The terrorist bombing of two nightclubs in Bali on 12 October 2002 was the greatest one day loss of life in Australian history since World War 2, killing a larger percentage of that nation’s population than the attack on the World Trade Center on 9/11. 192 people were killed in all, 78 of them Australians, 22 British, 27 Americans and over 100 Indonesians. There were over 500 seriously wounded.Three bombs were used in the attack. The first, which may have been in hidden in a backpack worn by a suicide bomber, went off at 11.05 pm at Paddie’s Club and consisted of 500 grams to 1 kg of TNT. The second device was a car bomb that exploded 10 to 15 seconds later in front of the Sari Club, which had around 300 people inside at the time. The third bomb, approximately the same size as the 1st bomb, exploded 45 seconds later near the US consulate, and used a handphone as a detonator. The third bomb did not cause any injuries.
According to Graham Aston of the Australian Federal Police, the Sari Club bomb was composed of between 50 and 150 kilos of chlorate, a chemical used in the making of detergents and rocket fuel. "The explosion resulted in a tremendous release of energy; this essentially caused a pressure wave, followed by fragmentation, which was then also followed by a large fire.” The force of the explosion was enough to “somersault” one vehicle 30 meters down the street, and destroy 53 buildings in the epicenter. Buildings nearly a kilometer away had ceramic roof tiles blown off by the blast. A crater was left in the road over 4 meters in diameter. Indonesian authorities, however, disagree, and disagree with AFP’s forensic analysis and have stated that the device contained RDX, (Cyclotrimhylenetrinitamine), HMX, (High Melting Explosive) and a detonator filled with PETN, (Pentaerythritoltetranitrate). The Chlorate was apparently purchased by a suspect named Amrozy (Many Indonesians use only one name) from the Tidar Kimia chemical warehouse in Surabaya, East Java.
It is difficult to assess the emergency response to this event by first world standards. Indonesia has only rudimentary emergency response. There is a fire department, but firemen are not given EMT or Paramedic training. No one in the police or military on the scene was apparently trained in CPR or triage – and if they were, they did not mobilize. Much of the response was done on an ad-hoc basis by local Indonesian volunteers, tourists at the scene, or expatriates with varying levels of knowledge. In this context, ordinary people from all walks of life became the emergency responders, and in many cases performed heroically and by any standard admirably - though not “correctly” from a technical standpoint. The sheer number of casualties must be appreciated - as one American EMT on the scene put it: “Any level one trauma center would have been overwhelmed with this. Completely. Where else on earth do you get 200 people killed instantly and 600 massively traumatized people, badly burned, completely fucked up – all coming in at once, to one hospital?”
Compounding the problem, it should be noted that basic things that EMS responders take for granted in the developed world – other trained responders, limitless medicines, equipment, and a mature command structure, meaning leadership – none of these things are available in Indonesia on the night of 12 October and in the days to follow.
The Bali Bombing wasn’t a typical “incident” or “event” in the standard EMS parlance, it was much more like a major battle in a war. “You could probably point to every single case and say ‘this is where you fucked up, you should have done this…’ But really, they didn’t have a choice.” It is hard to say the system failed, simply because there was no system.
AT THE SCENE
One of the most important figures in the early stages of the response was Haji Agus Bambang Priyanto, who arrived 20 minutes after the blast. Haji Bambang works as the head of parking in the Kuta area, and in this capacity was well known in the area. With the area filled with walking wounded, Haji exhorted local Balinese “ojek” – young men with motorcycles (often thugs) who provide transport for hire – to take anyone who could hold on securely to the hospital.
With no fire trucks yet on the scene, and intense heat preventing access to the area, he quickly returned home to don his uniform and locate members of the Fardu Ki Fayah, an Islamic volunteer group that performs last rites for Bali’s Moslem community. With volunteers in tow, carrying only white cloth (used to wrap bodies in traditional funerals) Haji and his group returned to the scene. Local fire responders were on the scene by that time (around 12:30 AM Oct 13th) and were attempting to put out the flames. Water pressure was apparently quite low. Haji Bambang ordered the firemen to arc water streams over the heads of himself and his volunteers as they moved forward into the fire zone. Agung Tresna, a community leader, worked side-by-side in this effort and also organized local Hindu youths to help with crowd control. Bodies and victims were dragged and carried out in this manner for hours. Around 2:00 am, Haji Bambang recalls feeling something brush against his ankle as he stood in the rubble. He absently kicked his foot and then felt the sensation once again. Looking down, he discovered a hand reaching out of the rubble. Calling for help, he recovered a female Japanese victim, who ultimately survived.
