Chronology of WHO response to Cyclone SIDR Notes from the field Benchmarking Safety and functionality of health facilities
LETTER FROM THE
Editor
Disaster, death and devastation take no time to turn into cold statistics. The human misery and emotional and crippling economic losses become heartless numbers in reports compiled after earthquakes, floods, cyclones and other natural disasters. But sometimes, the dead refuse to be consigned to tables and graphs. They break out of print, and their faces, filled with pain and anguish, tell the human story. When this happens, the faces of children, people young and old, the weak and vulnerable, ask a question that tugs at the heart. "Could I have been saved?“ The answer is often "Yes". Of the many lives lost in a disaster, a great number can be saved if simple, cost-effective risk reduction policies are put in place before an emergency arrives. Saving lives makes a convincing case for disaster risk reduction and a world less vulnerable to natural hazards. Every disaster is primarily a human and health tragedy. The economic fallout of disasters is also well recognized. The 1994 World Conference on Natural Disaster Reduction in Yokohama, Japan stressed the economic link between disasters and sustainable development. While most people understand the magnitude of human suffering that disasters bring in their wake and their consequences on health and livelihood, few realize that devastation can be prevented to a great extent through disaster risk reduction initiatives. WHO's Emergency and Humanitarian Action (EHA) Programme in the South-East Asia Region works to save lives and reduce suffering during crises by building and strengthening the capacity of Member countries to mitigate the effect of disasters on health. It has been observed time and again that disaster mitigation measures bring the best results when health facilities are able to withstand the event and remain functional in the aftermath. Making health facilities— be it a sophisticated hospital in a big city or a rural clinic—resilient to
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natural hazards is a vital risk reduction measure. Sources of health care must be able to continue offering their services at a time when they are needed most. For nurses, doctors, surgeons and health workers to be able to give their best to people when disaster strikes, it is essential to have a health system and facilities that can withstand disasters. Not only should the physical structure not collapse, but the network also should remain operational. If health facilities can continue to provide care during an emergency, the health consequences of a disaster will be lessened. The role of a health facility goes beyond saving lives during a disaster. They house blood banks, health laboratories and other facilities that safeguard public health. Health facilities also have a symbolic social and political value. When disasters snatch away loved ones, homes and livelihood and put other lives in peril, a safe and running hospital lends a sense of security and well-being. Current knowledge makes it possible, even with limited resources, to build safe health facilities that will be there for the people during crises. Not only is expertise available to make new hospitals disaster resilient; existing facilities also can be retrofitted on a selective basis. Data show that it costs the same to build a safe hospital as one vulnerable to disasters. More than finances, it is a strong political will that will give the people disaster resilient health facilities. The earth's climate is changing. Global warming and rising temperatures lead to the melting of polar ice caps, increased tropical storms, glacial lake outburst floods, droughts and floods. The need for disaster risk reduction, of which hospitals resilient to natural hazards are an integral part, is getting more and more urgent. Significant steps have been taken, such as the adoption of the Hyogo Framework for Action 2005-2015 by 168 countries committed to making hospitals safe from disasters, but crises continue to render health facilities nonfunctional. Communities continue to be deprived of the health care they need at a critical time. WHO, in partnership with the Secretariat of the UN International Strategy for Disaster Reduction (ISDR), will mount a biennial 2008-2009 "World Disaster Reduction Campaign on Hospitals Safe from Disasters." WHO will spearhead the campaign in the South-East Asia Region and will promote the concept of making disaster resilient health facilities in its 11 Member countries. With the expertise available today there is no excuse for health facilities to become victims of disasters. We have to work together to ensure their doors can remain open at all times for those in need of health care. This issue of FOCUS highlights how crucial it is to make health facilities disaster resilient in order to reduce death and suffering. Protecting critical health facilities from the consequences of disasters is also essential to meet the Millennium Development Goals. I am sure you will agree,
Dr Poonam Khetrapal Singh Deputy Regional Director
Letter from the editor
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Dr Poonam Khetrapal Singh, Deputy Regional Director, WHO Regional Office for South-East Asia, made a presentation “Benchmarking and Standards for EPR: A Regional Framework for Better Collaboration” at the Second Asian Ministerial Conference on Disaster Risk Reduction.
Highlights • WHO strongly advocates investment in measures to reduce risk to the health of people in the event of natural or man-made disasters. Preparing for an emergency before it actually occurs is essential for risk reduction. The need for improved preparedness is reinforced by the vulnerability of WHO's South-East Asia Region. The acute impact of climate change-related events could lead to increased flooding, droughts, displaced population and migration. The Emergency and Humanitarian Action (EHA) unit of WHO's South-East Asia Region has developed 12 benchmarks as a tool for countries to measure the level of health emergency preparedness and increase performance in Emergency Preparedness and Response. These benchmarks will assist countries to improve and work on disaster planning, mitigation and preparedness, coordinated responses norms and guidelines to reduce risks to human health following a disaster. Benchmarks and the accompanying standards are country-driven. Countries will set their own priorities and take action accordingly. The benchmarks have been developed through a multisectoral consultation. The agreed upon benchmarks and corresponding standards can help achieve intersectoral and intercountry cooperation on risk reduction. Benchmark 11 assists countries to build capacity to ensure that health facilities withstand expected disasters so that they are there for the people when needed most. Disaster management remains response-oriented, though Member countries of WHO's South-East Asia Region have built their national plans for disaster management. Preparing to meet a disaster and pre-event issues remain a challenge in a Region that is highly vulnerable to floods, cyclones, earthquakes, storm surges, volcanic eruptions and droughts. Bangladesh, India, Indonesia and Thailand have had a considerable number of chemical accidents in the last five years. During 1996-2005 natural disasters killed 536 176 people in WHO's South-East Asia Region. This makes up 58% of the total people killed world-wide by natural disasters. WHO assists Member countries to build and strengthen capacity in disaster reduction, coordinated emergency response and setting norms and standards to prepare for an emergency. WHO's South-East Asia Region covers 1508.2 million people. • • •
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Source: slide presentation by Dr Poonam Khetrapal Singh, Deputy Regional Director, WHO Regional Office for South-East Asia at the 2nd Asian Ministerial Conference on Disaster Risk Reduction, New Delhi, 2007
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2nd Asian Ministerial Conference on Disaster Risk Reduction: Call for regional mechanism for disaster risk reduction he Delhi Declaration on Disaster Reduction adopted at the Second Asian Ministerial Conference on Disaster Risk Reduction, hosted by the Government of India, New Delhi, November 7-8, 2007, calls for action by all stakeholders on the implementation of the Hyogo Framework for Action, mainstreaming disaster risk reduction, multi-hazard early warning and preparedness, integrating disaster reduction with climate change, integration of disaster risk reduction into recovery and reconstruction and for regional mechanisms for disaster risk reduction.
