Myanmar – Cyclone Nargis

International Federation of Red Cross and Red Crescent Societies (IFRC)

Myanmar – Cyclone Nargis

Cyclone Nargis (REUTERS/courtesy

On 2 May 2008 tropical cyclone Nargis hit the coast of Myanmar and devastated large parts of the low-lying delta region of the Irrawaddy River. Winds exceeded 190 kilometres per hour as the storm ripped through the Myanmar’s biggest city Yangon (estimated population 6 million) for over than ten hours. Homes were flattened, more sturdy structures damaged, trees uprooted and power lines downed. In rural parts of the country up to 95 per cent of all homes were destroyed.

This is a situation that the country has not dealt with before and the scale of the needs is clearly massive. Casualty figures continue to rise. The data that is currently available to the International Federation suggests that up to 1 million people might have lost their homes.


Google Earth High-resolution satellite images of the areas affected by Cyclone Nargis (requires Google Earth)
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momentum begins to build in relief operation. (REUTERS/courtesy May 2008
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Essential relief supplies are beginning to reach Myanmar, with the International Federation of Red Cross and Red Crescent Societies sending its first consignment of essential supplies today. However, getting help from Yangon to the worst affected areas is still a challenge, explains John Sparrow, the International Federation’s Kuala-Lumpur based spokesman for the operation.
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relief operation underway as full extent of devastation becomes clear. (REUTERS/courtesy May 2008
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Latest reports from Myanmar indicate that the destruction wrought by Cyclone Nargis is considerably larger than originally anticipated. According to state media, the government of the South-East Asian country believes that as many as 15,000 people have died with an additional 30,000 said to be missing. This makes Nargis the deadliest storm to hit Asia since 1991.
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Docs prescribe, pharmacists dispense, patients suffer (Pt 1)

Docs prescribe,

pharmacists dispense,

patients suffer (Pt 1)

Product Of The System in Malaysiakini | May 8, 08 12:34pm

Real life scenario – Madam Ong, 52, has a 12-year-history of hypertension and diabetes. She complained of generalised lethargy, lower limb weakness, swelling and pain. She brought along her cocktail of medications for my scrutiny. Her regular medications included the oral antidiabetics metformin and glicazide and the antihypertensives amlodipine and irbesatan.

Madam Ong also had a few episodes of joint pains three months ago for which she had seen two other different doctors. The first doctor suspected rheumatoid arthritis and started her on a short course of the potent steroid prednisolone. Thereafter, she developed increasing lower limb swelling for which a third doctor prescribed the powerful diuretic frusemide.

Madam Ong was not on regular follow-up for hypertension and diabetes. Additionally, she has been re-filling her supply of steroids and diuretics at a pharmacy nearby with the purpose of saving up on the consultation charges.

I took a more complete medical history and performed a thorough physical examination. I concluded that this lady’s health was in a complete mess.

She was under sound management by the family physician until the day she defaulted follow up and was started on prednisolone by a doctor who was unaware she was diabetic. The steroid probably helped in relieving her arthritic pains though the suspicion of rheumatoid arthritis was never proven serologically.

However, it also worsened her sugar and blood pressure control and weakened her immune system.

Her legs swelled up because of the fluid retentive properties of the steroids. In addition, early signs of cellulitis were showing up around her legs due to a weakened immune function. The diuretic prescribed by the third doctor helped a little with the swollen limbs but she became weak from the side effects of diuretics.

Madam Ong’s problems escalated when she decided to forgo her doctors’ opinion altogether and decided to self-medicate simply by collecting all her medications from the pharmacist who supplied them indiscriminately. Unknowingly, the pharmacist had added to the lady’s problems in spite of the wealth of knowledge the pharmacist must have possessed.

The above scenario is a fairly common scene in Malaysian healthcare. We see here an anthology of errors initiated by doctors, propagated by the patient’s health seeking behaviour and perpetuated by a pharmacist.

Noteworthy but untimely move

health care malaysiaThe Ministry of Health is set to draw a dividing line between the physician’s role and the pharmacist’s, restricting physicians to prescribing and according dispensing rights solely to the pharmacists.

Such a move virtually has its effects only upon doctors in the private practice and particularly the general practitioner who relies on prescription sales for much of one’s revenue.

