Cyclones, Tsunamis, and Human Health: The Key Role of Preparedness

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Oceanography Vol. 19, No. 2, June 2006
40
Cyclones, Tsunamis,
and Human Health
 e Key Role of Preparedness
Besides the many benefi ts of the ocean, human and other
populations living in coastal regions share in the risk for
meteorological and seismic hazards that originate from
the seas. Tropical cyclones (also known as typhoons and
hurricanes) and tsunamis represent the most powerful
and destructive of all marine hazards.
Tropical cyclones have caused an estimated 1.9 million
deaths worldwide during the past two centuries (Nich-
olls et al., 1995). During 1980–2000, an average of
11,800 deaths per year were attributed to cyclones (United
Nations Development Programme, 2004). The three
deadliest cyclones produced catastrophic loss of life:
300,000 deaths and 138,000 deaths in the Bangladesh cy-
clones of 1970 and 1991, respectively, and 100,000 deaths
in the Chinese typhoon of 1922. Sixteen of the 18 deadli-
est tropical cyclones occurred in the Asia-Pacifi c region.
Tsunamis have the potential to cause an enormous im-
pact upon the health of millions. Since 1945, more people
have been killed by tsunamis than by earthquakes (Noji,
1997; McCarty, 2002). In a 100-year period from 1895 to
1995, there were 454 tsunamis recorded in the Pacifi c, the
deadliest 94 killed over 51,000 people (Boyarsky and Sh-
neiderman, 2002). The 2004 Indian Ocean tsunami killed
nearly 300,000 and affected over 2,000,000 two million
people in twelve nations. (U.S. Geological Survey, 2005).
The human-health effects of cyclones and tsunamis
cannot be understated. In addition to the public health
and medical consequences of these disasters, the social,
cultural, and psychological impact of cyclones and tsuna-
mis have an enormous and long-lasting impact through-
out the world, and a direct effect upon human develop-
ment in general (see Miller case study, this issue). Table 1
compares the public-health impact of cyclone and tsu-
nami disasters.
Drowning during the impact phase of the disaster
causes the overwhelming majority of deaths from cy-
clones and tsunamis. Populations are at risk of death
simply by virtue of their physical proximity to low-lying
land situated near the coastline. However, there is signifi -
cant promise for the future in that nearly all these deaths
are preventable with the proper advance warning and
population evacuation. Very few drowning victims would
be expected to survive the initial inundation, even with
the added benefi t of fully adequate emergency-response
capacity. Preparedness is the key to preserving human life
in the setting of cyclones and tsunami disasters. All other
measures are less effective, less compassionate, and much
more expensive.
Whenever there is a disruption of routine public health
services (like that which occurs after a cyclone or tsu-
nami), there is the potential for secondary adverse health
effects to develop among the disaster-affected popula-
tion. The best opportunity to prevent or lessen secondary
health effects is during the emergency-response phase.
THE OCEANS AND HUMAN HEALTH
Oceanography Vol. 19, No. 2, June 2006
40
BY MARK E. KEIM
 is article has been published in Oceanography, Volume 19, Number 2, a quarterly journal of  e Oceanography Society. Copyright 2006 by  e Oceanography Society. All rights reserved. Permission is granted to copy this article for use in teaching and research. Republication, systemmatic reproduction,
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Oceanography Vol. 19, No. 2, June 2006 41
Oceanography Vol. 19, No. 2, June 2006 41
Preparedness is the key to
preserving human health in
the wake of cyclone and
tsunami disasters.

Oceanography Vol. 19, No. 2, June 2006
42
TROPICAL CYCLONES
AKA TYPHOONS AND
HURRICANES
Background
Tropical cyclones are low-pressure weath-
er systems that develop over the warm
waters of the oceans, typically between
the latitudes of 30°N and 30°S (Malilay,
1997; Williams, 1997). Cyclonic storms
with wind speeds surpassing 74 mph
(118 kph) are termed tropical cyclones.
