Could a ragtag group of doctors from California—the first medical team to arrive in the area hit hardest by the giant typhoon in the Philippines—be a model for better disaster relief?
Dr. Arlyn Santo spent most of Thursday night at Town Hall, prepping and distributing relief goods for local evacuation centers. As a member of the Municipal Disaster Coordinating Council of Tanauan, a city of 50,000 people hard on the eastern shore of Leyte Island in the central Philippines, she knew as well as anyone the force of the cyclone then raging toward them across the South Pacific. On the Internet it was being called the most powerful storm ever recorded. The Public Storm Warning Signal had been hoisted to 4, the highest level. The Joint Typhoon Warning Center was estimating landfall sometime the following morning, with maximum sustained winds of 190 miles an hour and a storm surge up to 17 feet high.
President Benigno Aquino III had made a speech on national television that evening. He called for bayanihan, a Filipino term meaning communal unity and cooperation: "I thought it best to speak to you to emphasize the gravity of the calamity our countrymen will face in these coming days, and to ask of everyone cooperation and solidarity." Relief goods had been positioned, he said. The Philippine Air Force's 32 planes and helicopters and three C-130s were on standby. "Rest assured," he promised, "help will arrive as soon as the storm passes."
Santo left Town Hall at 0330 hours, Friday morning, to get home and hunker down before the storm hit. By 0900 her house had been destroyed, her car had been lifted up and smashed against the gate, and she was back at Town Hall with a nurse, a midwife, and several volunteers, dressing wounds.
"There's nothing else to do," she would say to me, days later.
It was about then, several hours after the storm hit, that I first heard about Typhoon Haiyan. Early Thursday evening, California time, I was in line at the Vons pharmacy in Mammoth Lakes, Calif., waiting to pick up a big bottle of post-op-strength Ibuprofen. I was on my way to Mexico with a team of volunteers from a group called Mammoth Medical Missions. We would be meeting in Los Angeles in the morning: three surgeons (general, orthopedic, and obstetric), three anesthesiologists, two emergency department physicians, two registered nurses, a certified orthopedic physician's assistant who was also a paramedic, his 16-year-old son, two ortho techs, a handyman with a heavy backpack full of hardware and tools (hobbled slightly by a walking cast from a nine-day-old ankle surgery), and myself. My role, as logistics and community relations guy, was to think things through from a non-medical perspective. And to fill whatever gaps I could. Oh, and whenever possible to take notes.
Our chief surgeon Mike Karch's supersize Ford F350 pickup was piled high with 37 duffels and seabags of equipment, instruments, and supplies for what was to have been four days of elective surgeries in a municipal hospital in the town of Ocozocoautla de Espinosa, Chiapas. Rich Koehler, our team's general and thoracic surgeon, had gone to the mountaineering store to buy a headlamp. The line at the pharmacy wasn't moving. I scanned the extensive selection of trial-size personal hygiene potions, tried to think of what I'd forgotten. Whatever it is, I told myself, I can get it in Mexico.
Thumbing idly through the inbox on my phone, I came upon an email from someone named Sue Johnson. Hello From Team Rubicon was the subject line. I am needing a possible medical team to travel to the Philippines, the message read.
I'd seen these folks in action on Facebook: hardened veterans of Iraq and Afghanistan doing disaster-relief work in places like Haiti and southern New Jersey and Oklahoma. As one of the founding directors of a tiny nonprofit with two unofficial missions and a year's worth of incorporation paperwork under our belts, I'd allowed myself to think we might one day be like them—when we grew up. I hadn't yet heard about Typhoon Haiyan.
Sounds great, I wrote, assuming she meant at some point in the future. We're actually in transit now on a mission to Chiapas. Do you have dates in mind?
The response came right away: We are looking for deployment asap.
When I climbed up into Karch's crew cab to join the others—there were six of us packed in for the drive down to LAX—the critical concern was whether anyone had the appropriate peripherals to allow for the playing of music from an iPhone through the truck's stereo system. In 72 hours we'd be wondering if we had enough packaged calories to sustain ourselves for the rest of the week, or enough bandages, or enough iodine tablets to kill potential viruses in the water we were drinking and using to debride wounds. Or if Karch should've brought his gun.
