Rapid-reaction teams are responding to outbreaks of measles around the province and teams are spraying for malaria-bearing mosquitoes in the capital Banda Aceh while doctors struggle to cope with dozens of cases of tetanus.

All are waiting for the first deadly cholera outbreak as a desperate population searches for drinking water from polluted wells.

"I can't think of a situation where so many cards are stacked against the people," says Dr Muireann Brennan, a medical epidemiologist from the Centre for Disease Control (CDC) who specialises in preventing measles outbreaks in disaster zones.

"To have a child who survived an earthquake, a tsunami, the death of family members, rain, rain and more rain, terrible living conditions, only to die of measles is not acceptable."

Preventable diseases

Millions of children in the developing world die each year from preventable diseases such as measles, which proper immunisation programmes can reduce to little more than a three-day-long annoyance.

The Acehnese also suffer from
an ongoing separatist struggle

In countries including Indonesia, once lauded for its successful national child immunisation strategy, measles remains a leading cause of death among children. In 2002, measles claimed the lives of 660,000 youngsters, one-third of them in Southeast Asia.

Immunisation programmes around the country suffered from the Asian economic crisis, a situation further complicated by the government's devolving of responsibility for health services to local authorities four years ago. Since 1999, the number of cases of measles reported in Indonesia has risen five-fold.

The ongoing war between the Indonesian military and separatist rebels in Aceh and endemic corruption has further affected health services in the province. Measles immunisation has plummeted to between 20 and 40%, according to ministry of health statistics.

Prevention

Measles leaves depleted auto-immune systems vulnerable to opportunistic illnesses such as pneumonia and upper respiratory tract infections which thrive in the cool, damp nights of the monsoon season.

Workers from the UN and WHO
discuss health with the refugees

International humanitarian organisations are trying to prevent widespread outbreaks with an ambitious programme to immunise 1.1 million children between the ages of six months and 15 years. Vast quantities of vaccine are being distributed by truck, helicopter and boat to staging grounds in tsunami-affected areas.

Teams trained to inoculate children are on standby to fly or drive into areas where outbreaks have been reported.

Thus far there have been seven outbreaks but many parts of the province have seen little or no health services since the tsunami struck.

Struggle on

In order to prevent its spread, thousands of children in the areas where measles is reported must be reached within days to prevent a medical brushfire that would tear through a refugee camp and potentially claim hundreds of lives.

"We're really struggling to get ahead of these diseases," says Dr Brennan. "If you fall behind, you will never get ahead. It can be absolutely devastating. In south Sudan it is not unusual to find mortality rates of 20 to 30%."

The potential for a breakout of the lethal Plasmodium falciparum malaria is growing with each passing day, as monsoon rains turn fields and town sites erased by the tsunami into breeding grounds for the Asian Anopheles sindiactus mosquito that transmits the deadly disease.

Mosquitoes

"The number of mosquitoes is growing exponentially ... hundredfold increases in a short period," says Richard Allen, a former head of malaria response at the World Health Organisation whose organisation Mentor Initiative specifically targets malaria control.

"We do not normally expect to see malaria so early in the season but there have been reports of many cases in the camps just in the past week"

Richard Allan,
Mentor Initiative

"We do not normally expect to see malaria so early in the season but there have been reports of many cases in the camps just in the past week. This is the best chance we have to prevent deaths rather than watching tens of thousands die. This is a disease that will kill more people than wars and bullets."

Mentor Initiative has begun spraying the interiors of homes in the Banda Aceh and hopes to spread its operations throughout the province.

Some malaria prevention strategies focus on killing the mosquito in its larval stage which requires extensive ground and aerial fogging.

Emergency conditions

In emergency situations such as Aceh, Allan says, the best technique is to kill the mosquitoes after they have drunk blood. Too heavy to fly properly, the insects, which typically bite people in their homes, head for the nearest wall to digest and reduce their load.

Spraying the walls with chemicals and distributing insecticide-treated plastic sheeting to the camps will ultimately reduce the number of mosquitoes. With sufficient stores of the right drugs, those who develop falciparum malaria, the only variety that kills, can be treated and make a full recovery, Allan said.

Health officials are also bracing themselves for a dramatic spike in the number of tetanus cases. Fatal in up to 80% of cases, it produces agonising spasms and rigidity in patients.

An Acehnese boy receives his
tetanus shot

"We are not seeing the explosive rise in tetanus cases yet but it has a latency period of three weeks so the tide could be coming soon especially as the rebuilding starts and people come into contact with things like rusty nails and so on," says Dr Anton Chang, who has seen four patients die in the past few days.

"We are doing our best to provide 24-hour care but we are only 10 (staff) here. I don't know how we will we cope if we get many more.

"This is a war zone, it was a war zone and it is a disaster area," says Singaporean physician Dr Chang, whose team is struggling to keep alive 17 young people suffering from tetanus, roughly one-quarter of the cases reported province-wide in the wake of the tsunami. "We are preparing for the worst."