When Dr. Zuhdiyah Nihayati arrived at the liquefaction zone in the aftermath of Sulawesi’s devastating 2018 earthquake, her impression was of total chaos.

“There were so many damaged hospitals, including the main hospital in Palu,” she recalled. “The medical services were totally disrupted.”

The magnitude 7.5 earthquake struck the city of Palu and the surrounding area on September 28, triggering a tsunami, along with major soil liquefaction – a relatively rare phenomenon in which soil, placed under ongoing stress, behaves like a liquid.

“During the earthquake the ground became unstable and entire communities sunk into the earth in their houses. Seeing the aftermath was really quite horrendous and something I’d never witnessed before,” said Gordon Willcock, Direct Relief’s deputy director of emergency response, who traveled to Palu immediately after the quake. “The trifecta of disasters – earthquake, tsunami, and liquefaction – made this emergency response very distinct.”

Aprisal Malale, a former Direct Relief intern who helped coordinate the organization’s long-term response to the Sulawesi earthquake – he now works for the World Health Organization’s Indonesia country office as a national professional officer of planning – described losing touch with his parents for two days. “I did not know whether they were alive or not,” he recalled.

In the days that followed, Malale managed to speak to his parents, whose house had been damaged but who were otherwise safe. “They were outside sleeping with the sky as their roof,” he said.

But a friend of Malale’s was lost in the quake. Unable to find a body, the church held “a memorial service with an empty casket.”

The combined disasters killed more than 4,000 people and displaced more than 170,000.  

The Palu area is famed for its beauty, but it is also located at the intersection of three large tectonic plates, placing it at significant risk for earthquakes. During this devastating event, electricity and communications were interrupted, according to the Association of Southeast Asian Nations (ASEAN). Houses were swallowed up by the liquefaction. People dug through the rubble in search of loved ones.

Willcock described seeing part of a town that “had disappeared into the earth with only the roofs of a few houses showing above the ground. It was a cataclysmic event and eerie sight to behold.”

Many who survived the quake had severe injuries that needed urgent attention. Clean water, electricity, and gasoline were hard to come by. Many were traumatized by what they had experienced.

In the aftermath of the disaster, Direct Relief worked closely with a long-time regional partner, ASEAN’s Coordinating Center for Humanitarian Assistance on Disaster Management (known as the AHA Center), to deliver medicines and medical supplies, while also funding AHA Center-led water and sanitation projects directed at supporting displaced communities. In addition, rebuilding and strengthening health care infrastructure in the hard-hit area was an indispensable long-term goal.

Even before the disaster, Malale said, health care was harder to come by in the rural areas around Palu. “They were less fortunate and prioritized,” he said.

But the earthquake, which damaged hospitals and health centers throughout the area, made things worse for people. “They definitely got sicker,” Malale said. “I want to say that we managed, but we didn’t manage in a proper way.”

Three years later, much has been rebuilt, although Nihayati, a physician with the Muhammadiyah Disaster Management Center (MDMC), said that access to clean water and medical services were still issues until quite recently. However, that’s beginning to change.

Now, nine health centers damaged or destroyed by the quake are up and running, funded by Direct Relief. Several are in the rural areas Malale described as having lacked adequate access to health care, and one that previously lacked a clean water source now has one.

The organization has worked closely with MDMC, a long-term partner, to rebuild health centers and to construct a new local hospital. MDMC vice chair Rahmawati Husein explained that there are also plans for a maternal and pediatric hospital in the area.

One of the health centers, which are called puskesmas pembantu or pustu for short, is part of a larger project managed by the AHA Center on behalf of ASEAN, a cooperative body of 10 member states that work together on everything from economic issues to disaster response. Called the ASEAN Village or Kampung ASEAN, the project consists of 100 permanent houses designed for families who lost their homes during the quake, a mosque, and the health center.   

Progress in the region has been hard-won. First, Husein explained, labor and materials were hard to come by in the aftermath of the quake. Then, according to Agustina Tnunay, assistant director of operations at the AHA Center, the pandemic slowed construction. But the ASEAN Village’s opening in June of 2021 marks the slow return of normalcy for a region that has undergone three years of turmoil.

Direct Relief began working with ASEAN’s AHA Center in 2016. The two organizations signed a Memorandum of Intent – a document outlining their objective of providing mutual support in the region. “This has been a very strong and valued partnership for Direct Relief,” said Willcock.

Direct Relief has worked closely with the AHA Center on various projects, including the pre-positioning of emergency supplies in the tropical storm-prone region. Those supplies are housed at the AHA Center’s warehouses in Malaysia and the Philippines. When the organization moves to respond in the wake of a disaster, it is with the support of the center, which works to facilitate the movement of supplies, make reliable connections, and more. “Whenever there’s a major event in the region, we work closely with the AHA Center and try to support their work wherever possible,” Willcock said.

“The support of Direct Relief is valuable, and the flexibility given to the AHA Center is very appreciated,” Tnunay said. “Direct Relief always stands ready to support when disaster strikes the ASEAN region.”

The two groups have coordinated on multiple occasions, including the 2018 Lombok earthquake, a series of typhoons, and major monsoon flooding that struck Vietnam, Laos, and Cambodia.

But Willcock explained that Direct Relief’s work with ASEAN during the Sulawesi earthquake was the largest response the two organizations have yet mounted together.

“That’s when everything came together: all of our previous work and partnership,” he said.