"Now that I have you all gathered here," I said, "I'd like to propose the possibility of an alternate mission."
Over the last decade, with sharp increases in the severity, frequency, and overall profile of wide-scale environmental disasters—Indonesia, Pakistan, China, New Orleans, Japan, Haiti, New Jersey—there's been a corresponding proliferation of aid organizations, acronyms, and bureaucracies. Help was on its way to the central Philippines, to be sure. It would come from all over the world in the form of billions of dollars in cash, supplies, equipment, and thousands of military and NGO personnel with a variety of missions and capacities.
But it would take time. According to a study released by the World Health Organization two months before Haiyan, "of the 77 foreign field hospitals that arrived in five recent Sudden Onset Disasters, only one was operational before day three." The norm is more like five to 10 days for damage and security assessments to be made, for funds to be released, for stuff to start piling up at a forward air base somewhere, for chains of command and distribution to be established, and for people and supplies to start making their way outward to where they're needed.
In the meantime, the situation is left to "local resilience and response mechanisms." In other words: whatever local infrastructure and personnel happen to have survived the disaster. There was only so much Dr. Santo and her team could do for the hundreds of survivors with major traumatic injuries who started showing up at Tanauan Town Hall—there were now zero functioning hospitals serving a hard-hit population of 2.1 million people—on the morning of Friday, Nov. 8: administer first aid, clean and dress wounds as best they could, distribute whatever antibiotics they had, give tetanus shots and kind words, hope that social order would hold until help and supplies arrived.
The official toll, more than a month after the storm, would run as follows: 6,057 dead; 1,779 missing; 27,468 injured. What will never be known is how many of those who ended up dead had at first survived the storm with significant injuries, only to succumb a day or two or three later for lack of adequate medical care. Was it hundreds? Or thousands? Our team was on the ground and operational about 75 hours after the storm hit. Of the 109 surgeries our docs would perform in the following days, including two amputations, several open fractures, dozens of deeply infected wounds, and treating one gentleman stabbed 10 times in the chest, plus delivering 11 babies (two by C-section), how many represent lives saved? 10? 50? If there'd been 10 other teams like ours in a position to get in within the first 100 hours, by how many might we have reduced the final death toll? 100? 500?
We had no visas, no contacts on the ground, no security, no vaccinations, no idea how we'd get to the disaster area, nor what sort of facilities we'd find, if any, once we got there.
"There's a golden hour in trauma," says Koehler, who moved from Seattle to eastern California in 2012 to run the general surgery practice at Mammoth Hospital. "A brief period of maximal benefit when readily life-threatening injuries can be reversed." In a presentation they are drafting for an upcoming "Extremity War Injuries" conference in D.C., he and Karch, along with our team's head emergency physician, Dr. Sara May, who worked in a clinic in Haiti in the months after the earthquake, argue that there's an analogous "golden 100 hours" in the wake of a mass-casualty event, wherein lives can still be saved by surgical intervention. This may be especially so in tropical zones, where the first major spike of infections seems to occur within the first two to three days. The faster you can get there—"just ahead of the paperwork," as Karch puts it—the more lives and limbs can be saved.
According to Capt. Joe McQuade, M.D., medical director for public health at Naval Hospital Jacksonville in Florida and a veteran of the Iraq War, fast and light medical teams are not a new concept—except in civilian disaster-relief scenarios. "The military has long pushed forward on the concept of small mobile surgical trauma teams to get patients seen within the golden hour after trauma—literally the first one hour—to improve survival rates," he told me. Karch "used that idea—getting closer to the patients as soon as possible with the skills they needed urgently." It seems obvious. It just hasn't been made a priority.
