Humanitarian Response to the 1986 San Salvador Earthquake: A Personal Retrospective

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08 Mar 2023


Massive earthquakes are nothing new, but our awareness of their effects has increased substantially with the proliferation of social media. We have gotten much better at organizing and professionalizing international relief over the past quarter-century. There is still much to do, including a need to overcome recurring geo-political factors that impede rescue efforts, even as they have very recently in Turkey and Syria.

This essay is a personal account of a severe earthquake that devastated El Salvador and surrounding areas during the civil war in Central America in 1986. At that time, neither disaster relief coordination and nor rescue practice was as well-developed then as it is now.  I was working as a physician in El Salvador before the earthquake and shifted to a rescue mode – much as anyone would have - mid-stride. The civil war heightened the chaos. In fact, the first reaction of many to the destruction was misapprehension that it had been caused by a massive guerilla attack. It took some hours for the real situation to be appreciated.

A belt of volcanoes extends from northern Panama to western Mexico. The highest mountains in this belt are almost all volcanic. In addition, a deep trench, the Middle America Trench, has developed off the coast of El Salvador.

Mexico and most of Guatemala, moreover, sit on a westward-moving tectonic plate called the North American Plate, which abuts the stationary Caribbean plate on which El Salvador is situated. The dynamics of these plates has created a fault which leads to earthquakes in northern El Salvador. The continual motion of the Cocos Tectonic Plate is responsible for the frequency of earthquakes in the coastal region. [1]

San Salvador, the capital of El Salvador, has been demolished by earthquakes in 1756 and 1854, and again badly damaged in 1919, 1982, 1986 and 2001. ( undated). Ten major tremors ranging from 4.1 to 5 on the Richter scale were documented between November 17, 2022, and November 29, 2022, 10. [2]                                                               

Most of the scales utilized to measure the strength of an earthquake are based on the amplitude of seismic waves recorded on seismometers or seismographs. [3] The Richter scale, introduced in 1935 by two U.S. seismologists, Beno Gutenberg (1889–1960) and Charles F. Richter (1900–1985), is a base-10 logarithmic scale that rates earthquake size in terms of magnitude, or the amount of energy released and the distance from the epicenter. It is the oldest and remains the best-known scale. A tremor measuring 4 – 4.9 is considered light whereas 5 is deemed moderate. An earthquake measuring 5 on the Richter scale has 10 times the magnitude of one measuring 4. [4] (US Geological Survey 2021). Other scales have been introduced. Most strive to remain consistent with the Richter scale.

Neither the Richter scale nor others modeled upon it provided accurate estimates for large magnitude earthquakes. For that reason, it was eclipsed by the logarithmic moment magnitude scale (MMS) introduced in 1979 by Thomas C. Hanks and Hiro Kanamori. A third scale, the Modified Mercalli Intensity (MMI) scale, introduced in 1931 by two American seismologists, classifies earthquakes according to perceived effects (Table 1)

Table I. The Modified Mercalli Scale [7,8]

No scale can accurately detail all the consequences of an earthquake: that assessment requires on-the-ground inspection and exploration. Where the scales do help, however, is in helping to estimate in a very gross way what may have happened, and what rescue workers might expect. It also helps predict what equipment and supplies might be required, how wide an area might be involved, many of the logistical considerations that may prevail, and, to a lesser extent, the duration of the acute and subacute stages of the disaster response. Later stages, especially the reconstruction phase, are more difficult to foresee.


The Earthquake

On October 10, 1986, an earthquake measuring 5.4 – 5.7 on the Richter scale and IX (violent) on the Mercalli intensity scale, centered about 10 miles northwest of San Salvador, struck the capital at approximately 11:49 a.m. local time. The subterranean plate movement occurred at a relatively shallow depth of 10 km with vertical and horizonal excursions. The proximity of the movement to the earth’s surface was deemed to be responsible for the massive destruction.

The American Embassy twisted and pancaked. A 10-story office building, the Rubin Dario, was destroyed with around 1,000 people inside. About 150 bodies were eventually retrieved. Four of the six major hospitals in the capitol were severely damaged or destroyed. The Bloom Children’s Hospital collapsed, killing about 50 children and burying others.

Massive landslides were precipitated. Many of the shanty towns illegally erected around the capital were leveled, resulting in about 1400 deaths. Roughly 10,000 injuries (some reports doubled this figure) were reported, and an estimated 200,000 people became homeless.