Perhaps the greatest failure in the emergency response involves the police and military. Indonesia has a strong police and military presence, and at least three high-ranking military figures, along with troops, were on the scene, observing, two hours after the bombing. Neither the military nor the police took a pro-active role in the emergency response, not even in providing crowd control at the bomb site or later, at the hospital. Haji Bambang surmises that the military’s inaction was due to concern, at the command level, that action of any kind might implicate them in the attack; Indonesia’s military has a long history of human rights abuses, including alliances with Islamist militia groups that have been accused of a number of bombings across Indonesia in the past two years. Whatever the case, they played virtually no role in the medical response. “They were pretty much worthless.” said one observer at the scene.
There is no number equivalent to 911 in Indonesia. Bali has only two fully-equipped ambulances, which are owned by private clinics, though there are at least 50 vehicles that identify themselves as ambulances – white Colt minivans with sirens that are more often used to bring bodies to graveyards than injured people to hospitals. Ambulances were primarily a notified by cell phone and word of mouth, which traveled fast given the size and sound of the explosion. Triage at the scene did not exist. Those who could walk or ride on the back of motorcycles self-evacuated in that manner. Ambulances on the scene arrived from both Sanglah Central hospital but also from a number of private clinics in the Kuta area. “There was a major problem at the bombing site.” Said one Indonesian doctor later. “We don’t have paramedics trained to look at the priorities of the patients. Who is to be transferred first, second, - on this island we don’t have this system yet. And we need it.” Ambulances in Bali are minimally equipped by 1st world standards, and drivers know only basic first aid procedures. Ambulances were used mostly for unconscious victims, transporting less serious patients to clinics and military hospitals. By morning, ambulances were used to transport the dead, which were laid out in white cloth by Haji Bambang and the many Balinese volunteers. In the coming hours and days the hundreds of critical patients and all the dead ended up at Sanglah General Hospital, approximately 10 km to the north.
SANGLAH
Founded 1959, Sanglah General Hospital comprises 756 beds and has a total staff 2237. There are 169 specialists, 234 GP’s, 850 nurses, 375 non-medical support staff, 7 pharmacists and 376 non-contracted day employees. Nurses have a base salary of around approximately $50 a month. Doctors have a base salary of $100 a month, though they usually have a private practice that provides supplemental funds. In 1990 the emergency room was completed with funds provided by the Japanese Government. Only two years ago the Sanglah Trauma Center was created.
Dr. Tjakra Wibawa, head of Oncology at Sanglah, was called to the hospital and arrived at 12:15 am. The E.R. was already completely full with the first wave of victims. “There were people everywhere – mostly burns and blast injuries - foreign bodies and fractures. I saw many head injuries. There was vomit everywhere - blood, feces, urine – everywhere – an effect of the blast injuries - patients lost control. I went back to basics – ABC’s – Airway, Breathing, Circulation. I never had to make a decision between treating this person or that person – if they could talk, I moved to someone who couldn’t talk, someone who needed an airway.”