For Karch it was a simple, high-stakes race against the clock. We had personnel and supplies enough to run an effective field triage hospital with three full operating rooms for three to four days. With a couple of exceptions we'd each of us—even Carson, the 16-year-old—either cut our teeth in the fairly austere conditions of a rural clinic in Chiapas, bellied up to wide-open abdominal cavities, or else completed one of Karch's intensive, three-day mass-casualty seminars, working on cadavers that he and his colleagues had blown holes in with a variety of explosives and firearms to demonstrate the kind of ballistics damage you might see in a war zone. Jon Bourne, one of our anesthesiologists, had even served on previous medical missions to the Philippines.
Logistical obstacles were formidable: We had no flight, no visas, no official permissions, no contacts on the ground or with any other NGOs aside from Rubicon, no security, none of the required or suggested vaccinations, no idea how we'd get from Manila to the disaster area (if we could even get to Manila), nor what sort of facilities we'd find, if any, once we got to wherever it was we needed to go. What if half the group didn't want to go? What if we ended up stuck in an airport terminal for a week? What if things turned violent?
To grasp the unlikely chain of events that followed—how we got from Mammoth Lakes, Calif., to Haiyan's ground zero in about 52 hours, and what we were able to accomplish then—you should first understand a bit about Mike Karch. A compact, freckled, orange-tinted bundle of sinew, energy, and unalloyed derring-do, Karch has made self-reliance and preparedness for apocalyptic scenarios a fundamental part of his life's work. On the morning of Sept. 11, 2001, he was a surgery resident at Georgetown University in Washington, D.C. Having seen only one patient brought in from the crash at the Pentagon, he boarded a train from D.C. to New York City carrying a backpack with camping gear and basic medical supplies. That evening, after two hours at the Chelsea Pier hauling body parts and laying them out on the ice-skating rink, he was one of the first docs to hike in and establish a MASH unit at ground zero.
Karch now teaches one of the only mass-casualty team training courses in the country. He's a board-certified surgeon specializing in orthopedic trauma at the only hospital in the small ski town of Mammoth Lakes. He's also a mule packer, a bow hunter, a chicken farmer, a doctor to the U.S. Ski Team, and the founder and director of the largest winter biathlon event in the country. He's twice run the 135-mile Badwater Ultramarathon from the bottom of Death Valley to Mount Whitney. (Legend has it he trained for that event by running up and down the highway dragging a truck tire, and by driving around town with the windows up and the heat cranked in the midday heat of midsummer—zipped into a full-length wet suit. The same legend tells of a hitchhiker he stopped to pick up who politely declined the ride.) His professional traveling kit includes a pair of bolt cutters and a number of heavy hammers and hacksaws that he uses on human bones, and sometimes, a licensed, concealed handgun.
Ten miles down the road, assuming a buy-in from most of the team, the decision was essentially made. Karch turned the truck around so we could take 30 extra minutes to run home and grab items that might prove useful in a tropical disaster zone: rubber boots, camping gear, water filters, mosquito netting, MREs (military-issue meals ready to eat), backpacks, a generator, a shovel. (Only as I write this, weeks later, do I realize that it may not be particularly common outside of an isolated mountain community like ours for everyone to have this sort of equipment handy in the garage.) My wife and boys were snuggled in downstairs reading a chapter of Harry Potter. I kissed each one good-bye with a different level of emphasis than I had an hour earlier, shouldered my pack, and headed back out into the darkness.
At the last minute, with the truck idling there in front of his house, his wife and kids standing in the driveway, Karch considered grabbing his sidearm. I told him I didn't think it was a great idea. "All right," he shrugged. (Over the coming days he would find more than one occasion to express his good-natured regret for having listened to me.)
We never did come up with the right iPhone adapter.
For the rest of that night on the road and all the way to Sunday—that is, for the first 48 hours after landfall, until we got to Manila and began to cross paths with the few people who'd been in the disaster zone and managed to get out—there was no real news from the central Philippines. The entire region had gone dark. All electrical, communications, and transportation infrastructure was down. What we now know, of course, is that Yolanda, as she was called locally, had made her point. At 0440 local time on Friday (1240 on Thursday our time, about five hours before I got that first email from Sue Johnson) she'd sideswiped the southern tip of Samar Island at wind speeds of up to 235 miles an hour. Two hours and twenty minutes later she'd cannoned into the eastern shore of Leyte Island. She'd exploded windows, torn the roofs off buildings, hurled coconuts and trees and concrete-reinforced utility poles at fleeing people.
