After the surging ocean waters spawned by Japan's magnitude 8.9 earthquake receded, the drowned were only the first victims to be counted.
In the coming days, physicians and public health officials along Japan's hard-hit eastern coast can expect a second wave of tsunami victims with aspiration-related illnesses, trauma and crush wounds, as well as the threat of disease spread by contaminated water.
As they tend to survivors, Japanese officials can look to the experience of health workers who ministered to victims after the massive tsunami that inundated Indian Ocean nations on Dec. 26, 2004.
Writing to colleagues in the New England Journal of Medicine, physicians at a regional hospital in Phangnga, Thailand, noted that although drowning is responsible for most of the fatalities, a tsunami also inflicts head injuries, fractures and cuts as it slams together debris, people and stationary objects. In the week after the 2004 tsunami, physicians at Takuapa General Hospital treated 2,285 patients with trauma, with 11% of those cases categorized as serious and 17% considered intermediate.
Many surgical patients developed foul-smelling infections that had to be treated with an amoebicide and anti-protozoal medication in addition to normal antibiotics, the doctors reported.
A 2005 report by German physicians who cared for 17 critically injured tsunami victims listed some of the unusual strains of bacteria that had colonized the wounds. Many of those strains are resistant to multiple front-line antibiotics, they wrote in the journal Critical Care Medicine.
The flesh surrounding tsunami victims' wounds has often been crushed by falling or floating debris, cutting off blood supply and causing muscle to die, said Dr. Lee Weiss, regional medical director of Emergent Medical Associates in Manhattan Beach. Once victims reach a hospital, amputation is often the only option.
Public health officials often struggle with water treatment and distribution systems that have been contaminated by ocean water and by oil, gas, pesticides and decaying bodies carried inland by the waves.
"There's a very high likelihood of cross-contamination of waste water and treated water," said civil engineer Kripa Singh of the University of New Brunswick in Canada.
Though cholera and typhoid are unlikely in a country as developed as Japan, outbreaks can happen, Weiss said. Even run-of-the-mill gastrointestinal illnesses from contaminated water can make life miserable for uprooted and often grieving victims, he added.