As bad as the scene was 20 minutes after the blast, it only got worse. Patients who could self-evacuate generally had relatively minor blast injuries. They arrived on foot, by taxi and motorcycle, and they were treated as they came in. But then the ambulances started to arrive with the most serious patients – the burn victims. By then, though, the O.R.’s were completely full. And they had to wait. Said one witness “Sure, they blew it as far as triage. But under the circumstances? How many people are trained in triage? Even Doctors? The most triage you would ever get in Bali would be a bemo accident with 6 people hurt, they show up at the hospital and they say – you first, you second, you third. Sanglah had 500 traumas to deal with simultaneously…”
The Damage
Said one volunteer: “Burns, burns, - you opened a door, more burns…” Not surprisingly, the major problem was burns. Chemical residue was often apparent in the burns, and cooling off the wounds was performed with saline, and when that was not available, bottled water. SSD (silversulfadiazine) cream was applied as well, but that, too, soon became in short supply. Cheap gauze was most often used to cover the burns, which often tore off skin when changed. Staff at the hospital were unaware of the option of using plastic wrap, which can be used to cover a burn to prevent infection in the short term. IV’s were introduced and antibiotics were widely given, catheters were put in place. Many staff were not aware that plastic sheets are preferable to cloth sheets in the case of burn injuries. Some volunteers – both Indonesian and Western – understood the importance of keeping patients hydrated. Another major problem, as time progressed, was the management of patients over time. Initial treatment was often adequate, but follow-through was bad.
Blast injuries were also almost universal. One case that stuck out in the minds of the many of the doctors was a patient known as “girl with blue belly-button ring” Brought in unconscious, she had no apparent injuries, though she had clearly experienced the force of the blast – her hair was literally standing straight up. She was ventilated and demonstrated no signs of neurological activity. When the ventilator was taken off she died immediately. Common blast injuries were shrapnel and wounds from flying glass. Pneumothorax was also common, and commonly missed. Victims were released after treatment for minor injuries only to reappear hour or days later with pneumothoraxes that had been missed and were getting worse. Compounding the confusion in the E.R. was the fact that many patients were rendered completely deaf from the explosion.
By dawn Sanglah hospital was completely full of patients and over 150 corpses, which were unloaded on the ground near the morgue. The morgue had only 15 body bags in their inventory, so the corpses were either wrapped in cloth or left out in the open. Distraught families and friends of the dead, wounded and missing descended on the hospital grounds, along with hundreds of gawkers, press, and people offering to donate their blood and skills. Once again, the police and military were on hand but not engaged in crowd control. Given the completely overwhelming nature of the incident, along with a complete power vacuum, a variety of individuals – Indonesian and Western - from outside the hospital were able to insert themselves into the situation and provide aid. And by all accounts, they served an essential role.
VOLUNTEERS – Sunday, 13 October
Friends, family and total strangers who accompanied injured to the hospital very often stayed by the sides of their charges. With hospital staff unable to provide complete medical care, many volunteers stepped in. Their activities ranged from fanning the patients and bringing them water (air conditioners were not functioning at Sanglah) to treating burns and performing medical operations. Martin O'Neill, a civil engineer, spent many hours providing counseling to another Australian who had had both feet amputated. This patient had removed all his I.V.’s and wanted O’Neill to assist him in his own suicide. By morning, many volunteers with medical training had heard about the bombing and came in to offer their services. While Indonesian law prohibits foreign doctors from practicing medicine, the administration of Sanglah fairly quickly realized that they were in way over their heads. The leadership vacuum was acute. Sanglah administrators and medical staff were hesitant to give full support to trained foreign medical volunteers, but rarely got in their way if foreign volunteers took the initiative and started to work.
One illustrative scene took place in the early morning of the 13th involving a number of Australian doctors – tourists - who arrived at the wards and discovered patients needing immediate attention. An Australian RN recalls: “There were three very badly burned girls – they are all deceased now – they all had compartment syndrome – and they needed very quick release of the pressure. Their limbs were very, very cold, no circulation at all. So Dr. Veej (an Australian plastic surgeon) asked me for a scalpel to do escharectomy and the Australian consul stopped me and said, rightly, ‘You can’t do this without permission from the Indonesian authorities.’
So I walked with all the doctors back to the emergency rooms to see Dr. K. Dr. K said ‘Yes, but you have to follow procedure - please find Dr. L.’
So we found Dr. L and he said ‘Yes, but you have to follow procedure, you have to talk to Dr. X’.
So we went to talk to Dr. X and he said ‘It is not up to me, it is up to Dr. K’.
So I said to him ‘We’ve been to Dr. K!’ Dr. X said: ‘You have to go back to him.’
So I went back to Dr. K, and said ‘We are here, we are ready and willing to help, but we can’t work without your permission.’
