Health Situation Report
developed in conjunction with
United Nations Resource Centre in Ambon
July 30 – August 14
David A. Bradt
18 August 2000
WHO \ Ambon Health Situation Report page 1
I. PUBLIC HEALTH INDICATORS
A. Population at Risk
Maluku Province total and IDP population estimates are presented in Table 1.
Total and IDP Population Estimates in Maluku Province
Source--Provincial Health Authorities
1 August 2000
+ District Baseline IDPs Interval % ChangeIDPs * Population 04/0008/00 Change IDPs
Ambon Municipality 312,135 49,860 143,384 95,324 +190%
Central Maluku 568,034 61,690 63,338 1,648 +2.7%
Buru Island 115,082 25,662 10,347 (15,315) -60%
Southeast Maluku 176,640 41,375 33,642 (7,733) -19%
West Southeast Maluku 139,674 12,831 10,317 (2,514) -20%
Total 1,311,565 191,418 261,028 69,610 +36%
* census data of 4/00 + (interval change / IDP population April estimate) x100
The extent to which IDP flows have altered district populations remains unclear. The April census data show a decrease in Ambon Municipality population from 321,000 reported 11/99. Nevertheless, Provincial Health authorities are convinced the total population of Ambon Island and Ambon Municipality has increased by IDPs—largely immigrating from Buru and Central Maluku Districts.
Ambon Island subsumes 2 subdistricts of Central Maluku District as well as 3 subdistricts of Ambon Municipality. SATKORLAK estimates 149,834 IDPs inhabit Ambon Island equivalent to 57% of the total IDP population. Changes in total provincial population are speculative.
IDPs reside in a variety of sites including governmental and military buildings, dedicated camps, host families, and improvised shelter. The total number of settlement sites is unclear though surpasses 200 on Ambon Island alone. Existing registrations are commonly initiated by IDPs for secondary gain—such as
health cards enabling free health care at Ambon Municipal health facilities. Refugee site population sizes remain largely speculative.
2. Population Movements
IDP locations and movements are tracked by SATKORLAK. Interval changes from April-August reveal a 190% increase in IDP population in Ambon. The most substantial IDP movement of the past month on Ambon Island occurred from the village of Waai. Waai, a coastal Christian village situated between two Moslem villages in northeast Ambon Island, was attacked the night of July 31-August 1. This attack, the second on Waai in a month, reportedly left 29 persons dead and displaced 3,776 persons to the neighboring village of Passo. There, a factory there now houses approximately 5,500 IDPs. SATKORLAK itemized IDP movements for the province are presented in Annex 1.
B. Disease Surveillance Reporting
There are no comprehensive periodic disease surveillance reports issued by Maluku authorities. Dinas Kesehatan, through its Chief of Communicable Disease Control (CDC), takes responsibility for disease surveillance of the general population. However, disease surveillance is acknowledged to be the weakest
WHO \ Ambon Health Situation Report page 2
of four major functions of the CDC unit. Moreover, Kanwil and Dinas Kesehatan have not clearly delineated administrative responsibility for summarizing the health situation of IDPs. In general, provincial health authorities defer to SATKORLAK on denominator estimates of IDP population size.
Periodic disease surveillance data sets exist only for Ambon Municipality. There, the Chief of the Ambon Municipal Health Office provides health center staff salary upon submission of health center monthly surveillance reports. Real time compliance with reporting requirements approaches 100%. Data sets are fragmentary from other districts in the province. Even within Ambon Municipality, there are no reliable periodic disease surveillance data for IDPs. While occasional camp-specific reports emerge of IDP illnesses and deaths, there is no functional IDP camp surveillance system, district-wide aggregate profiles, much less trend analyses. The Chief of the Ambon Municipal Health Office reports neither international nor local NGOs working in Ambon have submitted surveillance reports to her office in four months.
Death data are incomplete. Officially recognized death reports originate in hospitals and health centers. Morbidity and mortality data follow a pathway prescribed by hospital type. The provincial hospital reports to the Ambon Municipal Health office. Military hospitals report to the Central Military Hospital in Jakarta, and those figures are routinely not provided to the Municipal Health Office. Private hospitals are generally non-reporting. The Al Fatah Hospital acknowledges non-participation in morbidity and mortality reporting. The limitations in collection and reporting of epidemiological data from the various health structures are characterized in previous WHO\EHA reports.