Depending upon geographic location,
tropical cyclones are referred to as “hurri-
canes’’ in the North Atlantic, the Caribbe-
an, the Gulf of Mexico, the eastern North
Pacifi c, and the west coast of Mexico;
‘‘typhoons’’ in the western Pacifi c; and
‘‘cyclones’’ in the Indian Ocean and Aus-
tralasia (Malilay, 1997).
Because warm ocean water is neces-
sary to power cyclone formation, only the
planet’s midsection can conceive tropi-
cal cyclones. Wind circulation within a
cyclone is controlled by an approximate
balance between pressure gradient and
Coriolis forces; the bigger the pressure
differential, the faster the winds. Because
the direction of the Coriolis force with
respect to wind velocity is opposite in
the northern and southern hemisphere,
cyclones rotate in a counterclockwise di-
rection in the northern hemisphere and
a clockwise direction in the southern
hemisphere. A corollary is that cyclones
can neither form at nor cross the equa-
tor. Consequently, tropical cyclones are
constrained to form within two tropi-
cal belts: one above the equator (where
two-thirds of storms develop), and one
below the equator (Schultz, 2005).
Human-Health Impact of Cyclones
Mortality Trends
Prior to the implementation of early-
warning, evacuation, and shelter systems,
drowning from storm surge accounted
Mark E. Keim, M.D. (mkeim@cdc.gov) is
Medical Offi cer and Team Leader, Inter-
national Emergency and Refugee Health
Branch, National Center of Environmental
Health, US Centers for Disease Control and
Prevention, Atlanta, GA, USA and Clinical
Associate Professor, Department of Inter-
national Health and Development, Tulane
University School of Public Health and
Tropical Medicine, New Orleans, LA, USA.
Table 1. Public Health Consequences of Cyclones and Tsunamis
Consequence Cyclones Tsunami
Death rates Developed nations - Low
Developing nations - High High
Severe injuries (% among survivors) Few Few to moderate
Loss of clean water Widespread Focal to widespread
Loss of shelter Widespread Focal to widespread
Loss of personal and household goods Widespread Focal to widespread
Major population movements Rare Rare
Loss of routine hygiene Widespread Focal to widespread
Loss of sanitation Widespread Focal to widespread
Disruption of solid waste mgt Widespread Focal to widespread
Public concern for safety High High
Increased pests and vectors Widespread Focal to widespread
Loss and/or damage of health care system Widespread Focal to widespread
Worsening of existing chronic illnesses Widespread Focal to widespread
Loss of electricity Widespread Focal to widespread
Toxic exposures Possible Possible
Food scarcity Common in low-lying remote islands Common in early stages only

Oceanography Vol. 19, No. 2, June 2006 43
for an estimated 90 percent of cyclone-
attributable mortality in both developed
and developing nations (Malilay, 1997).
Storm-surge drowning deaths have
decreased markedly in developed na-
tions due to improvements in hurricane
forecasting, evacuation, and shelter pro-
cedures (Centers for Disease Control and
Prevention [CDC], 1989b). Now, most
of the storm-related mortality, and much
of the morbidity, occurs during the post-
impact period; however, if major infra-
structure damage is sustained, it can be
diffi cult to document the true extent of
mortality and morbidity. In developed
nations, the most prominent causes of
death and injury are electrocutions from
downed power lines, chain-saw injuries,
blunt trauma from falling trees, and
motor-vehicle fatalities occurring dur-
ing the early post-impact period (CDC,
1989a; Philen, 1992). Unfortunately,
storm surge remains the primary cause
of mortality following tropical cyclones
in developing nations that lack critical
preparedness measures (Chowdury et al.,
1992; Diacon, 1992).
Storm-Associated Illness
and Injury
Injury represents the major cause of
death and the primary cause of morbidi-
ty for tropical cyclones (Meredith, 2002).