And Dr. K responded by saying, again, ‘Well, you can, but you have to follow procedure…’
I said ‘Will you PLEASE show me your procedure!?’
And Dr. K realized we called it, because they didn’t really have a procedure to do escharectomy. Dr. K stood there a moment and then just shrugged his shoulders.
I asked: ‘Can I take that as consent?
Dr. K said ‘I suppose…’
‘Does everyone witness that? Let’s go…’”
This interchange is consistent with a complaint heard over and over from interviews with volunteers – the lack of general leadership from some western consul officials – fearful of an “international incident”, and Indonesian hospital administrators, unwilling to take responsibility or make adjustments to the existing structure that was completely inadequate.
This is not to say that the volunteers were always doing the right thing. At one time an Australian doctor came into a ward and removed a patient’s I.V. line, denouncing the Indonesian staff and explaining that it wasn’t proper to put a line into a burn site. “But in this case, there was no healthy tissue.” recalls Dr. Wibawa “Everything was burnt – and we put it there just to get some fluid in…” Later, the Australian doctor tried to get a line back into the patient and was unsuccessful. Kim Patra, an Australian-born RN who is now an Indonesian citizen, found herself constantly telling volunteers to stop feeding patients. In the early stages there were too many volunteers and they were completely unorganized. “I told them to organize themselves – take one specific job.” recalls Dr. Tjakra “When that began to happen things started to go much better. We had a lot of volunteers helping us, working the help line, giving information, work at crisis center. After it was ok.”
MORGUE
“I think the morgue was mind-blowing -- just absolutely mind-blowing.” Kim Patra, RN
“The people in the morgue deserve all the credit…” Dr. Tjakra Wibawa
American expatriate Sam Schultz is a long-time Bali resident who in the 1970’s lied about his age became an EMT at age 16. Sam arrived at Sanglah at 10 am the morning after the bombing. “I went into the hospital, thinking I could help, but it was unapproachable – just way too much. So I headed to the morgue. And I saw immediately that it was just absurd. You know those breezeways at the hospital? Bodies everywhere. And just tons of people – tourists – Indonesians, expatriates, press. No security at all. People taking pictures. Cops and military people just standing around . It wasn’t till the 3rd day that they started to cordon off the area.”
“One tourist – this guy Baba – was there. Baba is a total lunatic – one of those kind of hippy European guys you meet in India with the flip flops, the bag containing everything he owns, the chillum – that kind of thing. He was a main mover at that point. Crazy as hell, but he was the effective. Baba was the guy calling fish processing plants - screaming into the telephone for them to bring ice to the hospital ,- because people at the morgue were not dealing with it.”
“The morgue personnel were all there since early, doing their absolute best, attempting to act like it was business as usual - you know, bureaucrats - trying to deal with this in a normal way, and that was impossible. That created the chaos in a way.”
One simple problem was tagging the bodies. Some of the Indonesian bodies had ID’s, and it was fairly easy to deal with them. Most of the tourists wore light clothes that burned off, and left ID back at their hotels before heading out Saturday night to party. Making matters more difficult was that many of the bodies – over 45 – were so badly burned it was impossible to tell if they were male or female, Asian – meaning local, or Caucasian – meaning tourist. A “miscellaneous” room was allocated for unidentifiable bodies and body parts, which continued to be found over the next 24 hours.
Simple problems – only 15 available body bags – body tags made of water-soluble paper that disintegrated when wet, created major problems as time progressed. Few of the volunteers wore protective clothing – even rubber gloves were in short supply.
EVACUATION
The first C-130 Hercules from Australian arrived at 5 pm on 13 October, 18 hours after the explosion. In the hours leading up to the evacuation Kim Patra, an Australian-born RN who is now an Indonesian citizen, was working closely with the Australian Consul, redoing triage. “David __ at the Australian Consul said to me ‘The plane is getting here at 3 o’clock, but don’t tell anyone, because if it doesn’t get here we’ll have a riot.’ And I said, ‘David, add three hours to that. I evac, I know. And I never tell them when the plane is going to land. For sure you can add 3 hours to it.’ And it arrived at 5.”