Doctors prescribe and pharmacists dispense. It’s the international role of each profession and very much the standard practice in most developed countries.

The Ministry of Health however has failed to take into account the local circumstances in mooting this inaugural move in Malaysian healthcare. The logic and motive behind the Ministry of Health’s proposal is in fact laudable, but only if the Malaysian healthcare scenario is more organised and well-planned.

Spiraling healthcare costs

In the United Kingdom, all costs are borne by the National Healthcare Services. In the United States, despite all the negativity painted by Michael Moore’s Sicko, most fees are paid for by health insurance without which one cannot seek treatment. In these countries and many European nations, there is hardly any out-of-pocket monetary exchange between patients and their clinicians.

This however is not the case for Malaysia. Most patients who visit a private clinic are self-paying clients. The costs of consultation and medications are real and immediately tangible to patients. A visit to the general clinic for a simple upper respiratory tract infection may set one back by as much as RM50.00 inclusive of consultation and medication. Most clinics these days are charging reasonable sums between RM5 to RM15 for consultation. Some are even omitting consultation charges altogether in view of the rising costs of basic healthcare. The introduction of the ministry’s ‘original seal’ to prevent forgery of drugs contributed much to this.

There is no denial that most clinics rely on the sales of medications in order to remain financially viable. From my personal experience, the charges for medications by private clinics are not necessarily higher than pharmacies. In fact, since each practitioner has a stockpile of one’s own preferred drugs, the cost price of the medications can be much lower than that obtained by the pharmacists who need to stockpile a wide variety of drugs. It is therefore a misconception that pharmacies will provide medications to patients at a much lower cost all the time for all medications.

Retracting dispensing privileges from the private clinics will only force practitioners to charge higher consultation fees in order to sustain viability of their practices. In the end, the patients end up paying a greater cost for the same quality of healthcare and medications. Inevitably, much of the increase in healthcare costs will also be passed on panel companies who will then be paying two professionals for the healthcare of their employees.

In this season of spiraling inflation, this proposal by the Ministry of Health is ill-time and poorly conceived.

Unequal distribution of medical and pharmacy services

As it already is, private general practice clinics are mushrooming at an uncontrolled rate. A block of shoplots in Kuala Lumpur may house up to five clinics. Does Malaysia have a corresponding number of pharmacists to match the proliferating medical clinics? If and when clinics are disallowed to dispense medications, the market scenario will become one that heavily favours pharmacists. The struggling family physician suddenly loses a significant portion of his revenue while the pharmacist receives a durian runtuh overnight.

The situation is worse in the less affluent areas and rural districts where the humble family physician may be the solitary doctor within a 50km radius and no pharmacy outlets at all. For example, there are no pharmacies in Kota Marudu, Sabah and only one in the town of Kudat. Patients seeking treatment in these places will get a consultation but no have no avenue to collect their prescription if doctors lose their dispensing privileges.

The absence and dearth of 24-hour pharmacies is also a pertinent issue. At present, many clinics operate around the clock to provide immediate treatment for patients with minor systemic upset. These clinics play an important role in reducing the crowd size and the long waiting hours at the emergency departments of general hospitals.

Without a corresponding number of 24-hour pharmacies to dispense urgent medications, the role of 24-hour clinics will be obtruded. The ministry’s plans of implementing its doctors-prescribe-pharmacists-dispense policy will merely backfire and result in the denial of services to patients.

A bigger problem is the system itself

The increasing number of medical centres around the country is not necessarily in the patients’ best interests or an indicator of improved healthcare provision. Most clinics and medical centres serve an overlapping population of patients. A person may be under a few different clinics simultaneously for his chronic multiple medical problems, resulting in a scattered, interrupted medical record. One doctor may not be informed of the interventions and medications undertaken by the patient at another practice. The concept of continuous care and a long term doctor-patient relationship is practically improbable.

This is unlike the system in the United Kingdom where each family physician is allotted a certain cohort of patients for long term care. The doctor remains in full knowledge over his patients’ progress, making general practice one that is rewarding and meaningful.

The trouble-ridden Malaysian healthcare system prevents optimal clinical practice especially for doctors in the private sector.

Until the Ministry puts in place a more systematic and organised approach to healthcare, patients will still be denied optimal medical services despite a clear division between the roles of doctors and pharmacists. The process of prescribing and dispensing is but one step in the cascade of events that may result in harm being done to the patient. Role separation between the doctor and the pharmacist will not eliminate drug-related malpractice and negligence as I have illustrated in the real clinical scenario above.