Ambon Municipal Health Office reports the following July data acquired from 15 of 15 municipal health centers:
1. Municipal Mortality
IDP camps 2 (1 TB, 1 old age unspecified)
Non camps 32
Total deaths 34
2. Municipal Morbidity
Malaria clinical 447
Diarrhea simple 215
LRI 50 (40 pneumonia)
Total visits 25,157
Crude mortality rates, proportional mortality, and incidence rates cannot be calculated. Overall, available data does not suggest excess medical mortality for Ambon municipality.
Ambon Municipal Health Office does not compile conflict-associated statistics for the Municipality. Provincial health authorities provide conflict-associated morbidity and mortality data for specific riots. These data are based upon verified reports from health facilities. These data are tabulated in official health summaries written after serial riots. The reports, therefore, encompass varying time intervals. Riot-specific reporting intervals with attendant morbidity and mortality are presented in Table 2 below.
WHO \ Ambon Health Situation Report page 3
Riot-associated Morbidity and Mortality
Source--Provincial Health Authorities
Riot Dates Injured Survivors Deaths
Mildly Injured Severely Injured
1 Jan – Jun 1999 658 958 250
2 Jul – 25 Dec 1999
3 26 Dec 1999 – 10 Jan 64 80 85
4 11 Jan 00 – present N/A N/A N/A
Data from the Governor’s office, by contrast, reveal 918 deaths and 2,256 persons injured from conflict during the period Jan 99 – Jan 16, 2000.
From February 2000 – present, aggregate data on district or province-wide conflict-associated violence remain unavailable from provincial authorities. Monthly data on trauma incidence in this period exist for Haulussy General Hospital (Table 3).
Riot-associated Morbidity and Mortality at Haulussy General Hospital
Source--Provincial Health Authorities
Month Outpatients Inpatients Deaths
January 1 29 4
February 2 14 4
March 0 9 0
April 6 11 2
May 2 30 2
June 79 70 20
July 24 27 9
Total 114 190 41
Anecdotally, provincial health authorities describe an evolution in trauma pathology during the conflict from edged weapons to high velocity firearms. Provincial health authorities suggest that official death reports are underestimates, that conflict is escalating, and that conflict-associated deaths in 2000 will surpass those in 1999. While rates are speculative, excess traumatic mortality clearly exists at a level consistent with a low intensity conflict.
3. Epidemics and Epidemic Potential
The Ambon Municipal Health Office reported no epidemics for July. Of the three measles cases reported in Ambon Municipality, one occurred in Latuhera Camp and two occurred in Passo village. All three cases were reportedly confirmed, and considered imported by IDPs from Buru and Southeast Maluku Districts. Public health response entailed camp-specific targeted measles immunization. Of diseases with epidemic potential, there were no reports of dehydrating diarrhea, dysentery, acute flaccid paralysis, suspected meningitis or hepatitis.
The Provincial Chief of Communicable Disease Control (CDC) expressed epidemic concern in two areas of the province. Masohi village, Central Maluku District, on Seram Island reported 1013 cases of clinical malaria over the past 6 months. While comparative baseline figures were not provided, Chief of Provincial CDC characterized these data as an outbreak.
WHO \ Ambon Health Situation Report page 4
Furthermore, MSF-B, working in Larike village, Leihitu Subdistrict, Central Maluku District, on Ambon Island, reported 5 cases of suspected measles among IDPs over the past two months. CDC has been unable to confirm. Nevertheless, these suspected cases have highlighted concerns over weakening EPI coverage, IDP population movements, and pockets of increasing population density. MSF-B, with concurrence of provincial health authorities, is planning a measles immunization and vitamin A campaign this month for Central Maluku subdistricts of Ambon Island. The Ministry of Health, with support of UNICEF and WHO, is planning a measles, vitamin A, and polio immunization campaign September - October for the entire Maluku Province.