The top three cyclone-related injuries are
lacerations, blunt trauma, and puncture
wounds, with 80 percent of these inju-
ries being confi ned to the feet and lower
extremities (Noji, 1993). An increased
incidence of animal and insect bites fol-
lowing tropical cyclones has also been
noted (CDC, 1986, 1996, 2000). Chronic
diseases (such as asthma and emphy-
sema) are also known to be exacerbated
after cyclones and other natural disasters.
There is also a potential for exposure to
hazardous materials during the impact,
as well as during the clean-up phase of
the disaster.
Infectious Diseases
Outbreaks of in fectious diseases follow-
ing tropical cyclones are rare (World
Heath Organization [WHO], 1979;
Toole, 1997; CDC, 1999, 2000; Guill and
Shandera, 2001). In developed nations,
post-hurricane infectious disease surveil-
lance has occasionally detected increases
in self-limiting gastrointestinal disease
and re spiratory infections (Lee et al.,
1993; CDC, 2000, 2002), but more typi-
cally, no increase in communicable dis-
ease is found (CDC, 1993; Toole, 1997).
There have been a few reports of isolated
outbreaks associated with vector-borne
illness in developing nations. For ex-
ample, interruption of health services
including an anti-malaria campaign may
have con tributed to a malaria outbreak
in Haiti following Hurricane Flora in
1963 (Mason and Cavalie, 1965; Bissell,
1983). Following Hurricane Mitch in
1998, rates of dengue fever increased in
Guatemala and Honduras, and the num-
bers of malaria cases increased in Gua-
temala and Nicaragua (Pan American
Health Organization [PAHO], 1998).
Psychosocial Consequences
Behavioral health effects are among the
most long-term and debilitating out-
comes of natural disasters, including
tropical cyclones (WHO, 1992; Ursano,
1994). Some persons experience persis-
tent distress, post-traumatic stress disor-
der (PTSD), major depression, or other
psychi atric outcomes. An ele vated preva-
lence of PTSD was specifi cally apparent
in three studies of hurricane survivors in
developing nations (Caldera et al., 2001;
Goenjian et al., 2001; Sattler et al., 2002).
Rates of suicide (Krug, 1998) and child
abuse (Keenan et al., 2004) appear to rise
following natural disasters. The National
Institute of Mental Health (NIMH) has
been quite proactive in seeking to address
mental-health issues of those disaster
victims affected by Hurricane Katrina
(Insel, 2005).
TSUNAMIS
Background
The Japanese word tsunami translates
in English to “harbor wave.” A tsunami
is a series of ocean waves generated by
any disturbance that displaces a large
water mass (Boyarsky and Shneiderman,
2002). About 90–95 percent of tsunamis
are caused by large earthquakes (usually
magnitude 7.5 or greater) at subduction
zones (where one tectonic plate slides
The world can no longer afford to
sustain these significant losses in human
development caused by these types of
catastrophic natural disasters.

Oceanography Vol. 19, No. 2, June 2006
44
over another); the remainder are pri-
marily due to volcanic eruptions (like
the eruption of Mt. Krakatoa in 1883)
or landslides (like the 1998 Papua New
Guinea tsunami generated by a subma-
rine landslide). There are also compos-
ite events such as the 1946 subduction
earthquake in the Aleutian Islands that
triggered a landslide-generated tsunami
killing 159 in Hawaii (Fryer et al., 2003).
Prehistoric geological evidence has im-
plicated meteorites or comet impacts as
a rare cause of tsunami (Bolt, 1978).
