persons with chronic diseases,” Calvot said.

Through this experience, Calvot explained, Handicap International now has greater appreciation for the need to address vulnerable populations as a whole, including those who are temporarily disabled, and to provide a balance of specific disability responses with basic needs, such as shelter, food and access to water. “We were expecting a lot of injured people and didn’t accurately anticipate that there would be a need for vulnerable persons to access livelihoods and other basic needs, for protection and for the mainstreaming of disability issues and directing resources to the camps,” said Calvot.

As a result of the internal and external assessments made of Handicap International’s tsunami response, the organization has implemented emergency programs with a broader focus on basic needs and ensuring intervention for the injured, persons with disabilities and other vulnerable people in both hospitals and in communities, particularly internally displaced persons (IDP) camps, simultaneously. 

Similarly, Handicap International now implements advocacy programming identifying both the rights and the needs of the injured, persons with disabilities and other vulnerable people with the larger international humanitarian community and with local governmental authorities, in communities, schools and within families. In Haiti, for example, Handicap International launched a hospital-based care and rehabilitation program within days of the earthquake, which was extended to community- and camp-based care within two weeks of the crisis.

International coordination and transition from disaster to development programming

Ensuring better coordination of international humanitarian aid, including better referral mechanisms among agencies, and ensuring a smooth and logical transition from disaster to development programming, were important lessons learned by both the international humanitarian aid community as a whole and by Handicap International as a new actor in emergency response in 2005[AP2] .  A considerable body of research has been compiled on exactly these lessons learned and the United Nations, through the Inter-Agency Standing Committee (IASC), regularly reviews the effectiveness of humanitarian response and reform measures. Nongovernmental organizations, governments and other stakeholders participate in these reviews and reports are published and presented in multiple fora.  The process is ongoing and each major disaster and corresponding humanitarian response presents an opportunity for introspection, assessment and innovation, not only for future responses but also, critically, for better approaches to risk reduction.

One of the main characteristics of Handicap International’s program in Indonesia was that development activities started very early during the emergency and post-emergency phases for two main reasons: First, disability is a long-term issue. Even if addressed in emergency contexts, sustainable solutions and services — particularly rehabilitation — must be available or secured.  For example, Handicap International’s decision to provide technical assistance to an ortho-prosthetic school in Solo for the upgrading of Indonesian orthotics and prosthetics technicians was seen as a precondition to further development of ortho-prosthetic services in Banda Aceh.

Beyond the specific situation of tsunami victims, a second challenge was to address the demands and needs of persons with disabilities who were deprived of adequate services as a result of the conflict that affected the province for many years. Handicap International very quickly decided to orient its support during emergency and transition phases to the development of local capacity for the rehabilitation of persons with disabilities through partnerships with local and national organizations and institutions.


The Indian Ocean tsunami was a significant event both for those affected and for the organizations and governments that responded, as this disaster marked a transition in the humanitarian landscape. The transition is evident in the global response to the January 12 earthquake in Haiti, as humanitarian actors seek to employ more efficient, effective and better coordinated responses to the massive injured, homeless and permanently disabled populations. 

For Handicap International, lessons learned in the tsunami response shifted the focus more definitively to that of a first responder in emergencies providing for the specific needs of persons with disabilities in all manner of disabling situations, including natural disasters. Its emergency response to the tsunami, particularly its response in Indonesia, as examined here, highlighted four primary weaknesses that Handicap International has since built on and turned to its advantage. Those weaknesses –the need for more rapid mobilization of emergency personnel, the inflexibility of funding, the need for community-based rehabilitation, and  the  disjointed transition among phases of emergency intervention — have been improved and streamlined into a much more efficient operation, as is evident in the programming currently in place in Haiti.

Handicap International’s evolution from a provider more focused on specific disability needs to a humanitarian aid actor covering the basic requirements of all victims of a natural disaster parallels a re-evaluation of the international humanitarian aid community at large. 

While not directly attributed to the 2004 tsunami, a report titled “Humanitarian Response Review,” was launched by the U.N. Emergency Relief Coordinator and the Under-Secretary-General for Humanitarian Affairs to assess the humanitarian response capacities of the U.N., NGOs, the Red Cross/Red Crescent Movement and other key humanitarian actors, including the International Organization for Migration, to identify gaps in the humanitarian aid community’s ability to respond adequately to crises, and to make recommendations to address its shortcomings.

This review, similar to the internal and external assessments of Handicap International’s emergency response to the Indian Ocean tsunami, identified one of the major challenges to be the ability of humanitarian organizations to “reconcile different, sometimes contradictory imperatives, to define the appropriate limits of accountability and to ensure that the accountability agenda is driven by the humanitarian principles and the needs of the beneficiaries[AP3] .” 

While all humanitarian organizations have mission statements and defined areas of specialization, broad or narrow, it is incumbent upon these actors to identify the actual needs presented in an emergency context while continuing to assess these needs as they evolve over time, with the full participation of local authorities and beneficiary populations. Organizations must concurrently assess their capacity, technically and otherwise, to respond to the sum of these needs and then, ideally, limit their responses to realistic interventions while coordinating with other actors to ensure that the full range of needed services and programs are offered to the target population in the emergency and transition phases of a crisis.   

This coordinating function is largely performed by the U. N. Cluster System, which was established in 2005 in the aftermath of the tsunami.  Equally as important are the ongoing efforts to improve the flexibility and rapidity of humanitarian response funding, which have also been implemented through a variety of mechanisms such as the CAP and the CERF. Although these systems have noticeable weaknesses in practice, they do allow organizations acting within a sector, such as health, to share information and resources, ultimately for the benefit of those in need.

 Another key finding of the U.N. review was that emergencies require a global vision to unite the various humanitarian organizations each implementing their individual initiatives. “The humanitarian system has developed sufficient tools and experiences to be able to go a step further and to establish and apply a limited number of benchmarks (and related indicators) to promote progress. Global benchmarks can be built on notions of effectiveness and relevance,” the report states. 

“For Handicap International, the tsunami was really a pivotal moment in fulfilling the organization’s original mission and vision to include humanitarian relief and response in a sustained, systematic and more comprehensive and effective way,” explained Wendy Batson, executive director of Handicap International’s U.S. national association. “We are now, five years later, an international federation with a presence in 60 countries dedicated to improving the lives of persons in disabling situations, whether caused by natural disasters, conflict or extreme poverty.”

Indeed, it is only with a comprehensive goal, employed through individual initiatives tailored to both general and specific populations in need that international humanitarian organizations will more effectively respond to humanitarian crises.  

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John Lancaster

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