She'd followed with the storm surge, her deadliest weapon. Sweeping the ocean overland at heights ranging from chest-high to 30 feet, like a vast, fast-rising river, she'd washed out roads and bridges, delivered tanker ships full of coconut oil onto city streets, carried tractor trailers into denuded palm plantations, demolished tens of thousands of wood-frame houses and spread their constituent parts across former neighborhoods and airstrips. In a matter of minutes, she'd left more than 4 million people homeless. Many of those who'd gone downstairs to seek shelter from the wind and flying debris ended up crushed or drowned in the rush of water. At two of seven evacuation centers in the town of Tanauan, I'd learn later, every person inside had perished. It would take several days before the government and the news organizations would begin to acknowledge the scope of things, but already thousands of people were dead. Thousands more were horribly wounded and on their way to dying slow, painful deaths beneath debris or in the septic pools among the wreckage.
A young woman pleaded that we press on to her hometown of Tanauan, nearer the epicenter. Lavinia worked as a nurse near Manila and was on her way home to see if her family had survived. In Tanauan, she explained, 'they have no rescue teams, no food and water. There are a lot of bodies in the street.'
Twelve hours later, we had the bulk of the team assembled in the lobby of the Hacienda Hotel, near LAX. It was Friday morning, L.A. time. The first available flight out was that night on Philippine Airlines. (The storm had missed Manila.) In the meantime, it would be a very busy day in L.A., with multiple type-A personalities bringing to bear the full weight of their contacts, their strategic acumen, their ingenuity, and their personal communications devices: coordinating with Rubicon, with the U.S. Navy, with the Marines, with the Philippine Embassy in D.C., with the Philippine Red Cross, with Fujifilm (for the procurement of a portable ultrasound machine in Manila), and with one of our number who'd ended up stuck in transit in Mexico City. Checking the weather; researching references to Islamist groups in the southern Philippines; looking at online maps; arranging for the waiving of excess baggage fees; arranging for late checkout from the hotel; getting 16 people vaccinated for hepatitis A and B, typhoid, and yellow fever; beginning a course of prophylaxis against malaria; shopping for last-minute survival gear, meds, and supplies; reorganizing, repurposing, repacking—and apologizing to Mexico. Team Rubicon was still staffing up. They'd be at least 48 hours behind us, team members said, but they'd meet us there. They loaned us one of their satellite phones so we could stay in touch.
The first international humanitarian team to arrive on Leyte Island was an assessment team from the European Commission's Humanitarian Aid and Civil Protection office in Manila. On Saturday (day 2), along with members of a children's development NGO called Plan International, the team hopped a boat to Ormoc City, on the leeward side of the island, and went in overland from there. "The extent of destruction and isolation was confirmed during this field visit," read their report. "The damage to infrastructure was massive within a 50 kilometre radius of the typhoon's eye. Ninety percent to 100 percent of houses and government buildings were damaged, the electricity system was completely down, hospitals were damaged and roads were blocked by fallen trees and electricity poles." The situation was bad enough that three days later, on day 5, the European Commission would announce its decision to fast-track the release of €3 million in aid.
Médecins Sans Frontières [MSF, a.k.a. Doctors Without Borders] would send a senior staffer from its Hong Kong office to coordinate with the Philippine government. A team of MSF medics would set out from Brussels to establish a field clinic in Guiuan, Eastern Samar, where the storm had made its first landfall. They'd be up and running by Wednesday (day 6). Yann Libessart, an emergency communications officer for MSF based in Sydney, who'd learned about the storm hours before it hit, would head for Cebu, an island to the east of Leyte that in the following days and weeks would become a hub of relief operations. There, he would meet up with a team of first responders from MSF's Paris operational center. It would be several days of infrastructure problems, bad weather, and security concerns before they could finally get to Tacloban on Thursday (day 7). Two days later 140 MSF personnel would be en route to the region, "including doctors, nurses, surgeons, logisticians, water and sanitation experts, and psychologists," along with "359 tonnes of MSF’s medical and relief items," the group reported on its blog. The Navy would be toying with the idea of recommissioning an old hospital ship in San Diego, and the Chinese would be shamed into sending their much newer one from Shanghai.
