MSF was among the first organizations to provide large scale assistance to victims of Cyclone Nargis that struck the Myanmar coastline on the night of May 2. However, one month after it devastated the Irrawady Delta in Myanmar, MSF teams are still encountering villages where survivors live in dire conditions and have not yet received any significant aid.

On the morning of Saturday, May 3, residents of Rangoon looked with disbelief at the damage done by Cyclone Nargis during the preceding hours; uprooted trees and piles of branches barring the streets; rooves crashed by falling trunks and pylons; walls brought down by flash floods. Never had the former capital of Myanmar experienced such a devastating phenomenon.

Even though, in the city's poor suburbs and further down south in the Irrawady Delta, Nargis' power had even more tragic consequences. Communication links were down but the little information that filtered out were all signs of a major catastrophy.

"We managed to send our first team to Pathein, in the Delta, on Monday and started first aid to victims further south the next day", recalled Frank Smithuis, MSF's Head of Mission in Myanmar.

Thanks to the immediate mobilization of its national staff, MSF was able to provide aid on a large scale from the very beginning. A total of 250 local doctors, nurses, and logisticians were soon working in the Delta, in the areas of Bogale, Labutta, Ngaputa and Pyapon. Teams travelled by boat from one village to another, bringing food, shelter, water and sanitation material, and giving hundreds of medical consultations.

"From the moment we left the boat, the villagers would come and follow us around. They'd help us to find a house to do consultations and set up the distribution. We saw a lot of patients with stress symptoms, aching limbs and hypertension, especially in villages where the destruction is on a massive scale and many people have been killed by the floods", said a 27 year old Burmese medical doctor who worked in the first two weeks in Ngapudaw, in the western part of the Delta.

As the first relief items were purchased locally, the need for a massive influx of food and equipment was obvious. On May 12, a first MSF cargo plane landed in Yangon, soon to be followed by four others, carrying a total of 500 tons of therapeutic food, plastic sheeting to build shelters, mosquito nets, pumps and water treatments units and more. These were loaded onto trucks, transported to the Delta and mostly transferred to boats for distribution in the affected villages.

MSF teams have progressively been able to reach the southern central part of the Delta. These remote areas and islands are accessible only by small boats or by foot. Villages there have basically been erased from the map and survivors are living in unimaginably hard conditions. Emmanuel Goue, MSF Field Coordinator, just returned from Setsan, a five-hour boat trip south of Bogale and described "a total devastation".

"A giant wave during the cyclone has simply flattened the area. Ninety percent of the houses have been destroyed. There are an estimated 21,000 people, including numerous children and elderly, who live in the middle of nowhere, in an ocean of mud. Everything has been broken and they have not seen any aid coming for one month."

The access issue

In relief operations such as this one, with a disaster comparable in scale to the 2004 tsunami, MSF would usually send to the field a large number of experienced international staff - doctors, emergency coordinators, water and sanitation experts... However, initial restrictions imposed by Myanmar authorities officially prevented foreign experts from working in the Delta in the first three weeks after the cyclone.

For instance, in the town of Bogale, MSF international staff were tolerated but could not carry activities in the periphery of the town. MSF could work with its national staff, but has insisted it needed more international staff in the field.

On May 23, UN Secretary General Ban Ki Moon came to Yangon, and announced that the Myanmar government had agreed to let international aid workers unhindered access to the Delta. A few days earlier, MSF had actually obtained formal authorization for eight international staff to go and carry activities in the Delta.

"That was a first, but obviously not enough," said Smithuis. "Given the scale of the disaster, we need more experts in the field. Our national staff are very capable, but they have no experience of working in emergencies. They have done a tremendous job, but they need expertise to support them."

International staff presence is also an added guarantee that aid remains independent and is distributed objectively. One month after the disaster, more travel authorizations for MSF expatriates have just been received.

MSF care for months to come

MSF medical staff have in the past month carried over 17,000 consultations, with an average of 500 per day in the last week of May. At first, more than half the patients were treated for injuries caused by the cyclone, but pathologies very quickly emerged that were linked to the dire conditions in which people lived.

Some MSF teams have seen a high number of respiratory infections and cases of diarrhoea, which could be linked to a lack of access to clean water, absence of shelters, exposure to heavy rains that continued to fall in May.

"In many areas, especially where death rates have been high, we are seeing more and more people suffering from mental health problems", said Alena Koscalova, MSF Medical Coordinator in Yangon. "Some can not talk anymore, others are highly depressed after they lost their loved ones. In the coming weeks, we will try to address this problem by giving trauma counseling and psycho-social support with mental health specialists."

Over a three month period, MSF expects to carry out around 50,000 consultations at a rate of 500 per day. A proportion of patients will have exit interviews to check their satisfaction with the care they have received. MSF aims to respond to any disease outbreaks within 24 hours of the report and to ensure that any patients with severe health problems will be referred to secondary level health facilities.

So far, no disease outbreak or alarming rates of malnutrition were reported by MSF's 36 mobile teams in the Delta.

Operations scope

Four weeks after the relief operations started, food, shelter, and access to clean water remain the biggest needs of the victims. Food supplies have been largely insufficient as specialized agencies have not been able to set up proper distribution channels and, in many areas, people have barely received enough to survive, if anything at all.

Tens of thousands of people have seen their houses destroyed, lost all their properties and food reserves and have to rely on external assistance. Wherever possible, MSF teams are meeting with each family to enquire about its needs and directly provide it with food and relief equipment.

MSF's objective in areas where it works is to provide the population with food rations of two kg of rice, 500 grams of pulses, cooking oil, and salt per family and per day. MSF is using the family lists available in each visit to ensure that people are receiving the right amount of supplies, and village representatives sign off the distribution reports.

Displaced families were moved out of their temporary settlements in schools and monasteries. They are now in overcrowded camps set up by the government in the periphery of the main urban centers or back to their villages where there is a lack of adequate assistance.

"The vastness of this operation remains our biggest challenge", says Vincent Hoedt, MSF Emergency coordinator in Yangon. "There are so many places to go, so many people that need to be served, there is an incredibly large amount of goods that have to be handled - shipped from Yangon, loaded, offloaded, distributed and tallied up. It is a huge operation and the challenge is actually keeping this immense machinery going."

Despite initial constraints in access to the affected areas, MSF has, as of today, provided support to 300,000 victims of Cyclone Nargis. But much remains to be done and the emergency is far from over.

"We sincerely hope that the UN and other international NGOs will now be able to quickly scale-up their presence and dramatically increase the level of food and relief assistance provided. There is a pressing need to send a lifeline to tens of thousands of people, especially those living in remote areas in the southern part of the Delta", said Arjan Hehenkamp, MSF Director of Operations, who came to Myanmar at the end of May to assess the situation on the ground.