Information coming from the Consul was often confusing. “I kept trying to get a list of what the plane had, how many ventilators, because I can’t do triage without that information.” Patra traveled around Bali’s capital Denpasar trying to round up all the patients that remained in local clinics and Military hospitals. “…and some of those patients had not gotten the right treatment and they had to be triaged again. All the dressings were taken off and it was all done again.”
When the Australian military arrived at 5 pm, the evacuation went very quickly. Nearly every ambulance in Bali was commandeered for the effort – “implicitly at gunpoint”, according to one witness. Kim Patra was one of the people in the difficult position of choosing which patients would be on the planes to Australia. “Our instructions were that we had to find the commonwealth patients - Australia, New Zealand, Canadian, English - because there is a mutual aid agreement between our countries. I can’t tell you how hard it was for me – to walk through a ward, thinking ‘You’re from France? I can’t talk to you. You’re Indonesian, I can’t talk to you. Oh, you’re Australian? I can talk to you.’ Really hard. But when the military arrived, they said – ‘We don’t care who they are, where they are from, if they want to come, they can come.’ I was so happy.”
Politics did, however, influence the evacuation process. The Australian Military insisted on bringing one Balinese patient with minor burns back to Sidney – much to the confusion of the people involved in triage. Apparently this patient was a witness and the AFP wanted to interrogate her. For the most part, the Indonesians remained in Sanglah – Indonesian doctors believed they could manage their patient’s problems, and the patients preferred to remain in Bali, close to their families and the support system it provides. It is also possible that many Balinese chose to remain in Bali out of fear of dying alone, overseas.
One commonly heard complaint among Balinese doctors – and confirmed by some western volunteers, that many of the transported patients were not stable enough to transfer. Says Dr. Wibawa: “I don’t criticize the Australian Military for the evacuation – if your son and daughters are hurt, you are going to want them back. But they didn’t trust us to take care of their patients. Some of the patients were very critically ill and not stable. And our National Trauma Team had arrived by this time. So we tried to talk to the Australian team and said ‘This patient should be stabilized first, before transport.’ They disagreed. They said they had an ICU on the airplane, ‘We can take care of it...” But I heard that at least one patient died at the airport, during transport. One patient we had tried to stabilize with severe burns, a hemoglobin level of 4. We had tried to give him a transfusion and stabilize him before transport - but they wouldn’t have it.”
But Australian medical personnel at the scene dismiss this criticism. “They would have died anyway because the weren’t getting proper care at Sanglah.” said one. Another controversy, the subject of many articles in local Indonesian papers, is the question of whether Indonesians received substandard care relative to the westerner victims. All the westerners believe this to be the case, as do many Indonesian volunteers. Doctors at Sanglah vehemently deny it, though some say that western patients got more attention simply because they demanded attention loudly and emphatically. From a cultural standpoint, it is fair to point out that Indonesians are far more stoic and resigned even when in extreme pain, and also much less likely to question authority – even when their lives are at stake.
MONDAY, 14 October
Even after the evacuation there were still hundreds of critical patients at Sanglah. With fewer western patients, many of the western volunteers – many who had been there for 24 hours – returned home. While the numbers of patients had lessened considerably, the hospital staff was still completely overwhelmed, and instead of the situation stabilizing, the bureaucracy collapsed further. Volunteers, mostly Indonesians, were still “dragooning nurses to change dressings” according to a witness.
Lee Downey one of the people who had been organizing the volunteers. A family center was created for western people looking for loved ones, because by Monday families were already arriving from Australia. A room was set up to post photographs of bodies for family members to identify. Coordination efforts were attempted with embassies, police, and the hospital. A week after the blast relatives were still showing up at the morgue looking for answers, because the volunteers were better informed than the embassies.