We landed in Manila before dawn on Sunday (day 3), having crossed the International Date Line somewhere in the long night over the Pacific. It was 48 hours after the storm's first landfall on Eastern Samar. Waiting for us curbside with three late-model vans was Ruel Kapunen, the spry young CEO of a local subscription-based emergency dispatch company (in the Philippines, 911 service is for those who can pay). He'd been recommended to us by the Philippine Embassy as the guy who could get us to where we needed to go. The airstrip at Tacloban, the only landing zone near ground zero on Leyte Island, had finally been cleared of debris, he reported. The U.N. had sent an assessment team, but as yet no operators were on the ground. We'd be the first. There were no commercial flights, and wouldn't be any for weeks, but he'd arranged (calling in favors, he said, "entirely on Facebook") for us to fly by military transport from Villamor Air Base, on the other side of the airport.
He introduced his associates, who wore excellent tropical-weight black-and-orange cargo pants they were not ultimately willing to trade for an old pair of Levi's 501s, and Dr. Duds Santos, an armed emergency physician with the Philippine National Police [PNP]. Santos would accompany us as our security attaché. He was going in light: All he carried was a small hydration backpack, two chocolate bars, a survival knife, his Glock 17, and five extra magazines of ammunition.
Due to delays at the airport—a temporarily misplaced passport, a series of psychological shenanigans too complex to get into, and the non-arrival of our generator, courtesy of TSA and/or Philippine Airlines—we missed the first C-130 cargo flight out. The upshot was that we had a few extra hours to appreciate the rising heat of the day, to change from our sweaty clothes into others that would within minutes become equally damp, to apply sunscreen, to grab a last decent meal at the commissary, to buy two cases of Gatorade and iced tea for future consumption (the bottles alone would prove indispensable), to recharge electronics, and to take delivery of the aforementioned portable ultrasound machine. There was time to squeeze out a handful of last emails through someone's anemic local hot spot (and to cultivate what would soon become a deep longing for a full lightweight sat comms setup with Internet capability and solar charging). There was even time to come up with a doomed buddy system. We picked partners, counted off, and then promptly forgot our team numbers.
Having secured the personal blessing of the vice commander of the Philippine Air Force (and a flight suit that I would eventually give to Carson), we hefted our bags through the gathering crowd of reporters and early assessment teams, weighed each piece—54 total—then laid them all out on the tarmac like bodies, in the sun, one alongside the next, to be sniffed by dogs for contraband. (Karch had explained to us a number of times that we might at some point be called on to move corpses and that if so, they should be laid out side by side in groups of 10, with room on either side for bulldozers or other heavy equipment.) Jon Bourne's chocolate melted.
In the small, air-conditioned terminal it was easy to fall into the notion that perhaps the disaster had been overblown. The morning's newspaper had claimed one confirmed dead. Then word circulated, apparently from Air Force personnel who'd just come back, that there were 5,000 dead just in Tacloban.
I sat on the floor and shared an electrical outlet with a tall, thin, vaguely sallow-eyed American fellow named George. He was with the U.N., he said, part of what he described with no small amount of fatalism as "the advance advance team." He would get to Tacloban sometime that day, he figured. He would find the others, who'd gone that way earlier that morning, and then figure out what to do next.
"All the rescue teams are going to Tacloban," said a young woman by the name of Lavinia Orline, who would fly down on the same plane as us. She pleaded that we not stay in Tacloban but press on from there to her hometown of Tanauan, just 16 kilometers south along the coast, nearer the epicenter of the storm. "You could walk," she said. Orline worked as a nurse at an upscale medical center in Marikina City, outside Manila, and was on her way home to see if her family had survived. And/or to help out however she could. In Tanauan, she explained, "they're telling me they have no rescue teams. There's no food and water. There are a lot of bodies in the street."
"Tanauan," Karch repeated, engraving the word in his memory. "OK."