Earthquakes caused by large, sudden
fault movement at subduction zones are
most often associated with generation of
the largest tsunamis (e.g., the Sumatra
earthquake and tsunami of December
2004). The amount of fault slip is an im-
portant factor in determining tsunami
size. At subduction zones, the fault zone
affected may be as much as hundreds
of kilometers long. Vertical movement
on the fault may displace tens of cubic
kilometers of water. The December 2004
tsunami, for example, caused the seabed
to uplift (or subside) 6–10 m in places,
displacing an estimated 30 km3 of water
(Dalrymple et al., 2006). Depth of fault
movement is also an important factor in
determining whether a tsunami will be
generated; shallower ruptures that break
the seafl oor will generate larger initial
tsunamis. No tsunami was reported for
the magnitude 8.7 earthquake that shook
Indonesia on March 28, 2005 (leaving
2,000 people feared dead on the island of
Nias), likely because fault movement did
not break through to the seafl oor. In ad-
dition, that earthquake occurred beneath
shallower water, where less water dis-
placement would occur (Hopkin, 2005;
Kerr, 2005).
Once the tsunami is generated, a series
of extremely low-frequency, long-wave-
length (~300 km) waves propagate in an
expanding radius from the area of dis-
placement. These waves differ important-
ly from surface waves (i.e., those caused
by wind) in that tsunami waves are prop-
agated throughout the entire depth of
the ocean. For this reason, tsunamis rep-
resent a tremendous amount of potential
energy, and can travel the speed of a jet
airliner (300–600 mph or 500–1000 kph)
in deep, open water. Because the energy
is spread throughout such a large volume
in deep water, tsunamis may be only a
few feet high in mid ocean, making them
capable of passing under ocean-going
ships with little disturbance or detec-
tion. The physical characteristics of the
fl uid pressure wave allow it to travel great
distances with very little loss of energy.
For example, a subduction earthquake
that occurred on January 26, 1700 at the
Cascadia subduction zone, encompassing
western Washington and Oregon, gener-
ated a tsunami that destroyed the island
of Honshu (Japan) (Anonymous, 1997;
Satake et al., 2003). About 90–95 percent
of the world’s tsunamis have occurred
in the Pacifi c Ocean due to its relatively
large size and its bordering “Ring of Fire”
comprised of major subduction zones.
Great trans-Pacifi c tsunamis are typically
caused by massive earthquakes located
at these subduction zones and occur
at an interval of about once a decade
(McCarty, 2002) (Figure 1).
As the tsunami enters shallow water
near coastlines, the kinetic energy previ-
ously spread throughout the large vol-
ume of deep ocean water becomes con-
centrated to a much smaller volume of
water, resulting in a tremendous destruc-
tive potential as it inundates the land.
Figure 1: View of the western Pacifi c Ocean during a cyclone.

Oceanography Vol. 19, No. 2, June 2006 45
Successive crests may arrive to shore at
intervals of every 10–45 minutes. This
phenomenon is particularly problematic
when responders attempt to rescue vic-
tims from the water after the fi rst wave,
only to become themselves victimized by
subsequent waves. A single tsunami may
be comprised of up to twelve wave crests.
Prior to inundation of the wave crest,
the sea may recede for an unusually long
distance. During the 1960 Chilean tsu-
nami that struck Hilo (Hawaii), this phe-
nomenon tended to attract more people
to the shoreline and into the ocean itself,
where they were then caught up in the
oncoming wave crest. One village in Pap-
ua New Guinea reportedly recognized
this as a sign of an impending tsunami
and took protective actions for shoreline
evacuation. In Simelue (Indonesia), an
old song about moving to high ground
when the earth shakes is reported to have
saved lives, and resulted in a relatively
low death rate compared to neighboring
Sumatra (which was further from the
quake epicenter).
A tsunami is usually 3–15 m high.