Loss of clinical autonomy

Private practitioners in Malaysia are at present enjoying a reasonable sense of autonomy over the health of their patients. In many ways, the freedom of clinicians to make decisions with adequate knowledge of the patient’s needs and circumstances is a plus point in clinical practice.

Involving the pharmacists in the daily management of every patient removes a great part of the doctor’s control over the clinical circumstances of the patient. He may prescribe one drug only to be overruled by the dispensing pharmacist later. The clinician has privy to much information about the patient’s circumstances that are available only in the patient’s medical records. It is based on this information that a clinician makes decisions on the final choices of medications for the patient.

A dispensing pharmacist does not have access to such priceless clinical history and may very well make ill-informed decisions in the patient’s medications. Once again, my introductory scenario demonstrates how pharmacists can help perpetuate a patient’s mismanagement.

Part Two: Selective implementation of rules

PRODUCT OF THE SYSTEM is the pseudonym of a doctor in government service.

Fears Burma storm toll could soar

Fears Burma storm toll could soar


Five days after a devastating cyclone struck, the UN has urged Burma to open its doors to foreign aid and staff.

Many of the estimated million people  

made homeless need food and water

                                                                 A girl drinks water from a container as her homeless family eat donated food in Konegyangone township in the outskirts of Yangon on WednesdayMore than 22,000 people were killed, says the government, but the top US diplomat in Burma warned that without speedy action that could top 100,000.

Amid the “increasingly horrendous” situation, there is a “real risk” of disease outbreak, said the head of the US embassy in Burma, Shari Villarosa.

Some aid has arrived but the UN says big obstacles remain for aid agencies.

Burma’s ruling military junta has approved the passage of some aid, but other offers have been spurned while many foreign aid workers are being held in a queue for visas.

In the area worst affected by Saturday’s cyclone, the vast Irrawaddy delta, survivors have walked for days past dead bodies to find help.

They are hungry, thirsty and vulnerable to disease – but roads and bridges are blocked and aid has been slow to arrive.

Disease risk

The last Burmese death toll, on Tuesday, said 22,464 people had now been confirmed dead and another 41,054 people were missing as a result of high winds and the tidal surge.

Up to a million people are thought to have been left homeless in the crisis, which has left thousands of square kilometres of the Irrawaddy delta under water.

Shari Villarosa, the charge d’affaires of the US embassy in Burma – also known as Myanmar – said food and water were running short in the delta area and called the situation there “increasingly horrendous.”

“There is a very real risk of disease outbreaks as long as this continues,” Ms Villarosa said, according to Associated Press.

The death toll could reach or exceed 100,000 as humanitarian conditions worsen, she said – based on information from a non-governmental organisation that she would not name.

UN map showing worst-hit areas,
based on satellite imagery

Detail from UN cyclone mapBut Burma’s generals will be suspicious of the source of the statistic – their opponent the United States, says the BBC’s world diplomatic editor Brian Hanrahan.

Accounts from the Irrawaddy delta have spoken of fistfights breaking out between survivors desperate to seize dwindling supplies of food and water.

Some are breaking open coconuts for the water inside, while others are driven to eating dead fish.

Deaths may top 100,000Poor sanitation, rotting bodies in the water, and flooding could all bring disease, aid agencies warn.

They highlight the risk of mosquito-borne malaria and dengue fever, along with water-borne diseases such as cholera and dysentery.

Calls for access

The Burmese authorities have attracted criticism over claims they are refusing to provide visas to waiting foreign aid workers and have spurned some offers of help, such as a US offer to deploy three naval ships and two planes in the region.

The US Secretary of State Condoleezza Rice is the latest to voice such criticism, telling reporters:

“What remains is for the Burmese government to allow the international community to help its people. It should be a simple matter. It is not a matter of politics.”

Speaking to reporters, the UN’s humanitarian chief John Holmes accepted that aid agencies had faced difficulties accessing the disaster zone.

But, he said, co-operation from the Burmese authorities was “reasonable and heading in the right direction”.

Devastation the days afterHe dismissed a suggestion by the French Foreign Minister Bernard Kouchner that the UN Security Council should adopt a resolution allowing aid to be flown into the country by force as unnecessarily confrontational.