The Delhi Declaration on Disaster Reduction, adopted at the Second Asian Ministerial Conference on Disaster Risk Reduction, hosted by the Government of India, New Delhi, November 7-8, 2007, calls for action by all stakeholders on the implementation of the Hyogo Framework for Action. This entails activities for mainstreaming disaster risk reduction, multi-hazard early warning and preparedness, integrating disaster reduction with climate change, integration of disaster risk reduction into recovery and reconstruction and for regional mechanisms for disaster risk reduction. The Asian Ministerial Conference on Disaster Risk Reduction which started in Beijing in 2005 will be expanded as the Regional Platform for Disaster Reduction. This will have the participation of national governments, regional and subregional organizations, the UN agencies, international financial institutions and other stakeholders such as civil society, scientific and technical organizations, the private sector and media. The conference also decided that the ministers in-charge of disaster reduction will provide the political leadership and commitment to the Regional Platform. The conference will be held once in two years by rotation in different Asian countries to review action taken by governments for the implementation of the Hyogo Framework for Action, to take stock of initiatives taken in various subregions of Asia for enhancing cooperation for disaster reduction and to share best practices and lessons learnt from disaster reduction in various fields. Malaysia has offered to host the Third Asian Ministerial Conference in 2008. The ministers and heads of delegations of countries of Asia and the Pacific attending the conference recognized the urgency of substantially reducing the loss of lives, as well of as social, economic and environmental assets of communities during disasters in order to achieve the Millennium Development Goals and sustainable development. The conference expressed concern at the recent spurt of disasters in Asia, including the 2005 earthquake in India and Pakistan, the typhoon in Vietnam, the 2006 earthquake and floods in Indonesia, the series of typhoons in the Philippines, the 2007 tsunami in the Solomon Islands and the floods in South Asia, which caused widespread loss of life and property. Source: Delhi Declaration on Disaster Risk Reduction in Asia 2007
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2nd Asian ministerial conference on disaster risk reduction
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Benchmarking safety and functionality of health facilities by Trine Ladeguard
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n the last issue of Focus, the entire benchmarks framework of 12 benchmarks for emergency preparedness was introduced. In this issue we will study benchmark 11 as it is concerned with making health facilities disaster resilient so that they can continue to function during an emergency.
Whenever the images flicker across television and computer screens of the latest natural disaster to take place somewhere on the globe, the consequences for the unlucky people who got in the way of the natural forces stand out. Disasters cause death and destruction to a large number of people. But they also have other, and very costly, implications. One of the main casualties in disasters is the health facilities of the affected area. It is well documented that hospitals, clinics and health posts more often than not suffer extensive damage from
earthquakes, floods and cyclones. Arguments and evidence exist that point to the cost-effectiveness and importance of safe-guarding health facilities to make sure they do not pose a risk to staff and patients, and to ensure that they can provide their vital services when they are most needed. Despite the overwhelming arguments, the sad reality is that the majority of health facilities in the countries of the South-East Asia Region are still very vulnerable to a range of natural hazards frequently occurring in the region. In recognition of this fact, the 11 Member countries overwhelmingly agreed that the safety of health facilities was an important aspect to include in the benchmarks framework formulated at the regional consultation in Bangkok in November 2005. Discussions led to the inclusion of benchmark 11: health facilities are built and/
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or modified to withstand the forces of expected events. But what does this actually entail? The benchmark contains provisions covering both the construction of new facilities and modification of existing ones. To clearly understand the difference, two standards have been formulated that highlight the different approaches inherent in the benchmark. The first standard is: New health facilities are built to withstand expected risks and will be able to continue to provide the required medical care at all times. The objective of this is to function as a standard for the construction and maintenance of all newly constructed health facilities. To ensure that new buildings are built in a way that keeps them safe from natural hazards requires a number of considerations: • Hazard, risk and vulnerability assessment of the chosen site and possible relocation if area is deemed high risk; the application and adherence to strict building codes, and perhaps consideration of whether the national building codes are strict enough to ensure not only safety but also functionality of critical infrastructure; appropriate design and material choices and strict quality control of construction practices; and availability of skilled manpower with knowledge of appropriate technologies.
• the structural integrity and vulnerability of buildings; • the vulnerability/resilience of nonstructural elements such as equipment, lifeline systems and architectural elements; • the capacity of the facility in terms of emergency management plans and skills and staff capacities; and • the vulnerability of the surrounding area and the anticipated emergency requirements for health services. The focus on existing structures means that careful consideration must be given to issues of feasibility, cost and need when it comes to deciding whether to initiate retrofitting. However, in many facilities it is not necessarily a question of either/or. Many interventions such as nonstructural mitigation to secure equipment, emergency planning and training of staff can greatly enhance both the safety and functionality during smaller, but frequently recurring events. A recent example of the many interplaying elements comes out of the recent series of earthquakes in Sumatra, Indonesia. Following the first earthquake of 7.9 RS on 12 September, the Bengkulu Provincial Hospital had to be evacuated following structural damage and fear of further damage from the many aftershocks. As a result, 120 patients had been hospitalised when the earthquake forced the evacuation. Within hours, however, a field hospital had been set up to treat these and another 20 people who had been seriously injured in the quake. The example demonstrates how a moderate-size earthquake could threaten the safety and functionality of an important hospital, but it also highlights the importance of proper emergency planning to mitigate and counteract the impact. With proper attention given to the “hardware” as well as “software” aspects of how health facilities can avoid becoming casualties of the next natural hazard, the health sector can take a giant step forward in minimizing its vulnerability and ensuring that people can access the health services when they need them the most.
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Now, not all of these and other considerations fall strictly within the Ministry of Health's authority, which highlights the need to work with all the relevant Government sectors, teaching and technological institutions, as well as other stakeholders such as hospital authorities and local communities. The second standard is: Existing health facilities have undergone risk mitigation and reduction to improve their security and ensure functionality during emergencies. This standard requires a somewhat different approach. The safety of existing structures in the face of common hazards must first be assessed and determined before decisions can be made as to what needs to be mitigated as a matter of priority. Safety and functionality are comprised of many elements, of which some are:
Benchmarking safety and functionality of health facilities
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BENCHMARK 11 Health facilities built/modified to withstand the forces of expected events.
STANDARD New health facilities are built to withstand expected risks and will be able to continue to provide the required medical care at all times.
HEALTH SECTOR INDICATORS
OTHER SECTOR INDICATORS
CHECKLIST
• Guidelines for • A national building • Are there provisions building new health code with adequate in the building code facilities are available standards for existing for building hazardand followed. hazards is passed resistant critical and enforced for facilities (e.g. health • Risks to life-line essential and critical facilities)? infrastructure is infrastructure. considered in the • Are the building design of new health codes enforced? Are facilities and internal there guidelines for back-up facilities are the implementation of in place (e.g. the building code? generators, water • Are there also tanks/wells with building code manual pumps). standards for the other lifeline infrastructure?
• Have vulnerability Existing health facilities • Risks from existing • Risks from existing assessments of the have undergone risk hazards are assessed hazards are assessed existing health mitigation and for all essential lifein all key health institutions against reduction to improve lines and facilities (e.g. impending hazards their security and infrastructure (e.g. hospitals, blood been undertaken? ensure functionality water supply banks, laboratories, during emergencies. systems, electricity, health posts). access roads and • Assessed risks in bridges, sanitation health facilities are and waste prioritized and management, essential problems communication). are mitigated and reduced. • Health facility maintenance staff is trained in mitigating the non-structural risks of the facility and regular resources are available for risk mitigation. • A hospital emergency plan is in place which outlines emergency management, mass casualty management and evacuation procedures, and staff are familiar with their role in emergencies. • Assessed risks to lifeline systems and infrastructure are prioritized and essential problems are mitigated and reduced.