Wave heights averaged 24 m above sea
level along the western coastline of Su-
matra during inundation of the 2004
Indian Ocean tsunami earthquake (Paul-
son, 2005). A 70-m wave was recorded
following the 1964 Alaska earthquake
(Alaska Division of Emergency Services,
1992). Extremely rare mega-tsunamis
produced by giant submarine land-
slides have been implicated globally
(McMurty et al., 2004). Evidence of soil
stripping and coral deposits purportedly
caused by tsunami inundation has been
reported up to an elevation of 365 m
in Hawaii (McMurty, 2004). At least
100 mega-tsunamis in different parts of
the world have been recorded in the past
2000 years according to interpretation
of the sedimentologic and geomorphic
imprints left by these events (Scheffers
and Kelletat, 2003). The highest tsunami
wave ever witnessed occurred at Lituya
Bay (Alaska) in 1950. It was triggered
by a magnitude 8.0 earthquake-induced
landslide, and reached the height of
524 m above the shoreline (i.e., a height
three stories higher than the World Trade
Center of New York City) (Boyarsky and
Shneiderman, 2002).
Human-Health Impact of Tsunamis
Mortality Trends
The vast majority of tsunami-related
deaths occur immediately (McCarty,
2002). In a large tsunami, deaths fre-
quently exceed the number of injured.
Average death rates are believed to be
50 percent for the population caught
up in a tsunami (McCarty, 2002). The
30,000 inhabitants of Calang in Aceh
province (Indonesia) suffered an esti-
mated 70 percent mortality rate during
inundation of the December 26, 2004
tsunami (Brennan and Rimba, 2005).
Most deaths resulted from drowning.
However, a tsunami does not consist
only of water. It also contains a great
amount of debris traveling with tremen-
dous momentum. The same 2004 Indian
Ocean tsunami is estimated to have been
traveling at 30 mph (48 kph) when on
shore in Aceh province (Indonesia).
Figure 2 reveals extensive destruction
and debris left in the wake of the tsuna-
mi in the city of Aceh (Indonesia).
According to a survey recently car-
Figure 2. Author surveying tsunami damage in Banda Aceh, Indonesia.

Oceanography Vol. 19, No. 2, June 2006
46
ried out by Oxfam (2005), four times as
many women as men were killed in the
tsunami-affected areas of Indonesia, Sri
Lanka, and India. Some of the reasons
postulated for this are similar across
these countries: women died because
they stayed behind to look for their chil-
dren and other relatives. Women in these
areas often cannot swim or climb trees,
which meant that they could not escape.
Deaths from tsunami injuries occur
in three phases. Victims usually succumb
to injuries that are incompatible with life
(severe head, chest, and spine injuries)
within the fi rst few minutes. Then im-
mediate complications set in over the
next few minutes to hours (such as bleed-
ing, lung collapse, and blood clots in the
lung). Finally, these immediate causes
of death are followed by delayed com-
plications over the coming days that are
mostly associated with infectious disease
(such as wound infections and aspiration
pneumonia) (Kongsaengdao, 2005).
The large number of dead bodies be-
came an issue of public concern in the
wake of the 2004 Indian Ocean tsunami.
Many families were not allowed to re-
cover their dead or to observe traditional
burial ceremonies due to the miscon-
ception that the dead bodies themselves
pose a health threat (Guha-Sapir and
van Panhuis, 2005). It is well established,
however, that dead bodies do not pose a
health threat, and it is more important
for families to recover their dead for psy-
chological reasons than to bury them for
sanitary purposes (Morgan, 2004).
Tsunami-Associated Illness and Injury
A tsunami directly injures the victims
by the mechanism of blunt trauma and
penetrating injury (Taylor et al., 1998).
People are bludgeoned by concrete slabs
and felled trees, stabbed by jagged sheets
of metal and glass, tangled up in mana-
cles of wire, and impaled onto tree limbs
and bamboo. Soil, small pieces of wood,
glass, and metal in the contaminated
saltwater penetrate the soft tissues of the
body at high velocity.