Mr Holmes said 24 countries had pledged assistance so far worth $30m (£15m), and a flash appeal would be launched on Friday once an initial assessment of need was complete.

Response to Myanmar's crisisAn assessment team was due in Burma on Thursday.

A stream of aid is now in, or on its way, to Burma:

  • The UN says a plane loaded with 25 tonnes of supplies and a small team of rescue staff will arrive in Burma within days
  • The UN’s World Food Programme has dispatched an additional four planes loaded with supplies including high-energy biscuits
  • Chinese media say a plane carrying 60 tonnes of aid has landed in the biggest city, Rangoon
  • Planes from Thailand, India and Indonesia are also being dispatched
  • The WFP has already begun to distribute existing food aid stocks in and around Rangoon, and the Red Cross has a handful of expatriate and many local staff on the ground.

The 10 deadliest storms in history

The 10 deadliest storms in history

Killer cyclones have an impact that lasts long after the winds die down


 Children on the island of Bhola wade through floodwater after a tropical cyclone and tidal wave hit the area on Nov. 13, 1970. The storm killed as many as 500,000 people and contributed to the secession of Bangladesh from Pakistan in 1971.


updated 2:08 p.m. ET May 7, 2008

Can catastrophic storms change the course of history? The answer is yes, based on what happened after the deadliest tropical cyclone in recorded history hit East Pakistan in 1970.

Low-lying islands were inundated, and entire villages were wiped out on Nov. 12, 1970, when the Bhola cyclone swept over the Bengal coast. Crops were destroyed throughout the region. The storm and its aftermath killed as many as 500,000 people.

At the time, East Pakistan was a province separated from the rest of Pakistan by hundreds of miles of Indian territory. Political discord had been in the air even before the storm, but the Pakistani government came under severe criticism for its handling of relief operations afterward.

The outcry drew thousands of protesters to anti-government rallies — and the opposition capitalized on the popular dissatisfaction by winning a landslide victory in national elections held a month after the storm.

The political situation quickly deteriorated to the point that civil war broke out in 1971 — a conflict that widened into a war with India and led to East Pakistan’s independence as the new nation of Bangladesh.

Will this month’s catastrophic Cyclone Nargis touch off a fresh wave of political change just across the Bay of Bengal, in the isolated nation of Myanmar? It’s too early to predict, but the Bhola cyclone shows that a fatal storm’s impact does not end when the winds die down.

Deadliest storms mostly in Bengal
Storms in the Bay of Bengal account for seven of the 10 deadliest hurricanes, typhoons and cyclones in recorded history, as documented by Weather Underground. The casualty figures are notoriously difficult to pin down, but here is the list:

  1. Bhola cyclone, Bangladesh (East Pakistan), 1970. Death toll estimated at 150,000 to 550,000.
  2. Hooghly River cyclone, India and Bangladesh, 1737. Death toll: 350,000.
  3. Haiphong typhoon, Vietnam, 1881. Death toll: 300,000.
  4. Coringa cyclone, India, 1839. Death toll: 300,000.
  5. Backerganj cyclone, Bangladesh, 1584. Death toll: 200,000.
  6. Great Backerganj Cyclone, Bangladesh, 1876. Death toll: 200,000.
  7. Chittagong cyclone, Bangladesh, 1897. Death toll: 175,000.
  8. Super Typhoon Nina, China, 1975. Death toll: 171,000.
  9. Cyclone 02B, Bangladesh, 1991. Death toll: 140,000.
  10. Great Bombay Cyclone, India (from the Arabian Sea), 1882. Death toll: 100,000.

Depending on how the final death toll is estimated, Cyclone Nargis may well find its way onto the top-10 list. On Wednesday, a U.S. diplomat told The Associated Press that the toll could top 100,000.

Other deadly disasters
To put those figures into perspective, other types of natural disasters have caused far more casualties throughout history. China’s 1931 Yangtze River flood rates as the very deadliest on the list, with estimates of the death toll ranging from 850,000 (or even lower, according to the Chinese government) to as many as 4 million people.

The deadliest earthquake in recorded history is China’s Shaanxi earthquake of 1556, which is said to have killed 830,000 people. The Asian tsunami of 2004 also rates a place on the top-10 list for the deadliest natural disasters, with the toll currently estimated at more than 230,000 people.