Overall, outside of Ambon Municipality, provincial health authorities anecdotally characterize epidemic preparedness as inadequate.
D. Health Personnel
Attrition of health staff is a major issue for provincial health authorities. Provincial health authorities report the following data on physician staff in their health facilities (Tables 4 and 5). Data for nursing staff remain unavailable.
Physicians Staff in District Health Centers
Source--Provincial Health Authorities
Location # Health Physicians Dentists
Centers Working Unmet Need Working Unmet Need
Ambon 15 8 7 3 5
Central Maluku 49 13 41 1 20
Buru Island 10 4 7 0 3
Southeast Maluku 19 9 12 1 2
West Southeast 17 3 17 1 4
37 86 6 34 Total 110
Physician Staff in Selected District Civil Hospitals
Source--Provincial Health Authorities
Hospitals Specialist Physicians General Practitioners
Working Unmet Need Working Unmet Need
Dr. Haulussy Provincial 6 6 6 2
Al Fatah (Ambon) 4 5 2 2
Masohi Hospital (Central 0 4 4 2
Much of the physician shortage is attributed to security deterioration. People have fled Maluku. Hiring and reassigning local physicians in response to local needs is precluded by bureaucratic regulation. Only the MoH reportedly has authority to contract and assign health staff. Temporary remedies have emerged from military medical teams seconded through the MoH to provincial health facilities. Nevertheless, Tables 4 and 5 reveal significant gaps remain in physician availability--particularly for health centers.
WHO \ Ambon Health Situation Report page 5
Moreover, physician secondments last 6 months with the some teams now due for replacement. Provincial health authorities believe that additional funding at ministry level could ameliorate physician staff shortages.
E. Essential Drugs and Supplies
Provincial health authorities report deficiencies in essential drugs and supplies. Site visits to hospitals and health centers confirm. Major reasons for these deficits include:
1. Marginal baseline provisioning of health centers
Yearly provincial budget for procurement of health center drugs and supplies is 5.4 b Rp. Provincial health authorities report 60% comes from provincial financial allocation (impress obat), 30 % comes from direct MoH distribution, and 10% comes from donations (typically international donors). The sources are considered marginally adequate without unforeseen circumstances.
2. Material destruction of warehouse stocks
The most recent example was complete destruction by arson of a Central Maluku district warehouse at Galala last month. This warehouse contained one year’s stock of essential drugs and supplies valued at 1.6 b Rp (20% of provincial procurement budget). While Central Maluku stock redistribution has restored 50% of the losses, government replacement of the remainder is considered unlikely. This deficit represents 10% of the province’s yearly supply. Specific items are listed in Annex 2 (electronic version not available).
3. Altered epidemiology with increased resource consumption
All major Ambon hospitals interviewed report increased trauma caseloads. Government decree stipulates that victims of riots receive free care at provincial government civil and military hospitals. These hospitals would ostensibly receive provincial government reimbursement for increased medical resource consumption. Local hospital authorities assert such reimbursement is not forthcoming. Moreover, private hospitals providing surgical procedures, such as Al Fatah, report receiving reimbursement inferior to that given government hospitals. Consequently, marked deficits have accumulated in resources needed for hospital-based trauma care. These deficits are detailed in Annex 3 (electronic version not available).
4. Interrupted distribution chain
Medical logistics remains impaired by security incidents (refer to Section IIA). Consequently, provisioning to provincial health centers is irregular and delayed. Moreover, lack of trucks and drivers complicates medical logistics even during periods of relative calm.