The situation at the morgue – which has a total of 12 refrigerated bays, was becoming more and more intolerable. By this time two American bodies had been identified and all 192 bodies were simply lying out on the ground or breezeway floors. “Baba”, one of the early organizers at the morgue, was removed after smashing the camera of a TV news crew. Sam Schultz found himself in very heated arguments with the Australian consul over how to best deal with the problem. “They kept saying that their forensic teams – the Pros From Dover – were going to show up and we had to do certain things. On our own we had spent 24 hours trying to get refrigerator trucks in because we knew that people were rotting on the ground. So finally we got the body bags, we got the trucks and said, ‘Okay, let’s put the bodies that we’ve I.D.’d in the freezers.’ We spent hours and hours and hours getting them in the trucks - cooled down, worked really hard to do this, because the bodies were just piled on the ground, with ice melting fast. Then the Australians came in and said – ‘No no no, we want them out again, because the forensic team is going to be here in 2 hours and…’
So it went back and forth. We’re screaming at each other. I’m saying ‘This is obvious! This is bullshit!’ And the Indonesian coroner is saying to me ‘Look, I have these ministers walking in, the President, the Vice President, and MY boss is telling me to do whatever the Australians ask.’ And the Australians are saying: ‘This is the Indonesian’s job, whatever the Indonesians want…’, and of course, you ended up with the dog’s breakfast.”
So I turned right around, and said to the coroner, Pak Edi, ‘Okay, lets do it’. We ended up pulling everyone out of the coolers, laying them out, and we saw every body all over again, opened the bags, checking ‘Is this am male or female? Identifiable as an Asian or not?’ This took hours and hours. So we got them all laid out again. I went home to sleep and when I came back the next day the bodies were still there, rotting. Because the Australian Forensic Team did not show up for another 36 hours.”
Kim Patra recalls: “I went down to the morgue because I knew that relatives were flying in. So I got my mask, hat, gown, boots, knowing full well that there were 200 bodies down there. I was shocked to see all these people dressed in shorts and thongs and singlets. Those people – and I hear they are having quite a few problems now – to think that they just walked out of their lives as surfers, students, hotel waiters, fourteen year old red cross volunteers in white bibs - into that… And do what they were doing…There were guys – dudes – beach bums - in the back of the trucks - two refrigerator trucks full of bodies – just wrapped in anything they could find. When I arrived they were taking the remains out and putting them in body bags, which had just arrived. And there they were, wearing nothing but beach clothes. And the smell. I was just amazed. I suppose it should not have been allowed, because they are coming down now with infections and psychological problems. But who was going to do it? Forensics had not arrived, there was no post mortem stuff.
I felt out of place in my O.R. scrubs. Like a big green robot.”
Sam Schultz: “Finally, the English consul showed up with his own freezer truck and said ‘We are putting all the English identified into the freezer’. And the Coroner said okay. You could do what you wanted if you could take responsibility yourself, and the English did that. Got the bodies in the truck – 18-19 people. I spent most of the day harassing the Australians – ‘Look, we’ve got three refrigerator trucks ready to go – 50 people I.D.’d already as Australian citizens, lets get them back in there.’ They said ‘Good idea, good idea, but…’”
TUESDAY 15 October
By Tuesday many of the overworked Indonesian doctors had help from additional foreign doctor volunteers. Recalls Dr. Tjakra “We had plastic surgeons from Singapore General Hospital come in on Tuesday. A team from Belgium. Then the Philippine team and one doctor – Dr. Bill Holmes – a hand surgeon - flew in from the United States. I had called him in the U.S. and informed him of the many hand burns. I just said ‘Please come, just come, we will see what you can do.’” By this time donations and medicine was arriving in large amounts from all over the world. Again, Sanglah did not have a mechanism to inventory, store, or secure the relief materials. There is a general consensus that a great deal was stolen. However, much of the supplies did reach their destination. Kim Patra was very surprise to discover that a week after the bombing Sanglah’s Melati ward had been completely renovated and converted to a burn unit. Air conditioners were working, and the staff was attired in sterile garb.
THE FUTURE
The western victims now are at least fortunate that they now have access to high standards of health care. Indonesian victims will continue to be treated for free, but the standards of care are much lower and overall outcomes less optimistic. A number of foundations have organized themselves under the umbrella of the Ibu Pertiwi Foundation which hopes to address this disparity. The main function will be to locate and provide follow-up care – physical and psychological – to the Indonesian victims of the blast.