The Salvadoran Ministry of the Environment and Natural Resources commemorated the 30th anniversary of the earthquake with a compilation of facts, photographs and film clips that convey the scale and ferocity of the event. [9]

At the time the earthquake struck, I was operating on one of the top floors of the very modern eight story Bloom Children's Hospital and begun implanting a ventriculo-peritoneal shunt in a toddler with tuberculous meningitis. Suddenly, there was a tremendous and explosive roar. The sound of an earthquake is often compared to a freight train rolling by in a very close proximity. This was certainly the loudest prolonged sound I had ever heard. The sound continued for what seemed to be minutes. It was actually only about 90 seconds before the sound diminished and the building began to sway.

At the time of the earthquake, I was serving as the physician attached to the American Military Group in El Salvador and posted to the American Embassy.  We had been warned to expect guerilla attacks in San Salvador around October 10th to commemorate an anniversary important to the Communists. My first thought was that the intelligence we had received turned out to be correct – it was a massive explosion close to the hospital – but the duration and the volume of the sound indicated it was something else.

One of the staff in the operating room began screaming “terremoto” (earthquake). Another shouted “guerillas,” suggesting that the explosion was due to a bombing in the context of the civil war. All discipline in the OR suite lapsed. Some individuals ran down the stairs, while others took shelter in the steel door frames. The operating table began shifting position as the swaying increased. Fortunately, I had an excellent partner in the anesthesiologist, who started waking the child while maintaining the endotracheal tube in place, reinforcing the IV, and allowing me to quickly close the small incision I had made. Fortunately, I had not proceeded to a burr hole or abdominal incision, nor had I yet removed the external ventricular drain that I had implanted emergently at the bedside to relieve the child’s intracranial pressure. I reinforced the drain and dressed the skull. As I was doing that the building twisted. The theatre filled with dust and debris as an entire external wall of the hospital collapsed, leaving the room open to the outside.

Priorities changed instantly. The most important task became the safe evacuation of the patient and the staff. The elevators could not be used, not only because power had been lost, but because the shafts were twisted. We did not know the condition of the stairways, but they were steel and seemed negotiable, if damaged.

Fortunately, there was a supply of sheets and light blankets in the hallway alongside the theatre. In an escape-from-Alcatraz-like manner, we quickly knotted together as many sheets as we could and fashioned a blanket sling for the child. We used the sheets as one would a safety rope while mountain climbing. One difficulty was deciding when to move rapidly and when to fasten the sheets to seemingly solid structural elements on the way down. Working by instinct and largely in the dark except for pocket torches and an ophthalmoscope, we were able to descend almost as far as the first floor. It was more difficult to find a way to get to the ground level, but the tremors had quieted by this point. By dint of easy rappelling, an impromptu bosun’s chair, and some remarkably good fortune, everyone was lowered to safety.

Dazed and injured individuals collected just outside the hospital. A number of physicians and surgeons had started tending to them. Other staff were helping remove patients from the wards. The tower of the hospital was collapsing.

It was a little more than an hour after the earthquake. The weather was warm and tolerable. It was ominously quiet. The unmuffled cars and motor scooters that provided the usual cacophonous background noise were simply gone. I made my way to the American Embassy.

The streets were strewn with rubble. Bricks from buildings of all variety spilled onto the roadway. Stretches of wall had fallen. Exposed and brightly painted inside rooms lent a bizarre carnival-like gayness to the devastation. I understood for the first time what was meant by “crowds with vacant eyes.”

I had no access to first aid or rescue apparatus. I saw many lightly injured people receiving assistance from neighbors, but ambulances and police were also beginning to mobilize. Blankets appeared. Churches opened their doors. I came across a collapsed building with a dozen injured. One young woman had severe facial and thoracic injuries and respiratory distress. I was unsuccessful in clearing her airway and so, in desperation, performed a cricothyroidotomy with equipment at hand but failed to save her. I did not encounter any other life-threatening injuries where I could intervene on the way.

The embassy building had twisted and pancaked. There was no obvious point of entry. People who had managed to get out before the collapse were lying on the ground or sitting up against whatever seemed to give support. Together with several military personnel, I crawled a short distance into the structure to see whether there was anyone easily retrievable. Aftershocks rattled what was left and made everyone concerned about the safety of the search short of shoring up the structure and bring in appropriate tools. As we crawled out, the building collapsed further.

Word of the damage to El Salvador’s hospitals spread rapidly. The military hospital, which had been built with prefabricated cast-iron arches imported from France a century earlier, lost parts of its roof, but was structurally intact. Together with the other remaining hospital facility, it became one of the centers of operation. The flexibility of the structure and the lightness of the roofing and cladding saved the hospital and made it useful. The military were also able to supply generators.