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Hospitals safe from disasters: Campaign WHO is partnering with the Secretariat of the UN International Strategy for Disaster Reduction (ISDR) for the biennial World Disaster Reduction Campaign. The theme of the campaign for 2008-2009 is “Hospitals Safe from Disasters: Reduce Risk, Protect Health Facilities, Save Lives”. The campaign begins January 2008 with a global launch in Davos on 25 January. Regional launches will follow in the next couple of months. The goal of the campaign is to effect changes that will ensure that health facilities and services are able to function in the aftermath of emergencies and disasters, protect the lives of patients and health workers by ensuring the structural resilience of health structures and improve the risk reduction capacity of health workers as well as health institutions. Health facilities, large or small, urban or rural, are the target of this campaign. During the campaign, WHO and the UN/ISDR secretariat will work with governments, international and regional organizations, nongovernmental organizations and individuals across the world to increase awareness about the crucial need for efforts that will ensure that health facilities can function during and in the aftermath of disasters. The primary scope of the World Campaign is keeping health facilities safe from natural hazards. Keeping hospitals safe from disasters is more than protecting the physical structure. Disaster-safe health facilities are those that are accessible and functioning at maximum capacity immediately after a disaster event. WHO's South-East Asia Regional Office (SEARO) will spearhead the campaign in the 11 countries of the Region. Although a number of countries are already undertaking activities to reduce risk to health facilities during disasters, the campaign hopes to generate momentum that will help sustain and mainstream disaster risk reduction into health sector initiatives. It is expected that, following the campaign, a large number of governments will have developed strategic action plans to ensure that health facilities will be disaster safe and to make disaster risk reduction an integral component of health policies. This will facilitate the advancement of the goals of the Hyogo Framework for Action by 2015.
For more information visit www.safehospitals.info and www.searo.who.int\eha
Hospitals safe from disasters: Campaign
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by Roderico H. Ofrin
yclone Sidr, a super cyclonic storm, hit Bangladesh on the evening of 15 November 2007. It moved north through the Bay of Bengal, directly affecting 4.7 million people in 28 southern districts of Bangladesh. Nine of the districts faced devastation. With a wind speed of 220 km an hour, Sidr triggered a humanitarian crisis to which there was a speedy international response. WHO, while supporting the Ministry of Health in its response efforts, coordinated health action by UN agencies, NGOs and other aid agencies. Lack of safe water supply and poor sanitation increased the risk of outbreaks of water-borne diseases. WHO helped in an assessment of health risk and damage to health facilities and heightened disease monitoring and surveillance. WHO has also prepared a plan for the next six months outlining proposed interventions to reduce avoidable mortality and morbidity by addressing the main risk factors after the cyclone. The chronology presented here covers the first six weeks of WHO response to the cyclone.
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Chronology of WHO response to cyclone SIDR
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Date 13 November
Activity Early warning for evacuation sent out by Meteorological Agencies from Dhaka The Emergency and Humanitarian Action (EHA) unit of WHO at the South-East Asia Regional Office (SEARO) informs all at SEARO and Headquarters at Geneva about the warning. Calls Bangladesh EHA country office (EHA-BAN) to discuss next steps for action
14 November
Meteorological warnings inform that the path of the cyclone has changed EHA-SEARO and EHA-BAN discuss field presence. Two EHA staff are deployed to Bagherat and Barisal before landfall of the cyclone Discussions with Health Action in Crises (HAC)-HQ, WHO Representative (WR) in Bangladesh, EHA-BAN and EHA-SEARO on next steps
15 November
www.searo.who.int/eha launches Cyclone SIDR emergency pages and updates daily Daily teleconferences with WHO-BAN, SEARO-EHA and HAC-HQ commence
16 November
First Situation Report released The UN Country Team (Joint UN Agencies in Bangladesh) needs assessment teams sent to the four most affected districts of Barisal, Borguna, Potuakhali and Pirojpur to conduct field investigation of the casualties and damages. Six investigators from WHO join them in the field trip
17 November
Initial findings arrive from the field reports: These are analysed to identify public health needs. • Power supply and road communication of the district had been totally disrupted • About 30% of the trees had been uprooted making the road communication between the district headquarters and the Upazillas totally difficult • District and the Upazilla administration focused highest priority on restoring the road communication by involving the local community and Joint Forces • Damages to the health facilities within the districts • Boundary walls of a few hospitals got broken due to fallen trees • Electricity was disrupted and a generator had been arranged in the Sadar Hospital to preserve EPI vaccines at optimum temperature • Billboards and other sign boards had flown away from all health facilities • Water pipelines and overhead water tanks were damaged in some health facilities • In some health facilities, buildings had been damaged by the fallen trees
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Date
Activity Public health needs: • Water- and food-borne diseases may increase due to lack of safe drinking water and poor sanitation • Training for personal hygiene, traumatic counseling, and psychosocial support services are urgently needed WHO-BAN begins coordination in Barisal with the Government, District Health Coordinator, Civil Surgeon, the Joint Armed Forces, UN agencies and NGOs. Dr Delwar Hussain is the WHO EHA Coordinator based there
19 November
Operational Structure at HQ-HAC, SEARO-EHA and WRO BAN completed. IP Negotiations with donors for movement of emergency health kits and water and sanitation supplies conducted First Operational Highlights and media talking points compiled and released from various points including HQ to keep all stakeholders informed Daily technical coordination meetings held in SEARO with participations from WSH, IVD, CSR and MSH units
20 November
23 November
Videoconference between HQ, SEARO and WHO-BAN conducted at 16:00 Delhi time (16:30 Dhaka and 11:00 Geneva time) at the operations room Dr Bipin Verma, EHA-SEARO, arrives in Dhaka to assist the operations WHO receives US$ 1.46 m from UN CERF for public health interventions
24 November
Information on the public health situation is collated and analysed. Public health initiatives are formulated based on the following highlights: • Number of affected districts: 21 • Total number of affected Upazillas: 93 • Number of Deaths: 2 929 • Number of injured: 12 979 • Highlights during last 24 hrs. based on regular information flow from 9 districts • Most number of diarrhoea cases reported from Barguna, Bagerhat, Jhalkathi and Patuakhali districts • Most number of ARI/Pneumonia cases reported from Jhalkathi, Barguna, Bagerhat and Patuakhali districts • Most number of eye and skin infection cases reported in Jhalkathi district • So far, 4 Upazila Health facilities have been reported damaged. Assessment of damaged health facilities, particularly in peripheral areas, is in progress Public Health Initiatives: • Monitoring the health situation on 24/7 basis and 1189 Medical Teams working • Control Room functioning at DGHS and all Civil Surgeons offices of affected districts
Chronology of WHO response to cyclone SIDR
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Date 25 November
Activity First Health Cluster Meeting conducted with 21 agencies and 41 participants Dr Alessandro Loretti, Director, Emergency Response Operations, and Cintia Diaz de Herrera for Resource Mobilization from HAC-HQ, assist the teams in Dhaka and the Districts Recruitment of field coordinators for the six worst-affected districts is completed Cooperation with IVD staff and team coordinated