When the 2004 Indian Ocean tsu-
nami hit the western coast of southern
Thailand, six to eight huge waves mea-
suring 5 to 7 meters high destroyed al-
most everything along the beach and
inundated areas more than 300 meters
from the seashore. Most of the survivors
had minimal to moderate injuries to the
body and extremities. Causes of death
included drowning, entrapment inside
collapsing buildings, and being thrown
under cars (Lim, 2005). No survivor
of the Papua New Guinea tsunami was
found to have head, spine, thorax, or ab-
domen injuries, implying that survival
of these life-threatening injuries was vir-
tually impossible in that remote setting
with delayed resuscitative and surgical
care (Taylor et al., 1998). Bone fractures,
soft-tissue injuries, and near-drowning
were the most common conditions re-
ported among survivors in Papua New
Guinea and of the Indian Ocean tsuna-
mis (Holian and Keith, 1998; Lim, 2005;
Watcharong et al., 2005).
As mentioned before, chronic diseases
(such as asthma and emphysema) are
also known to be exacerbated after natu-
ral disasters. And similar to cyclones,
tsunamis have the potential to cause
exposure to hazardous materials during
both the impact as well as the clean-up
phases of the disaster. After the 2004
Indian Ocean tsunami, documents writ-
ten about the tsunami were critical of
the over-abundance of health resources
focused on non-emergent trauma care
as compared to relative lack of attention
paid to the needs of special populations,
including the elderly (Mudur, 2005)
and maternal-child and women’s health
(Brennan and Rimba, 2005; Mudur,
2005; Perera, 2005).
Infectious Diseases
Near-drowning is common in tsunamis
and is frequently associated with aspi-
ration pneumonia or “tsunami lung”
(Holian and Keith, 1998; Allworth, 2005;
Chierakul et al., 2005). Wounds are in-
...it is possible to detect tsunamis and
cyclones in advance of these hazards,
and provide early warning before they
strike those vulnerable populations
living along coastlines in their paths.

Oceanography Vol. 19, No. 2, June 2006 47
evitably contaminated with soil, debris,
and foreign bodies. Therefore, wound
infections are common. For example,
16.9 percent of all diagnoses by Janu-
ary 10, 2005 at the International Com-
mittee of the Red Cross (ICRC) fi eld
hospital in Calang (Indonesia) (Bren-
nan and Rimba, 2005) and 15 percent
of all consultations at the ICRC fi eld
hospital in Banda Aceh (Indonesia) were
for wound infections (Guha-Sapir and
van Panhuis, 2005).
Wound infections frequently involve
multiple, relatively uncommon patho-
gens (Lim et al., 2005; Andresen et al.,
2005). As was the case in populations
affected by hurricanes Andrew and Iniki,
tetanus cases increased after the 2004
Indian Ocean tsunami as a result of in-
juries sustained at the time of impact.
The number of cases then returned to
baseline within one month of the event
(Guha-Sapir and van Panhuis, 2005).
Contrary to initial concerns for out-
breaks of malaria, cholera, and dengue
(Moszynski, 2005; Krishnamoorthy et
al., 2005), the Indian Ocean tsunami,
like previous natural disasters, was not
associated with epidemics of infectious
disease (Guha-Sapir and van Panhuis,
2005). No increases in cases for cholera,
measles, malaria, or dengue were noted
in Aceh in the post-tsunami period
(Guha-Sapir and van Panhuis, 2005).
Experience has shown that these dis-
eases, despite common beliefs, are not
always a priority immediately after a
natural disaster. Overall, the number of
disaster-related health conditions need-
ing emergency response decreased sub-
stantially within two weeks of the event,
and became negligible within four weeks
(Guha-Sapir and van Panhuis, 2005).
Psychosocial Consequences
As mentioned before, behavioral health
effects are among the most long-term
and debilitating outcomes of natural di-
sasters, including tsunamis (WHO, 1992;
Norris, 2005). The monumental devasta-
tion of the December 2004 Indian Ocean
tsunami prompted a meta-analysis of
the psychosocial consequences of natural
disasters in developing countries versus
developed countries (Norris, 2005). Gen-
erally, during a natural disaster, a much
higher proportion of the population in
developing nations sustains severe loss
and extreme trauma, and experiences
that constitute clinically signifi cant dis-
tress (Schultz et al., 2005). Table 2 com-
pares the direct health effects of cyclones
and tsunamis.