Impromptu treatment centers were set up in parking lots, playing fields, basketball courts and schools. Many buildings that had stayed upright showed deep cracks in their walls, were clearly leaning out of plumb, and were not fit for use before inspection and reinforcement. Fortunately, there were still five hours of daylight to go, and efforts were focused not only on rescuing survivors who might be buried, but also on establishing receiving centers for both ambulatory and non-ambulatory patients, retrieving medical equipment and supplies, and bringing in water, electricity, light and heat. Here the military sector was better prepared than the civilian, and their cooperation was critical to the rescue effort.

The local telephone system included hand-held radiotelephones. I was fortunate to have a hand-held radio that continued to operate within the city. Coordination and damage assessment were first on the order of priority. One important concern was where to recharge the radios, and how long radio relay towers would function. Without electricity, no one could count on easy communications.

Within the first several hours, members of government, the business community and the military came together to try and divide responsibilities and plan a response. There were no effective contingency plans in place. Even so, regular meetings were established for the exchange of information several times a day. Because the military, unpopular and had been widely for various excesses, were eager to participate and appear in as good a light as possible. They had heavy equipment and vehicles that could be used to transport rescue personnel and the injured. Most importantly, they had fuel supplies and could generate power.

Improvisation was crucial, because the municipal water supplies had been disrupted, it was necessary to bring water down from the hills and mountains surrounding the city. An electrical company provided plastic conduit which, though certainly not food grade, sufficed to bring water to critical locations where it could be purified by boiling. Fruit companies brought refrigerated trucks that were pressed into service to preserve food supplies and medications. Some were also used as morgues.

By mid-afternoon, reasonably well-equipped military hospital tents had been set up in playing fields. Miners came into tunnel through the rubble and buttress unstable buildings. Engineers assessed the structural integrity of buildings that seemed suitable for emergency repurposing. I had a four-wheel drive vehicle and driver put at my disposal to drive through and around the city to help with the needs assessment.

Within 24 hours, British troops arrived from locations in the Caribbean with water purification equipment and medical supplies. American search and rescue assets came next (the needs of the search and rescue dogs proved to be a constant problem for the Salvadorans, who were accustomed to caring for highly trained dogs). Mexico sent additional miners. Elite search and rescue avalanche teams came from Switzerland and Italy. Containers filled with tents were delivered from the US as the first part of massive assistance from the Office of Foreign Disaster Assistance of the US Department of State (OFTA). Other groups from Central America and Europe contributed as well and neighboring countries sent food and supplies.

Within several days, the situation stabilized and I was seconded to OFTA. The central focus of my efforts changed from immediate medical response, search and rescue to needs assessment, and to assist in coordinating local and international rescue and relief efforts.

My notes from 1986 helped me think about the changes in disaster relief that have ensued since then. [10-13]

The details of setting up emergency medical facilities in stairways, churches and schools, establishing a labor and delivery service outdoors under paraffin lanterns, creating impromptu ICUs in shipping containers, and practicing emergency medicine under resource constrained circumstances share many similarities across different scenarios. Of course, weather, location, surviving assets and many related factors make all the difference. On the one hand, every natural disaster and every mass casualty incident is unique. On the other, there are enough parallels and similarities to allow for certain broad conclusions to be drawn and a number of general strategic guidelines to be established.

Every disaster response requires for command and control. It is better, however, to think in terms of command, control and communication. Command and control fail without communication. When international groups convene, they may not share compatible communications systems. In San Salvador, they did not share compatible frequencies and they spoke different languages. Coordination requires expedients to bridge these gaps.

Water, temperature control, light and shelter are very basic needs without which no effective disaster response can be mounted. To that must be added fuel. Secure locations for helicopter and eventually fixed wing transport are essential.

In addition to communications, there must be documentation. Documentation starts with survivors and medical interventions provided, but ultimately includes the identification and location of victims, medical and essential non-medical supplies, and related assets, and the results of inspections and surveys, and of plans, responsibilities, and emergency infrastructure revisions and recommendations.

The importance of light cannot be overstated. Mains power cannot be relied upon in many circumstances. Rechargeable batteries will not be recharged. Alternative energy sources, like solar panels, are highly weather dependent and may be of little use after a volcanic eruption or when dust filters the sun. For these reasons, battery-powered equipment should be procured, and fresh batteries in sufficient quantity stored appropriately and available.