27 November
UN Joint Assessment finalized and released WHO Bangladesh formulates a six-month plan for the work of WHO to fit with the health cluster priorities The Japanese Government gives almost US$ 1 million for procurement of emergency medicines and other emergency health interventions 2 Interagency health kits (without malaria module) and three Integrated Diarrhoeal Disease Kits were sent from the Brindisi Warehouse, Italy for WHO Bangladesh A consignment of emergency relief goods, including water supply systems, generators, blankets, kitchen sets, tents, plastic rolls and medicines was sent from the Brindisi warehouse, Italy, which will be received by the Italian Embassy in Bangladesh
28 November
Six national public health experts are posted in Barisal, Jhalokathi, Bhola, Shatkhira, Pirojpur, Barguna, Patuakhali, Bagerhat and Khulna, to support the Civil Surgeons in collecting information on diseases, assessing damage to health facilities and planning response operations The second health cluster meeting takes place, during which an overview of the current public health situation is presented In the affected areas, current trends of diarrhoea and ARI/pneumonia cases are low, but it is anticipated that water-borne diseases as well as ARI/pneumonia cases may increase due to lack of safe drinking water, poor sanitation and inadequate shelter and shortage of warm clothes especially for children Priority actions for the next 10 days are outlined and followed up
3 December
5 December
Dr Roderico Ofrin, EHA-SEARO, and Dr Vijay Chandra, Regional Advisor, Mental Health-SEARO, arrive in Dhaka to support operations Four subgroups of the health cluster are formed and their terms of reference and priority actions developed. The four groups focus on surveillance, psychosocial health, nutrition and reproductive health, respectively Discussions on interventions by the Mental Health Unit with national institutes, NGOs and UNICEF commence
8 December
National Immunization Days for Polio conducted and in the nine worst affected districts a house-to-house campaign is carried out over an extended period of five days Discussions to finalize tools for in-depth assessment after field testing of tools conducted with Merlin Discussions on improvement of surveillance forms also begin
10 December
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Date 11 December
Activity Discussion with cluster leads on the following: • Progress of clusters and closing of logistics clusters • Early recovery issues and assessments • Documentation
13 December
Meeting with Disaster Management Bureau together with all cluster leads and line ministries to outline priorities and early recovery concerns It is agreed that the health cluster will proceed with its in-depth health assessment separate from the Early Recovery assessment and the damage assessment planned by the World Bank early January Restructured Operational Organization for the WHO Operations in Dhaka and the districts put in place and completed Third Health Cluster Meeting conducted with the assessment tools and modalities discussed Fourth Health Cluster Meeting conducted WATSAN supplies for health facilities arrive in districts and training on use to commence in second week of January In-depth health assessment commences
14 December
17 December 27 December
Chronology of WHO response to cyclone SIDR
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Hyogo
Framework
In January 2005, 168 Member States of the United Nations adopted the Hyogo Framework for Action 2005-2015 (HFA) at the World Conference for Disaster Reduction in Kobe, Japan.
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n January 2005, 168 Member States of the United Nations adopted the Hyogo Framework for Action 2005-2015 (HFA) at the World Conference for Disaster Reduction in Kobe, Japan. Its overarching goal is to build resilience of nations and communities to disasters and to achieve a substantial reduction of disaster losses in human lives, and in social, economic and environmental assets, by 2015. HFA is a road map for nations and communities working to become more resilient and cope better with natural disasters that threaten development. It has set five clear priorities for action to achieve disaster resilience and reduce the vulnerability of people to disasters. The priorities for action are: 1. Ensure that disaster risk reduction is a national and local priority with strong institutional basis for implementation, 2. Identify, assess, and monitor disaster risks and enhance early warning, 3. Use knowledge, innovation and education to build a culture of safety and resilience at all levels, 4. Reduce the underlying risk factors, and 5. Strengthen disaster preparedness for effective response at all levels. Fewer than eight years are left to achieve the goals set by HFA. Since the adoption of the HFA, disaster risk reduction is being addressed at the global, regional, national and local level. To
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promote the HFA, the United Nations General Assembly has called for its implementation, reconfirmed the multi-stakeholder ISDR System and the Global Platform for Disaster Reduction. Many regional bodies in Asia, the Andean Region, Central America, the Caribbean, Pacific, Africa and Europe have formulated strategies at the regional scale for disaster risk reduction in line with the HFA. More than 100 governments (March 2007) have designated official focal points for follow-up and implementation of the HFA. Some centres have been established to promote regional cooperation in disaster reduction. However, much remains to be done. Droughts, floods, cyclones, earthquakes, wildland fires and other natural hazards continue to affect more than 200 million people every year. Global warming is expected to make things worse. Disasters caused by nature have taken hundreds of thousands of lives and livelihood across the world, be it the Indian Ocean Tsunami, the South Asia earthquake, hurricanes in the United States, the Caribbean and Pacific to heavy flooding across Europe and Asia and cyclone SIDR in Bangladesh.
In 2005, the HFA called on countries to promote "the goal of hospitals safe from disasters by ensuring that all new hospitals are built with a level of resilience that strengthens their capacity to remain functional in disaster situations and implement mitigation measures to reinforce existing health facilities, particularly those providing primary health care." This problem has been recognized to a certain extent and steps have been taken to address it. Yet in some parts of the world, an alarming number of facilities, from large complex hospitals to small rural clinics, are vulnerable to disasters. Health facilities continue to collapse and become nonfunctional during an emergency. Disasters can affect everyone and, therefore, disaster risk reduction is everybody's business. Everyone is responsible for taking steps to reduce vulnerability to disasters. Natural hazards cannot be prevented, but it is possible to reduce their impact by reducing people's vulnerability to them. Strong partnerships across sectors are essential to develop a culture of risk-reduction and to integrate disaster riskreduction into policies and planning. Source: United Nations International Strategy for Disaster Reduction, HFA
Hyogo framework
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Notes from the
Pranay K. Dutta National Consultant, WHO India
Field had destroyed his house. With no shelter and just a blanket to keep him warm, his asthma had become worse. He was now exhausted and too weak to walk. Another family had a woman in labor. "After the earthquake we decided to let the elder experienced women of the village help her deliver. But we have no house or shelter now. She needs privacy and has to be kept warm. We have to take her to a hospital as soon as possible." She too was put on a cot enclosed with sheets to provide her a curtain of sorts. As the men hurried their pace, other women relatives ran along with a prayer on their lips for the mother-to-be and her unborn child. The journey, arduous as it obviously was, seemed to matter little to them. Driving them was the critical need to find a source of medical assistance.