II. SECTORAL ISSUES
The security situation in Ambon is unpredictable and dangerous. From July 31-August 13, mission team members witnessed, heard, or obtained firsthand reports of the following events:
; village ambush Waai Village; August 1
; arson Ambon Municipality—old market; August 1
; grenade explosions Ambon Municipality; recurring
; extrajudicial execution by hanging Ambon Municipality—Al Fatah; August 8
; snipers Ambon Municipality—Air Mata; recurring
; urban transportation choke points Ambon Municipality--Jl. Dr. Tamaela; recurring ; hate speech—Laskar Jihad threats Siwalima Newspaper, August 7, 8
against Christian villages; Governor’s
The state of civil emergency is evidenced by:
WHO \ Ambon Health Situation Report page 6
; curfew from 22:00 to 06:00;
; TNI checkpoints at corners of the Governor’s civil administration building, major intersections in
Ambon, roads from Ambon, and the airport;
; TNI patrols in public streets;
; helicopter gunship making multiple landings to discharge soldiers before the Governor’s civil
; disrupted public services—garbage uncollected for months on city streets; electrical blackouts
In Ambon Municipality, activities of daily living continue. Street traffic is orderly. Pedestrians walk leisurely. Pedestrian fear is not evident. The Governor’s administration building which houses the UN Resource Center is reportedly considered neutral. Work at the building was precluded only once over two weeks by security concerns.
However, snipers and choke points have markedly altered patterns of daily activity. One violence-prone area curtails traffic on Jl. Dr. Tamaela. Closure of this road divides Ambon Municipality and precludes vehicular access to the major military hospital and provincial hospital. Overall access is recurrently impaired to lifelines of markets, hospitals, and schools. Utilities have been under attack, and administrative work at the Governor’s administration building was impaired 25% of the time by electrical blackouts.
Outside Ambon Municipality, field work is complicated by needs to negotiate corridors of access in response to an evolving security situation. Burned villages are common. Many streets have makeshift barricades. UN drivers expressed fear of driving through villages of different religion without police escort.
International aid workers have not been expressly targeted. Indeed, UN agency affiliation confers locally acknowledged privileges of movement and access. MSF-B reports that flag mounted vehicles attract the least interference.
B. Environmental Health
The most recent IDP movement to Passo led to makeshift housing in local factory buildings which fail to meet minimum standards in water quantity, sanitation facilities, and shelter space. Moreover, the largest existing IDP camp at Halong, with approximately 10,000 persons, also fails to meet minimum standards in water quantity and sanitation facilities. MSF-B is presently working to address these deficiencies. Nevertheless, breaches of environmental health standards in the largest as well as the most recent camp augur poorly for local capacity to manage future IDP flows.
Moreover, in Ambon Municipality, garbage piles tens of meters in length accumulate in numerous parts of the city. Public Works reportedly lacks vehicles and operating funds for garbage removal. While environmental health appears as yet uncomplicated by epidemic disease, it clearly emerges as a major risk factor in future excess medical morbidity and mortality for the entire population.
C. Coordination of External Assistance
The Vice Governor’s coordination meeting occurs weekly on Wednesdays at 11:00. Health coordination
meetings between Provincial Health Authorities and MSF occur biweekly on Fridays at 10:00. A component summary of humanitarian health assistance on Ambon Island, compiled by WHO, is presented in Annex 4.
WHO \ Ambon Health Situation Report page 7
A. Health Sector of Ambon Island
1. Complete measles immunization campaign on Ambon Island.
2. Deliver minimum standards of water supply to Passo and Halong Camps.
3. Construct minimum standards of sanitation facilities in Passo and Halong Camps. 4. Clear the garbage from streets of Ambon Municipality.
5. Replace 800,000,000 Rp of destroyed essential drugs at Galala warehouse.
6. Investigate adequacy of provincial medical logistics—particularly for drug and supply
distributions to hospitals and health centers.
7. Establish agreements with Al Fatah and Haulussy Hospitals on needs prioritization in
anticipation of equal, pre-announced, publicized, concurrent, and transparent distributions of
8. Print and distribute health cards enabling health care access by IDPs.
9. Recruit 10 physicians for Ambon Health Centers by salary support to MoH.
10. Provide qualified health professional to support disease surveillance at the Ambon Municipal
Health Office and Provincial Communicable Disease Control. Equip this professional to provide
technical assistance in epidemic preparedness, outbreak investigation, and disease control. 11. Disseminate clinical case definitions and treatment protocols including IMCI guidelines to the
Health Centers and health NGOs.
12. Initiate IDP camp sentinel surveillance to include Halong and Passo camps.
13. Develop contingency plan for further IDP flows. Urgently prepare two reception facilities
capable of receiving 3,000 persons each. Consider structural rehabilitation of local university
and former Moslem market.
