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Surprise Killers

Sabirin lays contorted on a hospital bed, writhing and delirious. "No! I can't believe it!" he screams as his wife pumps gruel down his throat with a syringe. The 38-year-old survived the massive tsunami that tore through his Aceh village on Dec. 26. But like countless others he was swept away by the water and suffered cuts and bruises. Within two weeks he developed lockjaw and agonizing spasms--classic symptoms of tetanus, a bacterial infection contracted through open wounds. "The U.N. textbook didn't warn us about this," says Singaporean physician Charles Johnson, referring to the 16 tetanus cases admitted to his small emergency ward at Zainal Abidin Hospital in the provincial capital of Banda Aceh since Jan. 10. "We'll never know, but there are probably thousands of them out there."

Cholera, malaria and gastrointestinal disorders are usually what haunt the world's disaster zones. Yet in Indonesia two other diseases have caught emergency medical teams off balance. "Tetanus resulting from minor wounds, and aspiration pneumonia from sucking in seawater and all the cruddy stuff that goes with it--they're the most common medical problems we face," says Capt. Charmaine Tate, a military doctor from New Zealand. "There are wards full of them." Such patients constitute a second phase in the post-disaster health crisis in Indonesia, and ultimately will outnumber those who sustained major injuries as the tsunami hit, say doctors working in Banda Aceh. (Indonesian health agencies are also bracing for a potential malaria outbreak as unusually large mosquito breeding grounds multiply in the tsunami's wake.)

Tetanus, in particular, wasn't anticipated. In the late 1980s Jakarta won plaudits from the World Health Organization for achieving a 90 percent inoculation rate across the sprawling archipelago--a major step toward total eradication. But Aceh's local health networks have since fallen into disarray. The main reason: a bloody separatist rebellion that drove frontline caregivers like midwives and local medics from the hinterland in the 1990s, leaving children and pregnant women without access to inoculations. "When the conflict [intensified], volunteers no longer went to villages," says Dr. Cut Idawani, former head of Aceh's provincial health department and now a program manager with Save the Children.

Tetanus and pneumonia are similar in several ways. Both take days to manifest themselves in acute symptoms, rendering carriers walking wounded. Prompt treatment--tetanus shots or antibiotics--restores patients to health quickly. Treating the seriously ill, on the other hand, takes weeks, requires constant medical care and sucks up scarce resources like bottled oxygen. Those who don't receive quick care often end up suffering preventable deaths. Sadly, amid a public-health emergency as acute as Aceh's, these kinds of cases are easy to set aside. Says Lt. Hayden Ricketts, who serves with Australia's medical contingent in Indonesia, "There's an awful lot of triage going on here."

Medical experts from hospitals and relief agencies in Aceh held an emergency meeting last week to coordinate a response to infections. The next day, mosques across the province implored the faithful to seek prompt medical attention for cuts, abrasions or fatigue. Even relief workers are at risk, unless they get tetanus boosters before climbing through tsunami debris, says Pandu Riono, an epidemiologist from Jakarta. "People don't realize that we face a problem with survivors and volunteers becoming infected." That's the last thing ravaged Aceh needs.

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