A month since the quake and tsunami, poor sanitation and dirty conditions fuel sickness among the displaced.

Palu, Indonesia – The tsunami that hit Palu last month swept Muhammad Afif’s brother from inside their coastal home.

Muhammad spent a day looking for his sibling. But it was a friend who found him, among the wounded in one of the city’s hospitals.

“The hospital was so busy that we had to clean his wounds ourselves,” Muhammad said. The 38-year-old truck driver took his brother home, where he died two days later. “At least we could care for him ourselves before the end.”

At least 2,000 people are now known to have died in the 7.5-magnitude earthquake and tsunami that devastated the central Sulawesi city and the areas around it a month ago, leaving thousands homeless and a damaged health system struggling to cope with the injured, spread over a vast area from coastal lowlands to mountainous villages.

Vast area of disaster

“We have a lot of trouble reaching people here. People aren’t focused in one place, they’re spread out all over,” said Viktor, a doctor at an Indonesian Red Crescent clinic who helped in the aftermath of the Lombok quake in August, and the 2016 earthquake in Aceh.

“Even if we want to use our mobile clinic, we have to do long surveys and comb through villages.”

Undata Hospital, Palu’s biggest, fears more severe aftershocks will bring more victims, so the hospital authorities have kept the bright orange emergency tents that were erected around the hospital in the immediate aftermath of the disaster, said director of services Amsyar Praja.

The hospital itself receives the most medical referrals of any hospital in the disaster zone with patients coming from other hospitals in Palu as well as villages in remote parts of Sigi and Donggala.

Some 45 health facilities were damaged in the double disaster and nearly 4,500 people seriously injured, according to an official update this week.

Administrators haven’t needed to turn patients away, but because the earthquake destroyed medical equipment they’re forced to make tough decisions. Not long ago, as many as 10 patients with severe respiratory infections sought treatment at Undata. Such diseases are becoming more common because so many people are living in tents, but with only one useable ventilator, doctors were forced to treat only those who needed it most.

While medical cases have mostly followed the typical post-disaster pattern – severe wounds and broken bones in the first week and illnesses like diarrhoea and respiratory infections after that – there are cases that uniquely common to Palu.

Hajiah Mariam, 69, arrived at Viktor’s clinic more than three weeks after the earthquake with a foot injury that got infected in her tent in a village in Sigi. It took doctors 20 minutes to clean the wound.

Red Cross medics treat Hajiah Mariam [Ian Morse/Al Jazeera]

“Now we have a lot of wound infections, too, because people live in the unsanitary tents,” Praja said. “The toilets are often not clean and sanitation is a problem.”

Water problems

The Indonesian Red Cross is managing sanitation in the farthest areas of the province, such as Donggala, where water supply has still to be restored. They’ve built 35 bathrooms and distributed 1,288 hygiene kids to those in need.

“Sometimes we can’t go by road, so we have to hike the mountains for two hours,” said the organisation’s director of disaster management Rafiq Anshori. “Eighty percent of houses are destroyed, [and while] there is water it isn’t distributed well, so the bathrooms and showers are very unclean.”

MERCY Malaysia, a disaster response agency working on the outskirts of Palu, said hygiene is the main problem in their small evacuation centre of 30 tents where Muhammad lives with his family. Like thousands of people across the area, they could save only the clothes on their backs. Now, his wife, mother-in-law and two children live together in a small tent.

“The bathroom is next to the shower and clothes washing area and drainage is a problem,” MERCY’s Tengku Reza said. Before the washing blocks were built, the makeshift community of about 700 people was using a single toilet, and people were being forced to dump excrement in plastic bags.

The Indonesian arm of Save The Children, Yayasan Sayangi Tunas Cilik, has established three centres around the region where workers teach hygienic practices through games and other activities.

“We try to support them – maybe to forget is difficult, but how they can get back to normal,” senior operations manager Aduma Situmorang told Al Jazeera. “It’s hard for them to understand everything, but things like ‘what you should do if there’s an earthquake’, we will include that in psychosocial support.”

Trauma

Volunteer groups are also focussing on mental health, especially with children. Gemma Nine, a youth volunteer organisation sent a team of medics to Donggala’s coastal villages for assessments in the first two weeks after thousands of residents fled the giant wave for the mountains.

“Twenty kids need help forgetting their trauma,” said volunteer nurse Dewi Koesuma, 22, after she arrived at an evacuation centre set up among coconut trees in Lende village, where several people had lost their lives beneath falling houses, and homes had been destroyed by the tsunami.

“But they aren’t thinking about long-term problems, only the short-term like food because there is so little.”

Didik Wahyu Pratam, a volunteer with a local Palu youth group, holds sessions for kids with a team of students. They are focusing their attention on the worst-hit areas – the villages where the earth swallowed entire neighbourhoods as the quake destablised the soil and children lost friends, parents and entire families.

Two Indonesian boys at an event to help children who survived the earthquake and tsunami in Central Sulawesi [Ian Morse/Al Jazeera]

Next to their collapsed houses and makeshift shift tents, children sing songs at the top of their lungs and dance with the volunteers.

“Our way is to give them games and lessons so they forget what happened a few weeks ago,” 22-year-old Wahyu said. “And besides the kids, we are also victims and it’s so much fun to play with the kids, that it helps us too.”

The state of emergency that was declared in the wake of the disaster ended on Thursday, but the local health office has extended free services until the end of the year, because hospitals and clinics are still struggling with inadequate equipment and thousands remain without reliable health facilities.

‘Everything is broken’

Anutapura Hospital is waiting for the city’s health office to replenish its broken medical equipment.

But its medics are also struggling to work amid fallen masonry-cracked walls and crooked walkways.

A few minutes after the quake, the entire nursing wing collapsed on itself, splitting the six-floor hospital in half. Ten people were trapped inside and crushed. By the time the last four were found a week later, their bodies couldn’t be identified.

“We started working again last Saturday, but definitely not at normal capacity,” Anutapura deputy director Herry Mulyadi told Al Jazeera. Many of the staff are too frightened to work in the damaged building, but demand is such that even though the hospital has rented a nearby school room and apartment building, it still has to turn away between 100 and 200 people every day.

The ruins of Anutapura Hospital, which was badly damaged in the earthquake and tsunami last month [Ian Morse/Al Jazeera]

“We have to work without all our tools. Equipment for teeth, heart, everything is broken. We couldn’t save them because the building where they were crushed them all.”

Pregnant women have been forced to travel to Undata to give birth because it is the only hospital that still has the ability to perform caesarean sections. Since the quake, some 70 women have had their babies there, almost 50 more than normal.

But midwives are also helping women in rural communities to have their babies as they would have done before the disaster struck.

In the rice farming village of Dolo, which narrowly escaped the liquefaction that swallowed the neighbouring settlement, one of the residents when into labour a week after the disaster.

As they looked at the healthy baby girl, the new mother wondered what to all her. Then they remembered the earthquake. In Indonesian “gempa”.

“She didn’t have a name so I just said why not Gempitha?” said Ani, the midwife who helped with the birth. “It fits.”