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he WHO team arrived near Tithwal, a far-flung village in the Indian State of Jammu and Kashmir, for rapid health assessment almost two weeks after the massive earthquake of October, 2005. It was obvious that Tithwal had been left to fend for itself when it came to medical care for the sick and injured. Not only the village but the entire Tangdar zone in which it stands had lost all its health facilities during the earthquake. Ambulances and medical equipment lay under debris. The village health clinic had collapsed, killing some of the health workers. Within hours of the disaster, army helicopters had evacuated the critically injured to the Srinagar Hospital. But the rest were left with no functional Hospital or health centre nearby. The winter cold and living under the stars had begun taking its toll. People were suffering from respiratory infections and running fevers. The old, the weak and children were unable to trek in search of a hospital or doctor. Pregnant women too required medical assistance. Tithwal could not wait any longer for the arrival of a temporary medical relief camp. The community, driven by an acute need for medical care, decided instead to go in search of it. Ambulances were replaced by string cots. The ailing who were too weak to walk the 12 kilometers to the Tangdar subhospital were placed on a cot. The cot was carried by four able-bodied family members. "How many hours will it take?" I asked a man who was carrying his old uncle on a cot to hospital. "I don't know, but at least he will not die for want of a doctor" he replied. The old man, a chronic asthma patient, had run out of medicines supplied by the village health clinic and had no idea where to get more from. The earthquake
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This was no time to tell them of the situation at the Tangdar subdistrict hospital the day before. The roof of the hospital had caved in and the building declared dangerous. Hospital beds, equipment (whatever could be salvaged) and fresh supplies of equipment and medicines had been moved to the newly constructed building in the same compound. The new construction too had cracks but the doctors felt that from here they could keep the hospital functional. The old damaged building, however, had set up a crucial tele-medicine post via which the doctors were connected to selected major hospitals in other cities of the country and could consult other professionals for guidance.
The satellite phone proved to be another lifeline for the doctors. They were in constant touch with health officials in the state capital of Srinagar for alerts, directives and feedback. The satellite phone also helped connect the field health camps with Srinagar when communications broke down after the earthquake. Though more than 70% of the hospital was damaged, it was able to treat 8 000 people in the makeshift OPD, carry out 400 surgeries and keep 22 patients plus six earthquake victims since the morning of the disaster. As I saw the sick being carried from Tithwal on cots to the Tangdar hospital I was thankful that at least there was a place for these people to go to when
Notes from the field
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they so urgently needed medical assistance. It may well not be the perfect place but it was there. WHO had provided water purification tablets and chloroscopes to the hospital to assist in maintaining a supply of safe water. Four surgical kits, which can make possible surgery on 400 people, and guidelines for disease surveillance, psychosocial support, nursing care and environmental sanitation were also given by WHO after the earthquake. Delwar Hussain, National Coordinator, WHO Bangladesh Cyclone Sidr had hit Morelgang in the southern district of Bagerhat about 24 hours before the WHO team arrived there to assess its impact on people and health facilities. Even before we saw the subdistrict hospital at Morelgang, there was enough evidence around to know that the news could not be good. All along the road were people scrambling to hire vans and filling them with the injured and sick. "The hospital is flooded with water" told an old man who had a fractured foot and broken ribs. "My sons are waiting to find a van to take me to the Bagerhat hospital". It would be many hours before he would have access to medical assistance because there was an acute shortage of transport and the hospital was a good 40kms away.
Many others had decided not to wait. They had made a hammock of sorts with sheets and bamboo poles, usually meant to carry goods to nearby markets, to transport the injured all the way to the Bagerhat hospital. I saw a good number of children, women and old people being carried in this manner. Many of them had grievous head injuries, some had fractures and others who had been pulled out of swirling waters before they drowned were in immediate need of life support systems to help them breathe. The only health facility in Morelgang was virtually nonfunctional following the cyclone. Its first floor had six feet of water. Three of the four vaccine refrigerators in the hospital were flooded with water, which had destroyed the stored vaccines. The computers and other equipment too were under water. There was no electricity and water supply. The doctors and nurses were fighting hard to care for those admitted to hospital before the cyclone. When they saw the water hit the ward door repeatedly with force they rushed the patients to the first floor. "We just had time to save them but not the equipment. We could not move heavy equipment nor did we know where to install it," the hospital staff told us. The receding wave had made the hospital ground slushy. There was thick mud on the floors and all the
20 FOCUS • February 2008
medicines and equipment had been damaged. The hospital was not in a position to offer any medical assistance to people injured in the cyclone. I wished the hospital staff had been trained and equipped to meet such an emergency considering it is situated in a disasterprone area. If the hospital was disaster resilient, the 250 000 people dependent on it for medical care would not have to carry the injured 25 kms to access it. I wondered how many of the injured were still in their houses and would not be able to reach even a hospital like this let alone be carried to Bagerhat Sadar hospital. Before Morelgang we had visited the Port Authority Hospital at Mongla in which some people had taken shelter after the cyclone alert. Luckily the tide was not high enough to reach an important health facility in the second largest port city of Bangladesh. But if it had, the hospital would have suffered the same fate as the one in Morelgang. Earlier in the day, as we were driving from Khulna to Mongla we met a number of people busy removing uprooted trees and carrying them away for firewood. These were fishermen and wood pickers who had lived through the cyclone a few hours ago. Their houses had been brought down by the cyclone and they needed the wood to sell and build a shelter for themselves. I asked why they had not left the area after the cyclone alert? "We didn't realize the gravity of signal level nine. Earlier there had been an alert signal 10 but nothing happened. So we thought that this time too nothing serious will happen. How could we leave our house, because there are so many expensive things in it like TV, fishing nets, cooking utensils etc. If we left our houses would be looted," one of the men told us. When the alert for cyclone Sidr was given, WHO decided to send two teams of public health experts to areas expected to be affected to assess risk to people and health facilities. I was part of the two member team which left Dhaka for Khulna the day before the cyclone landfall. Our plan was to reach Mongla at least three to four hours before the landfall. Expecting the ferry service to be disrupted due to the Sidr storm, we decided to take the longer land route using the Jamuna bridge route from Dhaka to Khulna district. Though this would add 200kms to the journey we expected to be there the night before the cyclone
landfall. But it was a slow drive and we were delayed. The wind was already very strong and rain was lashing around. About three hours before cyclone Sidr hit, we were met with high intensity wind and rain. As we were about to cross the bridge over the river Jamuna we were instructed by our office to retreat and stay at least 150 kms. away from the cyclone landfall as the intensity was much higher than expected. We were already about 100 kms from the landfall zone and there was no place to go back to. We spent the night at the nearest town of Pabna and left early morning the next day for Khulna. As we drove we could see the devastation Sidr had brought the previous day, even though the areas we were traveling through were not badly hit. The strong wind had flattened the paddy fields and uprooted many of the Kushtia trees planted on the roadside to provide shade. Banana trees lay across roads. As we approached Khulna, the city expected to be hit by Sidr, there were more signs of devastation. Electricity poles had been uprooted. Billboards and tin sheds had been blown away and scattered the road. The mud houses had collapsed. When we arrived at Khulna, the district officials were already out in the field assessing the casualties and health situation. But all the offices were open though it was a holiday. Even in the early hours of the morning, every official right from the civil surgeon to the district officials were carrying a slip of paper with the number of dead, injured and lost due to Sidr. We could sense the situation would be worse further south to Khulna where Sidr had hit with all its energy. We left for Pirojpur to assess the damage. It was heart rending to learn that there was a large number of women, children and young men who had drowned in the cyclone tide. As the tide started to rise, the women put their children on a bed. When the water reached the bed they put the children on their heads and tried to walk through waist-high water in search of a safe place. The young and strong men thought they would swim to land. But the tide brought in by the cyclone swept them out to sea as it receded. As WHO teams did an assessment of needs after the cyclone, it was evident that though it had made available buffer stocks of medicines their rapid distribution had been hampered by blocked roads and a breakdown of the transport system.