Search and rescue dogs are very delicate creatures. They will work until they drop, but their sense of smell can be overwhelmed in a very short time in the presence of massive casualties. They need to be rotated away from the search sites and allowed time to rest, together with their handlers, protected from the elements and well fed in ways that may seem odd, and even spur resentment amongst the local population.

Morale after natural disasters is subject to variation. Often, people come together, and morale is surprisingly good. Other times, moral plummets. It is hard to predict what exactly will influence morale. In San Salvador one of the most salient events was neither the number of victims, nor the loss of housing, nor the damage to infrastructure, nor the damaged hospitals, but the fact that an iconic statue of Christopher Columbus had reportedly lost its head. The reports of damage to the statue carried a semiotic significance that outsiders did not easily fathom.

Communication is more than a technical challenge. Rumors always abound, and no rumor, no conspiracy is too remote to capture the imagination of some group and precipitate some combination of fear, panic, and desperation. These reactions cannot be entirely mitigated through communication, but near constant, always measured, invariably accurate and totally comprehensible communication in the local idiom reaching its intended audience must be established. This is the only measure that will help balance the loss of trust that seems to follow inevitably as a consequence of catastrophe.

Social media was not available in 1986, and neither were cellular phones. However, battery powered radio telephones were fairly common in the business community. Even so, they lasted only 24-48 hours because relay stations depleted their back up batteries. Even when the handsets themselves could be recharged, transmissions failed. Satellite phones might do better, but ordinary cellular telephones and internet networks might not. In 1986, police cars and military trucks with public address systems helped meet communications needs.

It is important to have local, regional, and national leadership as a partner in any effort that takes place. The return of the president of El Salvador to the capital from his country estate was important, particularly because he was known himself to be seriously ill at the time. Those assisting in international disaster relief must be prepared to credit local figures, local responders and national leaders for every initiative and every success.

In many circumstances, smaller nations and local facilities will try to fill or refill their larders with equipment and supplies as part of the disaster relief. In 1986, such efforts were controversial. How to respond was then a matter of humanitarian and moral debate as well as of political and strategic urgency.  Perspectives have subsequently changed, entities such as the Organisation for Economic Co-operation and Development, the Environmental Emergencies Centre, the World Health Organization, and the Pan American Health Organization have published useful guidelines. [12-16]

Natural disaster may occasionally precipitate social violence, including rioting, in war-torn areas. Violence may not be common, but looting does occur. The physical safety of rescue personnel must be assured. There are times rescue efforts may have to be halted if the safety of rescuers is threatened. To be sure, acts of altruism, collaboration and kindness are more common.

The response to natural disasters unfolds in phases. The importance of specialized skills at each phase is sometimes forgotten. Structural engineers are needed immediately after an earthquake, followed by specialists in power, water and communications. Surgeons, traumatologists and emergency physicians cannot function without nurses, technicians, and administrative coordinators. The importance of advanced practice practitioners including nurse practitioners, anesthetists, physician assistants and others, many of whom are fully capable of functioning independently, cannot be overstated. [12, 15,16] Language abilities are key. Additional skills, both medical and non-medical will be called upon in later phases.

International responders come and help for a short time. They cannot substitute for local medical resources. As part of the coordination of emergency care, it is important to think about how to continue assistance after they depart. This concern leads to a more involved discussion than can be pursued here. [11, 12, 14]

Local medical personnel worked tirelessly in San Salvador, underlying the efforts, however, were understandable concerns about family and friends, especially because communications and transportation were totally disrupted. There simply was no way to find news. Their professionalism meant that most stayed at their posts well beyond when they should have.

Caring for the caregivers is a responsibility that must not be neglected. People cannot help but be worried about their own. They become exhausted. The fears and insecurities precipitated by a natural disaster or mass casualty event are often highly realistic. All human beings have physical and emotional limits. Even though the endurance of first responders cannot help but be tested under these circumstances, people almost always find ways to do what is needed. Outside medical personnel are often in a better position to care for those caught up personally in the events we describe more than anyone else.

In this account, I have outlined some of the issues that recur in one form or other in natural disaster. However much one prepares, one is never totally prepared. The medical, logistical, technical, and political realities are forever daunting. And yet, no matter how intimidating, the opportunity to respond is a humanitarian privilege open to all those who would do so.

Written by T Forcht Dagi, MD, DMedSc, DHC, MPH, MBA, FRCSEd, FAANS, FACS, FCCM, FS.                                                                                          Professor of Neurosurgery, The Mayo College of Medicine and Science, Honorary Professor, Queen’s University Belfast, International Surgical Advisor, The Royal College of Surgeons of Edinburgh.



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