THE CRITICAL ROLE OF
PREPAREDNESS
No man-made structure can be relied
upon to resist the incredible power of a
large tsunami. Seawalls and reinforced
construction are of limited benefi t (Mc-
Carty, 2002). The recent events of Hur-
ricane Katrina in the United States reveal
that even well-developed engineering
controls can fail in the event of a direct
hit by a severe tropical cyclone. In the
absence of emergency-preparedness
measures, the majority of tsunami- and
cyclone-related deaths will occur im-
mediately during the impact phase when
emergency response activities are the
most vulnerable and the least capable.
As previously noted, since 1945 more
people have been killed by tsunamis than
Table 2. Estimated Relative Frequency of Health Eff ects
Associated with Cyclones and Tsunamis
Type of morbidity Cyclone Tsunami
Crush injury ++ ++
Head injury + ++
Asphyxiation + ++
Isolated bone injury + ++
Skin soft tissue injury + ++
Burns + 0
Drowning ++ ++
Asthma/emphysema + 0
Hypothermia 0 +
Epidemics 0 0
Starvation + 0
Aspiration pneumonia 0 +
Tetanus + +
Wound infections + ++
Psychological illness + +

Oceanography Vol. 19, No. 2, June 2006
48
by earthquakes (McCarty, 2002). How-
ever, unlike earthquakes, it is possible to
detect tsunamis and cyclones in advance
of these hazards, and provide early warn-
ing before they strike those vulnerable
populations living along coastlines in
their paths.
Preparedness is the aggregate of all
measures and policies taken by humans
before an event occurs that reduces the
negative impact that otherwise would
have been caused by the event (Sundnes
and Birnbaum, 2003). Emergency health
preparedness includes activities such as
risk assessment, planning, hazard moni-
toring, early warning, and population-
protection measures. The objectives of
preparedness for health emergencies have
been offered as follows (Lechat, 1985):
• Prevent morbidity and mortality
• Provide care for casualties
• Manage adverse climatic and environ-
mental conditions
• Ensure restoration of normal health
• Re-establish health services
• Protect staff
• Protect public health and medical
assets
The actions required to meet these
needs can be grouped in four categories
(Lechat, 1985):
1. Preventive measures (e.g., building
codes, fl oodplain management)
2. Protective measures (e.g., early warn-
ing, community education, evacua-
tion, shelter)
3. Life-saving measures (e.g., rescue,
relief)
4. Rehabilitation (e.g., resettlement,
rebuilding)
Preventive and protective measures are
not only the most cost-effective and ef-
fi cacious actions that may be taken to
protect human health from the hazards
of cyclones and tsunamis, but they are
also the most consistent with the pro-
motion of human dignity and develop-
ment. The tremendous societal impact
of hurricane Mitch in Central America
in 1998 dramatically illustrated the real
costs of these natural disasters on devel-
opment when the public-health accom-
plishments of an entire generation were
wiped away by the storm (PAHO, 1998).
The long-term impact on human health
and development after the 2004 Indian
Ocean tsunami is diffi cult to predict. It
will likely take generations to restore the
Aceh province (Indonesia) to pre-event
levels, even with the assistance of nearly
all of the richest nations on Earth. The
world can no longer afford to sustain
these signifi cant losses in human devel-
opment caused by these types of cata-
strophic natural disasters. Preparedness is
the key to preserving human health in the
wake of cyclone and tsunami disasters.
DISCLAIMER
The material in this article refl ects solely
the views of the author. It does not neces-
sarily refl ect the policies or recommenda-
tions of the Centers for Disease Control
and Prevention or the U.S. Department of
Health and Human Services.
ACKNOWLEDGEMENTS
The author would like to acknowledge
the assistance and support of Dr. Jill
Russell. This article is dedicated to my
daughter, Cassidy.
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