Notes from the field
21
forms its first EHA Regional Technical Advisory Group Disaster Management Experts meet to look at challenges ahead
(RTAG)
An 11-member Regional Technical Advisory Group (RTAG) of disaster management experts will now provide independent opinion to WHO’s Emergency and Humanitarian Action (EHA) programme in the South-East Asia Region. Disaster management “gurus” like Dr Claude de Ville de Goyet, Dr Manuel Carballo and Dr Marvin Birnbaum met for the first RTAG meeting at New Delhi on December 20-22 to review progress by WHO in the crucial area of emergency preparedness, response and risk reduction to formulate strategies to meet the challenges ahead. WHO Regional Director Dr Samlee Plianbangchang, while addressing the RTAG, drew attention to the fact that the "most difficult part of this (Emergency Preparedness and Response) effort is to ensure effective coordination and cooperation among the concerned sectors and the concerned authorities." He pointed out that "WHO is one of the many stakeholders to ensure effective implementation of the EPR programme. Therefore WHO has to strengthen its own capacity to work successfully in the multisectoral environment." The Regional Director suggested that RTAG continue advising WHO on this important aspect. As WHO works to meet the public health needs of vulnerable communities in the SEAR countries, it is acutely conscious of the vital need to invite wide-scale suggestions and advise on regional EHA strategies, programme monitoring and setting new targets. This becomes all the more imperative as there have been changes in the conceptual approach to disaster management in the UN system. The areas of emergency preparedness, response, rehabilitation, mitigation and prevention in the context of the health sector are fast expanding. It was decided that RTAG would meet every year and keep up a constant interaction via teleconference to take the significant initiative forward. RTAG is to provide independent opinion on strategic, scientific and technical aspects of WHO's EHA area of work and review progress made. RTAG will review and make recommendations on EHA activities and priorities, provide technical guidance by identifying gaps and proposing appropriate solutions, identify new strategies and advise on resource mobilization and partnerships.
22 FOCUS • February 2008
Casualty of Disasters Build disaster resilient health facilities By Rashmi Saksena
R
ecall any disaster, and the snapshot that springs to mind is of critically injured people being operated on, injected, connected to IV bottles, lying on stretchers in overcrowded makeshift field hospitals. Temporary emergency hospitals are usually set up where a sophisticated health facility stood before being reduced to rubble by an earthquake, swept away by a cyclone or submerged by flood waters.
After a disaster doctors and nurses usually are left with no option but to resort to an emergency medical system. Makeshift health care facilities are set up in spaces spared by the disaster whether in school buildings, tents in public grounds, in the shade of a tree or at times under the open sky. Aid workers and others involved in emergency response and relief operations during the 2001 earthquake in Gujarat, India, tell of surgeons carrying out amputations under the open sky with the severely damaged Bhuj General Hospital forming a tragic backdrop. International agencies could bring in a field hospital and make it operational only seven days after the collapse of the Bhuj Hospital.
The Indian Ocean Tsunami, which overwhelmed health systems in most of the affected countries, left huge numbers of injured in need of critical care that would decide between life and death, between recovery and a lifetime of suffering. For example, in Aceh, Indonesia, 1 051 inpatients and 22 242 outpatients had been admitted to hospital within 10 days of the tsunami. (Source: Moving Beyond the Tsunami: The WHO story) Since the killer wave had flattened hospitals and health care centres as it roared inland (in some countries as far as 12 kms), crippling health infrastructures, the injured had extremely limited access to normal medical aid. This also meant putting together an emergency medical system that could cope with thousands of desperate people in search of health care. For every three people killed by the tsunami in Sri Lanka, approximately two were injured. (Source: The National Disaster Management Centre, Sri Lanka) In the Andaman and Nicobar Islands, India, 111 stationary and 53 mobile medical teams were out in the field after the tsunami incapacitated health centres. In the Maldives, at least 1 800 pregnant women were impacted by the tsunami. Five hundred were left with no access to delivery facilities (Source: United Nations Children's Fund). Within hours after the tsunami struck, the number of injured in need of medical help soared and kept climbing for a number of days. The 100-day WHO strategy for dealing with the emergency, among other things, focused on replacing lost health assets and medical supplies in the tsunami-lashed countries. Action to re-establish basic health care systems along with hospital-based care was a top priority. One of the important lessons learnt from the tsunami is the crucial need to develop disaster resilient health systems, which includes making health facilities safe from various hazards and risks.
Vulnerable health facilities: Casualty of disasters
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On 15 November 2007, Cyclone Sidr damaged a number of health facilities. The rushing water damaged equipment and rendered it nonfunctional. The injured were forced to move further in-land in search of a working hospital that could take them in. Poignantly, people affected by a disaster often rush to a health facility only to find that it too has fallen victim. Their trauma and sense of loss is exacerbated at finding a nonfunctional hospital when they are desperate to save life and limb. Many do not leave. They still expect health care from the source that provided it in normal times. There are emotional repercussions of losing a health facility to a disaster. It can lead to a dip in morale and add to the sense of insecurity and social instability, particularly when other alternatives are not available. Disaster casualties among patients and staff in a health facility strike a particularly sensitive emotional chord. People expect health facilities not only to provide medical care but also to ensure the safety of their vulnerable clientele. The importance of a health facility, be it a big hospital or a small but vital clinic, is more than its role in saving lives in an emergency. It is viewed as a powerful symbol of social progress, economic development and a source of stability. For any community, the main health centre is of utmost significance, similar to airports, power-generating plants and firefighting stations. It is a community’s lifeline in normal times and even more critical in an emergency. That is why health facilities contribute to a community's sense of security and well-being. It has been seen that disaster mitigation measures bring good results when health facilities withstand the effects of disasters and continue their services to the people. Why do mega-hospitals and small rural clinics alike fall to disasters? Because awareness of the critical need to build disaster resilient health facilities among policy-and decision-makers, as well as the public, is still extremely low. Political commitment and public awareness are both essential to ensure that communities are not deprived of the care they need. The message that protecting health facilities from the avoidable consequences of disasters is a social and political necessity has yet to penetrate all levels of society. Disaster resilient health facilities are vital to everyone in society as everyone can be affected when they cannot remain operational.