As of this writing, there are 3 separate plans to develop an International Hospitals in Bali. Most observers agree that one good hospital is all that is really needed. In the short term, it is felt that there must be an emphasis on training and raising health care standards. “You can’t have a level one trauma center if you don’t have the trained staff to run it.” Said one observer. It is universally agreed that the Indonesian medical system needs help on all levels, but particularly at the administration level and at the level of first responders – there is no such thing as a paramedic or an EMT in Indonesia. Doctors and surgeons can become wealthy from their private practices – and in fact many are highly skilled with advanced degrees from foreign medical schools. In contrast a nurse – whose training usually ends upon graduation from a nursing high school – gets a salary of around $50 a month. E.R. patients may get adequate or good initial care, but once they are released to the ICU or the wards they are badly monitored. The Indonesian medical community has been on the defensive since the bombing, and most alarming to doctors is the growing call that Indonesia allow foreign physicians and nurses to practice, which would impact heavily on their livelihoods.
The total absence of 1st Responder training may be a blessing in disguise. If foreign aid organizations can fund such programs they will not have to do battle with an entrenched bureaucracy. Indonesians from outside the medical community can be brought in, international standards can be established from the beginning, and the benefits will be immediate. Nurse training and standards must be improved drastically, and allowing foreign nurses, doctors and administrators to work in Indonesia would have a positive effect on overall standards. A common argument made by Indonesian doctors is that this would result in a 2 tiered health care system – with the rich going to foreign doctors and the poor given to the Indonesian doctors – but clearly this is already the case: a 2 tiered health care system is already the norm in Indonesia.wealthy Indonesians usually seek medical treatment in Singapore or Australia, the poor have Sanglah. When the health gap is made worse by an inefficient, stagnant bureaucracy, and the result is a system with the worst Indonesia seems to have the worst aspects features of both for-profit and socialized medicine.
Lessons Learned
Tourists are ideal “soft targets” for terrorists, particularly in countries with porous borders and lax security. While Australia is only two hours away from Bali, it took 17 hours before military transports arrived to evacuate the injured. It also took forensics investigators nearly three days to arrive on the scene, by which time a great deal of evidence had been lost or degraded. At this writing, more than a month after the bombing, there are still 31 unidentified bodies at Sanglah hospital awaiting DNA testing. Western governments should develop emergency response protocols that will allow them to respond quickly and effectively when large numbers of their citizens have been victims of a terrorist attack or natural disaster in a foreign country..
It would take an incident of immense proportions to overwhelm a 1st world hospital the way that Sanglah hospital was overwhelmed, but if 9/11 has taught us anything, it is that we should expect it. The Bali bombing highlights the role that volunteers can play in such an incident. The day may well come that a terrorist or natural disaster may create so many casualties that a first responder – along with his normal duties - may be called to demonstrate leadership and marshal the efforts of untrained volunteers until a system is in place.
As Sam Schultz put it: “This situation was very much like a war. Now you can train 100 men for war but when the war comes only about 6-7 are going to be able to handle it – and a good military will support those people regardless of their place in the command structure. And also in a war you’ll find outsiders who can handle it. And when they come forward, you’ve got to point them in the right direction and support them too. Even if it is just means giving them positive feedback.”
“You’ll also find that there are people who can’t deal with it, and if they are part of the bureaucracy they can cause a lot of problems. They can’t drop their normal reality and say, ‘Here we are in an emergency situation, we have to adapt.’ Find the people who are willing to deal with it - trained or not – and support those people – until you’ve got a functional system in place.”
The Bali Bombing, from a response standpoint, was primarily a failure on the level of infrastructure, administration and command. It points to the importance of developing and maintaining command structures that are both clear, well defined, yet contain enough flexibility – “tensile” strength – to stretch and bend to accommodate skilled and/or willing volunteers.
It was is hard to find many instances of people in the response at the scene who did not work until exhaustion and take great personal risks in order to help others. People from all walks of life, all religions, nationalities, education levels, and cultures pitched in with an esprit that is both courageous and heartbreaking. Had there been a response mechanism in place in Bali that could have organized and focused the human resources, no doubt many more lives could have been saved.
END
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