The 1900 Galveston hurricane, which killed about 8,000 people in Texas, is considered the deadliest natural disaster in U.S. history.

U.S. envoy: Myanmar deaths may top 100,000

U.S. envoy: Myanmar deaths may top 100,000

YANGON, Myanmar (CNN) — The death toll from the cyclone that ravaged the Irrawaddy delta in Myanmar may exceed 100,000, the senior U.S. diplomat in the military-ruled country said Wednesday.

“The information we are receiving indicates over 100,000 deaths,” said the U.S. charge d’affaires in Yangon, Shari Villarosa.

The U.S. figure is almost five times the 22,000 the Myanmar government has estimated.

The U.S. estimate is based on data from an international non-governmental organization, Villarosa said without naming the group. She called the situation in Myanmar “more and more horrendous.”

“I think most of the damage was caused by these 12-foot storm surges,” she said.

Villarosa also said that about 95 percent of the buildings in the delta region were destroyed when Cyclone Nargis battered the area late Friday into Saturday.

On Wednesday, U.S. Secretary of State Condoleeza Rice once again called on the junta to allow aid into the country and said she is speaking with leaders from other nations who may be able to help persuade Myanmar’s leaders to do so.

“It should be a simple matter,” Rice said. “This is not a matter of politics; this is a matter of a humanitarian crisis, and it should be a matter that the government of Burma wants to see its people receive the help that is available to them, and so we are speaking with governments that might have influence with Burma.”

Myanmar is also known as Burma.

The United States has pledged $3.25 million and offered to send Navy ships to the region to help relief efforts — if Myanmar’s government agrees.

The U.S. military has flown six cargo helicopters onto a Thai airbase as Washington awaits permission to go into the south Asian country, two senior military officials told CNN’s Barbara Starr.

Villarosa said 70,000 people are missing in the Irrawaddy Delta, which has a population of nearly 6 million people. The official Myanmar government figure for the missing is 41,000.

“I can only assume that the longer the delay, the more victims that are created,” Villarosa said.

Little aid has reached the area since Nargis hit, and on Wednesday, crowds of hungry survivors stormed reopened shops in the devastated Irrawaddy delta.

The United Nations urged the military junta to grant visas to international relief workers amid estimates of 1 million homeless.

A United Nations official said that nearly 2,000 square miles (5,000 square km) of the hard-hit delta are still underwater. Video See amateur video of the cyclone’s crashing ashore »

Charity workers have gathered at Myanmar’s embassy in Bangkok, Thailand, with vehicles, emergency food supplies and medicine, waiting for their visa requests to be approved.

“We need this to move much faster,” said John Holmes, U.N. humanitarian chief, after reading a statement from Secretary-General Ban Ki-moon.

There were reports of “civil unrest” in the worst-hit areas where people are scrambling for limited food supplies, a U.N. spokesman said.

In the flood-soaked Irrawaddy delta townships, U.N. assessment teams observed “large crowds gathering around shops — the few that were open — literally fighting over the chance to buy what food was available,” World Food Program spokesman Paul Risley said Wednesday from Bangkok.

There were also also reports of price gouging in urban areas around Yangon, Myanmar’s largest city and former capital.

“There were long lines of people trying to buy what food was available, even at those higher prices,” Risley said.

The delta, Myanmar’s rice-growing heartland, has been devastated by Cyclone Nargis, threatening long-term food shortages for survivors, experts said.

“We can’t delay on this; this is a huge disaster, and the longer [Myanmar] waits, the worse it’s going to become,” International Rescue Committee spokesman Gregory Beck said.

The Rome, Italy-based U.N. Food and Agriculture Organization estimates that five states hit hardest by Saturday’s cyclone produce 65 percent of the country’s rice, The Associated Press reported.

“There is likely going to be incredible shortages in the next 18 to 24 months,” Sean Turnell, an economist specializing in Myanmar at Australia’s Macquarie University, told AP.

Holmes said 24 countries had pledged financial support, with a total of $30 million expected in aid.

The WFP, which has started feeding the estimated million homeless, said there were immediate concerns about salvaging harvested rice in the flooded Irrawaddy delta. Photo An iReporter documents the destruction »

The cyclone battered the country with winds of 240 kph (150 mph) and 3.5-meter (11.48 feet) storm surges.