24 FOCUS • February 2008
Though disaster-prone countries are now realizing the benefits of preparing for such events and are working towards disaster risk reduction, emergencies and crises continue to leave health facilities unable to function. In some parts of the world, hospitals and health centres are still built in disaster-prone areas and are unable not only to provide timely assistance to affected populations, but also to maintaining critical services like health laboratories, blood banks and pharmacies. Keeping health facilities safe from destruction is more of an urgent need now with climate change expected to cause more severe and more frequent natural hazards. It is a formidable challenge for nations and communities. But the good news is that a solution is at hand. With the current knowledge, even countries on a limited budget can bring down the risk to health facilities from disasters by reducing their vulnerability. This can be done by raising the level of investment and operational protection, just as the Patan Hospital in Nepal has done. A seismic assessment of the
Keeping health facilities safe from destruction is more of an urgent need
Vulnerable health facilities: Casualty of disasters
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hospital revealed that a major earthquake would leave the hospital unable to function. Patan Hospital was one of the first in Nepal to develop a hospital emergency plan and take measures to reduce seismic risk (Source: UN/ISDR 2008-2009 World Disaster Reduction Campaign Information Kit). Training the health workforce to function in such an emergency plays a pivotal role in making a hospital safe from natural hazards. The medical superintendent of the Ampara General Hospital in Sri Lanka had no inkling of what lay ahead when he attended the Public Health and Emergency Management in Asia and the Pacific (PHEMAP) training course a couple of months before the December 2004 Indian Ocean Tsunami. The course organized by WHO and the Asian Disaster Preparedness Centre includes multi-hazard disaster management including Tsunamis. On return he conducted a workshop for all hospital staff across the board based on what he had learnt and developed a hospital disaster plan. When the tsunami hit and casualties started flocking to the hospital, the staff knew how to respond. In fact, Ampara Hospital managed the highest number of tsunami victims. Vulnerability of a health facility to disasters is more than a medical issue. The other factors that have to be taken into account are public health, socio-political significance and the economic aspect. Let us begin by looking at the economic factor. The 1994 World Conference on Natural Disaster and Risk Reduction, Yokohama, Japan stressed the economic link between disasters and sustainable development. It is recognized now that disasters affect the Gross National Product (GNP) of developing countries and reduce their prospects for growth. The destruction of a sophisticated hospital is an economic burden for society because of the
The destruction of a sophisticated hospital is an economic burden for society
enormous investment that has gone into building it and making it operational. The cost of the building and physical infrastructure forms only a small fraction of the total cost of a modern health facility. There are two components of a health facility: structural elements and nonstructural elements. Structural elements include load-bearing components that make a building stand. Nonstructural elements are the contents rather than the building. Experience shows that a functional collapse (affecting elements that allow a hospital to operate on a day-to-day basis) and not structural damage is often what renders health facilities useless during disasters. The cost of nonstructural elements in most health facilities is higher than the structure itself. The need to also reduce nonstructural vulnerability, which contributes to functional collapse, has to be widely recognized. Coming back to expenditure, it is worthwhile to mention that it costs almost the same to build a disaster resilient health facility as it does to build a vulnerable one. Making new health facilities safe from disasters is not a costly exercise. It has been estimated that incorporating comprehensive disaster protection from earthquake and weather events into designs of a vast majority of new health facilities will only add 4% to the total cost.(Source: Pan American Health Organization, Principles of Disaster Mitigation in Health Facilities, Mitigation Series, Washington, D.C., 2000) Reducing the vulnerability of existing health facilities, however, is another story. Retrofitting to correct structural and nonstructural weaknesses is more expensive. Besides the cost factor, retrofitting of all existing hospitals would be disruptive. Developing countries can only do this gradually by working on critical areas like operation theatres and blood banks in selected facilities. Since the mid-1980s, earthquake-prone countries like India have been retrofitting. Documented case studies of health facilities during earthquakes confirm that retrofitting is technically and politically feasible and effective in saving lives and reducing disruption of essential services.
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Failed health facilities mean a higher loss of human life. During a disaster, a hospital has not only to respond to mass casualties but at the same time resume treatment of normal medical emergencies and provide routine medical care. People in hospitals before the disaster, especially those on life support systems, are affected. Quick evacuations are not always possible. Medical care itself becomes a casualty. Nonfunctional sources of medical care can neither look after the disaster-affected, nor continue serving chronic patients. And when a health facility is damaged, others nearby are overwhelmed. There are indirect costs too which include unforeseen expenses. When health facilities fail in emergency situations, not only are they not available to people at the moment they are most needed but also have a hidden long term impact on public health. Damaged hospitals also mean damage to facilities like testing laboratories. This brings to an end its contribution to the diagnosis and early warning of communicable diseases affecting a great segment of the population when immediate response is off the front page of newspapers and fades from public memory. Health sector damage during disasters can cause devastating secondary disasters. Interrupted health services can bring about a decline in the population's well-being. The Indian Ocean Tsunami affected entire national healthcare systems. For example, in Indonesia's Northern Aceh Province (where 61% of the health facilities were damaged), its primary healthcare, maternal health and neonatal care went into a crisis. Its public health system recovery has required intensive investment. Temporary facilities such as field emergency hospitals required during emergencies not only are expensive, but have also proved to be an ineffective alternative to a disaster resilient health facility. Disasters, of course, are not only an economic issue, because human lives are involved. But even if financial expenditure was the only factor to consider, the scales would tip in favour of disaster resilient health facilities. Governments would actually save money in the long run by making health infrastructure less vulnerable. The direct and indirect costs far exceed the investment needed to build safe health facilities. But when it comes to saving lives and livelihoods from the devastating effects of natural hazards, issues cannot be viewed merely in
Vulnerable health facilities: Casualty of disasters
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c Every health centre is a development gain. When it collapses during an earthquake or is washed away by flood waters, it means the loss of a development gain. terms of money spent. Safety comes at a cost, but the cost of not protecting these and cutting economic losses can be far more. Making hospitals less vulnerable to natural hazards is first and foremost a social issue. It needs a strong political commitment and political will to make use of available scientific knowledge and incorporate disaster mitigation measures into the building of new health facilities and improving the safety of existing ones. Hospitals, primary health centres and other health facilities are central to sustainable recovery from disaster as they play a key role in ongoing health surveillance to prevent disease outbreaks, undertake public health and sanitation campaigns; practice preventive medicine; foster health research and host reference laboratories. When disasters wipe out large parts of the health systems in developing countries, the country's potential to achieve the Millennium Development Goals of reducing child mortality, improving maternal health and combating HIV/AIDS, tuberculosis, malaria and other diseases are seriously compromised. Making disaster-safe health facilities is essential to meeting the MDGs. Every health centre is a development gain. When it collapses during an earthquake or is washed away by flood waters, it means the loss of a development gain. Maldives had been taken off the list of least developing countries three days before the Indian Ocean Tsunami struck in December 2004. The devastating wave put it right back on. The link between disaster safe facilities and development is obvious. Risk reduction can go a long way in assisting countries to achieve the MDGs, in particular the overarching target of halving extreme poverty by 2015. WHO, while addressing disaster situations, works to reduce risks and assists Member countries to build capacity to meet the health challenges that disasters bring. Helping to strengthen the resilience of health facilities and health systems is an initiative in this direction.
