Shortly after the scope of this disaster became clear, it occurred to me, and likely many others in the injury control field, that most of the deaths from this still unfolding mega-disaster, two weeks now after the earthquake, are from injuries (including drowning). Yet it seems the media coverage focuses more on body counts and infectious disease potential, and not as much on survivor counts, serious injury impact, possibilities of future injuries, or the needs of the acute care and longer term rehabilitation responses.

Watching scenes of barefoot survivors stepping through wreckage, unprotected rescue workers, and demolished infrastructures makes us wonder who is thinking about addressing additional falls, crushes, lacerations, burns, and long term care, injuries from transport vehicles, community violence (looting and crowds), criminal violence, stress induced family violence, post traumatic stress disorder, suicides, after shocks, and wildlife dangers, and what they are thinking about. Of course in the worst hit areas, with infrastructure gone, people need emergency care, clean water, safe shelter, and food for survival; of that there is no doubt. But new injuries will undoubtedly take an additional toll and many injured victims will not get the short and long term care they need.

Many questions arise. Perhaps the most important question for us in the injury fields at this juncture is: What can and should the injury control community be doing to help out right now and in the immediate future? Other important questions that come to mind are:

• How are the Centers for Disease Control and The National Center for Injury Prevention and Control getting involved in the disaster response?

• How are the national and international health and relief agencies addressing injury issues?

• What are the key lessons that have been learned about acute injuries and secondary injuries from other large disasters that relief teams need to know about right now?

• Does the unprecedented scale of this mega-disaster spread out the expertise so much that there is still an urgent need to help communicate to recovery teams and populations the need to be aware of the myriad injury related issues?

• How can other tsunami, volcano, and planetary scientists work with injury control and disaster preparedness and response officials to better protect populations at risk before nature’s fury is released?

INJURY EPIDEMIOLOGY ISSUES

The epidemiology of this disaster is also important to look at, both during the acute and recovery phases. This is the only natural mega-disaster (more than 100 000 deaths) to hit since injury control has become a legitimate part of public health practice and science. But with this terrible disaster comes the opportunity to focus on a myriad collection of issues, so that we, as a public health discipline, learn from the experiences. Some epidemiologic questions and issues that come to mind include:

• In the face of seemingly obvious danger, why did some people go down to look at the ocean recede while others fled?

• What protective role did an oral tradition of tsunami danger play in the less developed societies?

• The differential impact on women and children who were caught inside structures is an important observation.

• What structures (man made or natural) offered the best opportunities for survival?

• Was swimming ability an important survival factor?

• What other factors were important to death, injury, and survival among people caught in the open?

• What injuries are occurring after the acute phase to residents and rescue workers?

• What protections do residents and rescue workers have and what do they still need?

• Are injury surveillance efforts in place and adequate?

• How can we detect increases in certain injury risks when there was no baseline data or infrastructure to build upon?

• What acute care issues are most important in a disaster of this scope and magnitude?

• Will the disaster induced stress lead to more suicide and family violence? How will this vary by culture?

• How will long term rehabilitation needs for the thousands of severely injured fare in competition for the limited resources and limited international attention spans?

• What are the other long term injury related issues?

• Which of these questions deserve priority attention?

Many other questions need to be framed and discussed. That is one use of the Asian Earthquake and Injury News and Discussion Forum CIRCL has placed on the internet at http://www.circl.pitt.edu/earthquake/. This website also contains links to photos and videos that help to increase awareness of the injury prevention and public health related issues.

FORETHOUGHT AND PREVENTION

An interesting note was published in The New York Times on 31 December 2004: Phil Cummins, an Australian seismologist, apparently had grasped the dangers of this worst case scenario early in 2004 when he delivered a pre-earthquake presentation to tsunami experts, “It really seems strange now to see the title” Dr Cummins recalled yesterday. “Tsunami in the Indian Ocean—Why should we care?”

This is a historic event for the modern world, but also, I believe, an opening for our young field. It is an opportunity to build new partnerships, rectify past omissions, and educate and demonstrate to the public and decision makers about the legitimate and important role of injury prevention in disaster preparedness and in the short and long term local and international responses to such events.

One last thought. While the loss of life, injury, and property from this widespread and cataclysmic event is horrendous and deeply shocking, single events of this magnitude are nevertheless, historically rare. It may help to put this event into perspective and to appreciate more the enormity of the overall injury problem to global health and the inadequate public health response. Each year, worldwide, an estimated 1.2 million people are killed and as many as 50 million are injured from road traffic crashes alone¹ and millions more die from violence and other injuries.² Seen in this light, the enormity of the overall injury problem composed of countless small scale but daily personal disasters and less frequent cataclysmic natural and man made disasters becomes clear. The challenge for us is to respond better and garner public attention on both types of loss: those that occur to a large number of people in a short period of time and those that are spread out over time but carry an even greater burden on all societies throughout the world.