14. Hire 50 community aid workers through the UN Resource Center. Disseminate health promotion
information on survival in low intensity conflicts through contacts established by UNDP
community development activities.
B. Precursors to Effective Humanitarian Health Assistance on Ambon Island
1. Saturate local media and information outlets with UN Resource Center mission statement, goals,
2. Establish military duty posts at chokepoints to Al Fatah Hospital and Dr. M. Haulussy General
Hospital. Specifically open and ensure traffic through Jl. Dr. Tamaela.
3. Extirpate snipers from Air Mata and other inner city areas.
4. Report security incidents and maintain spot maps of security incidents at UN Resource Center in
cooperation with regional Police Chief Firman Gani.
5. Declare humanitarian corridors to IDP sites, major markets, and hospitals in Ambon
6. Condemn hate speech in print and broadcast media.
7. Support UN Resource Center with 2 satellite phones, one vehicle and driver-translator per
international staff member, and US $100,000 in unallocated funds.
8. Hire 2 water trucks, 2 cargo trucks, 2 garbage trucks, and four international drivers. 9. Staff the UN Resource Center with an international security officer to establish UN civil-military
liaison. Provide salary support to Bakornas to hire one Indonesian disaster management officer
for the UN Resource center.
10. Prepare UN Resource Center staff withdrawal plan from Ambon Municipality to rural village
safe house, and staff evacuation plan from Ambon Island.
WHO \ Ambon Health Situation Report page 8
Updated IDP Numbers and Location: Provided by SATKORLAK on Request, Dated August 1, 2000.
Location Number of IDPs Island
Satkorlak notes that this is not to
be taken as a comprehensive list,
recognizing that there are IDPs
who have not yet registered.
AcF had a count of 1,631 IDPs
on Haruku Island (between
Ambon and Seram) in April
2000. A current update is not
readily available. The situation
in the Kei islands is also
confused at this time.
IDPs seeking refuge before January 25, 2000
Kab. Maluku Tengah 25,490
Kab. Maluku Tenggara 33,642
Kab. Kota Ambon 49,054
IDPs seeking refuge since January 25, 2000
Tantui, Galala, Waai 32,500 Ambon
Benteng, Kuda Mati, 26,150 Ambon
Kusu-Kusu 7,530 Ambon
Ema, Kilang, Naku 28,150 Ambon
Alang, Lilibooy, Hattu, 6,450 Ambon
Wailawa, Hative Besar
Saumlaki 10,317 Tanimbar
Namlea, Leksula, and 10,347 Buru
Masohi, Waipia, and 31,398 Seram
Total Ambon Island 149,834
Grand Total 261,028
WHO \ Ambon Health Situation Report page 9
Humanitarian Health Assistance Component Summary
Components of Assistance Milestones and Benchmarks Status Priority Lead/Contact
Rapid Epidemiological Assessment
Security stabilization Access Negotiable Governor Beneficiary identification Site mapping Not done
Registration Not done Communication Radio handset provision Variable Rapid epidemiological assessment Template None Assessment priorities Crude mortality rates Not available
Environmental Health Services
Water supply Minimum standards Unmet PU, MSF-B Food supply Minimum standards Met intermittently AcF Sanitation Minimum standards Unmet PU, MSF-B Shelter Minimum standards Unmet Vector control Service delivery Inadequate PHA
Public Health and Clinical Services
Primary prevention Measles immunization campaign In process PHA, MSF-B
Vitamin A distribution In process PHA, MSF-B Health services delivery Complete camp allocation Not done Standardized case management Clinical case definitions NGO specific MSF-B
Treatment protocols NGO specific MSF-B
Essential drug list NGO specific MSF-B
Referral guidelines Not done
Secondary prevention measures Not done Epidemic preparedness
Communicable diseases of epidemic potential Clinical case definitions Not disseminated PHA
Case management guidelines Not disseminated PHA
Outbreak management protocol Staff to investigate Assigned PHA
Specimens to collect Assigned PHA
Reference lab to identify Assigned PHA