Damage was also extensive in the country’s largest city, Yangon. Much of the former capital is without power and littered with debris and fallen trees. Photo See photos of the destruction »

CNN’s Dan Rivers, the first Western journalist into the devastated town of Bogalay, said Wednesday that it was difficult to find the words to describe the level of destruction. Video Watch Rivers’ report from Bogalay »

“Ninety percent of the houses have been flattened. … The help that these people are getting seems to be pretty much nonexistent, from what we’ve seen.”

He saw members of Myanmar’s army clearing roads but handing out little food or medicine.

“There has been scant help, really. I think we saw one or two Red Cross vehicles in the entire time we were driving,” Rivers said of his travels over a 12-hour period. Learn more about Myanmar »

Hundreds of World Vision staff are in Myanmar with limited supplies, according to spokesman James East.

Tons of supplies have been readied in Dubai and can be brought in quickly once clearance is given.

“Even when aid comes in, it’s going to be a logistical nightmare to get it out to the remote delta region,” East said.

However, Yangon is almost back to normal, World Vision health adviser Dr. Kyi Minn said. Roads have been cleared of debris, and electricity and potable water are available.

The Myanmar Red Cross has been handing out relief supplies, such as drinking water, plastic sheeting, clothing, insecticide-treated bed nets to help prevent malaria, and kitchen items, the International Federation of Red Cross and Red Crescent Societies said.


Other countries and world bodies offering help include Britain, Japan, the European Union, China, India, Thailand, Australia, Canada and Bangladesh have also pitched in.

Based on a satellite map made available by the U.N., the storm’s damage was concentrated over a 30,000-square-kilometer area along the Andaman Sea and Gulf of Martaban coastlines, home to nearly a quarter of Myanmar’s 57 million people. Video Watch as some aid arrives in Myanmar »

Dead are thrown into rivers as the living wait for aid

BOGALAY, Myanmar (CNN) — Homeless children watched Tuesday as solemn men unceremoniously dropped dead bodies into the river of this southern Myanmar township.


CNN’s Dan Rivers was the first Western journalist to visit Bogalay and see the devastation.

more photos »

The funeral-like procession to the river was one of the many disturbing images of the destruction left by Myanmar’s deadly cyclone.

The cyclone’s devastation could be seen everywhere in Bogalay. The estimated 240 km/hr (150mph) winds spared only four of the 369 homes in a village here.

The nationwide death toll was estimated by state run media and opposition sources at more than 22,000.

Almost half of the total death toll could have come from Bogalay, according to an estimate by China’s state run news agency Xinhua. Many of the survivors have been left with nothing.

They sat in roofless homes, parasols their only protection from the rain that continued to fall. Video Watch Rivers report from Bogalay »

One family who sat in the remains of their home — shreds of the roof and walls littered the floor — said they only had enough food to last a couple of days. We could see their meager supply of eggs and rice.

New supplies will be hard to come by after the storm destroyed the area’s mills, leaving only about a five-day supply of usable rice, locals said. Water pumps were also ruined, and fuel is scarce.

Monasteries were being used as temporary shelters for hundreds of people left homeless. At one there were about 600 people sleeping where they could.

Many had lost someone they loved. Some sat with bleak, numb stares as small piles of food were guarded by young apprentice monks.

The monks said they have food for two days. After that, they say, they have no answer.

Another monastery was called an operating theater, but there were no medical supplies. One man sat with open wounds, blood running down his back.

Members of the military could be seen all over Bogalay on Tuesday, some trying to cut through fallen trees.

International aid groups are waiting for the Myanmar government’s approval to enter the country. Photo iReporter documents the destruction. »

But the worry here in Bogalay, south of the former capital Yangon, was how relief workers would be able to cross the difficult tropical terrain to reach victims.

The journey to the town is very difficult — crisscrossed by rivers and lush patches of trees. It is punctuated by few roads, many which are clogged by debris. Video Watch how the cyclone crippled Yangon »

International disaster experts have warned that a lack of water and food could lead to a health-related crisis; they want aid to get in as fast as possible.

Also, there is concern that areas to the south of Bogalay could have suffered even more because they are low delta lands that were hit first.

Meanwhile, Bogalay’s survivors wait and try to put the pieces of their lives back together.