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losses counting the 2004 December, Maldives, Indian Ocean Tsunami One regular hospital, 2 atoll hospitals, 20 health centres were destroyed. As many as 5 000 people had to be evacuated from 13 islands. Source: Moving Beyond the Tsunami, The WHO Story
2004 December, Sri Lanka, Indian Ocean Tsunami 92 health facilities were destroyed. This included 35 hospitals. 2001, Gujarat (India) earthquake 3 812 health facilities were destroyed during the earthquake. There was a total collapse of the health infrastructure in Kutch district which was the worst affected. Most difficulties encountered during the response phase in the Kutch district were because of the collapse of the health infrastructure. The cost of reconstruction for the health sector alone was estimated at US$ 60 million. Source: Moving Beyond the Tsunami, The WHO Story
2004 December, India, Indian Ocean Tsunami 7 district hospitals, 13 primary health centres and 80 subcentres were damaged in the southern Indian States of Tamil Nadu, Andhra Pradesh, Kerala, the Union Territory of Pondicherry and the Andaman and Nicobar Islands Source: Moving Beyond the Tsunami, The WHO Story
2005 December, Jammu & Kashmir (India) earthquake 38 health facilities in the Kashmir Division were completely damaged. 14 were partially damaged. The worst affected blocks, Uri (district Baramulla) and Tangdar (district Kupwara), lost all their health facilities including ambulances and equipment. The Uri Hospital, which serves a population of 130 000, was totally destroyed. Patients were shifted to a nearby hospital, under construction, the roof of which had caved in. In Tangdar, patients continued to receive medical assistance in the damaged building because there was no other option. The injured and the ill who were in a position to be carried were taken to the temporary health care outlets set up by the Directorate of Health Services. Source: Joint UN-World Bank Health Need Assessment Mission Report, Health Sector, Jammu & Kashmir, December 16-22, 2005
Source: Joint report by the World Bank and Asian Development Bank (2001) to the Government of India, Gujarat Earthquake Recovery Program Assessment Report
2004 December, Aceh province (Indonesia) Indian Ocean Tsunami 30 of the 240 health clinics were destroyed. 77 others were damaged seriously. 40 suffered minor damages. As many as 700 health workers (of an estimated 9 800 in the province) died or were reported missing. Sources: Carballo M, Daita S, Hernandez M. 2005. Impact of the Tsunami on health care systems. J R Soc Med. Sep; 98(9): 390-5
2006 March, Bantul district (Indonesia) earthquake One of the six hospitals in the district was destroyed. This led to overcrowding in the surrounding hospitals. Bantul was worst hit by the earthquake. Source: World Health Organization, Regional Office for South-East Asia reports
2007 February, Indonesia floods 49 health facilities were damaged by the flood waters. Source: World Health Organization, Regional Office for South-East Asia reports
Counting the losses
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Safe health facilities and uninterrupted health services during disasters— Is it possible in developing countries such as Nepal By Amod Mani DIXIT Executive Director, National Society for Earthquake Technology—Nepal (NSET) Email: adixit@nset.org.np
S
eismic hazard assessment conducted during early 1990s for the development of a building code for Nepal revealed a very high level of earthquake hazards. Subsequent risk assessment of Kathmandu Valley revealed that a IX MMI shaking, similar to the one produced by the earthquake in 1934, would result in a scary scenario of more than 40 000 deaths and 100 000 casualties injured to the extent of requiring hospitalization. Another comparative study towards the end of the last century revealed that Kathmandu Valley was the most at risk in terms of potential death and injury by an earthquake, among the 21 cities located in seismic regions of the world, developing or developed. These facts already were a matter of concern for the Nepalese. The extent of earthquake damage to health institutions in Bam (Iran) and in Bhuj (India) convinced the National Society for Earthquake Technology - Nepal (NSET) and other related organizations working in the health sector in Nepal to focus attention on the safety of heath systems during disasters, leading to a series of strategic decisions that paved the way for developing collaborative efforts among related institutions. The following paragraphs briefly describe these initiatives to
30 FOCUS • February 2008
demonstrate that disaster risk of health facilities can be reduced significantly even in the weak economy environment of developing countries. Disaster Heath Working Group (DHWG): The DHWG established together with the Food and Agriculture and Logistics Working Groups in the aftermath of the 1993 floods in south-central Nepal is a formal outfit under the Department of Health Services and draws membership from government organizations, (including health services and emergency response systems), private hospitals, NGOs and WHO Nepal. In 2001, DHWG already developed the Emergency Preparedness and Disaster Response Plan for Health Sector in Nepal. Computer-Based Mass Casualty Management Training: WHO Nepal has developed a software for training health-sector personnel on efficient management of mass casualties. More than 400 personnel have been trained in Nepal. Structural Vulnerability Assessment of Hospitals and Health Institutions of Kathmandu Valley (2001): As per the health sector plan, WHO provided support for the structural assessment of 15 health institutions in Kathmandu Valley. An important
aspect of this work was to bring in the experience of Pan American Health Organization (PAHO) in Latin American countries of such assessments. An expert from South America worked with NSET Earthquake Engineer for two months in Nepal—a successful case of technology transfer. Nonstructural Vulnerability Assessment of Hospitals in Nepal (2003): The assessment included structural, nonstructural and functional vulnerabilities of a total of 14 health facilities in and outside Kathmandu Valley. By assessing the structural and nonstructural components against possible earthquakes, expected performances of hospital were evaluated and compared with standard risk acceptance matrices. The results show that about 80% of the hospitals assessed in the study fall in the unacceptable performance level for new construction and remaining 20% of the hospitals may withstand collapse. Recommendations of the study included improving seismic performance of different hospitals on a priority basis. Fixing of all equipment and contents, strengthening of critical systems, training for hospital personnel and provision of some redundancies in critical systems were the proposed activities to implement in first phase. Seismic retrofitting of hospital
Safe health facilities and uninterrupted health services during disasters
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buildings, further strengthening of critical systems and provision of extra redundancies in the systems were the activities for the second phase implementation. Considering the opportunity of immediate implementation of nonstructural risk mitigation, the study identified several mitigation options to solve the problems. Some hospitals, for example, the Patan Hospital of Kathmandu focussed on vulnerability reduction by implementing nonstructural improvements and by taking prudent decisions to avoid adding storeys to existing buildings. The most important aspect of the work was that there existed no comprehensive methodology for such assessment of health facilities in the region, which required NSET engineers to develop an appropriate methodology for such assessment based on the codes and standards from developed countries and from the WHO guidelines. The methodology was later consolidated in the form of Guidelines for Seismic Vulnerability Assessment of Hospitals: structural vulnerability, nonstructural vulnerability, functional vulnerability and mitigation, which was published in Nepal with support from WHO. Another important aspect of this work was the realization that vulnerability reduction can be done in phases and that improvement in nonstructural elements and functionality of the hospital services can be done at very low costs. This work was a milestone for developing local capacity, confidence and the conceptual framework for improving seismic performance of existing as well as new buildings, private residential or public (such as health facilities). NSET is regularly conducting vulnerability assessment of institution buildings and recently completed such assessment of seven blood banks of Nepal in cooperation with the Nepal Red Cross Society, with WHO financial support. Hospital Preparedness for Emergencies (HOPE) Course: This is a very successful four-day training course for hospital administrators, doctors and nursing staff to ensure readiness of hospitals to receive and treat disaster victims during emergencies. Both technical and management skills are imparted, and it includes overall guidance to develop a hospital emergency response plan. HOPE is a part of the Programme for Enhancement of Emergency Response
(PEER) that NSET is implementing in Bangladesh, India, Indonesia, Nepal, Pakistan and the Philippines. A related training programme under PEER is Medical First Response (MFR), a 13-day course to impart knowledge and skills on assessment of disaster victim condition, stabilization before extrication from underneath the collapsed structure and preparation of the victims for transport to a secure medical setting. So far, PEER has been able to develop a total of 154 instructors and train 437 end-users in HOPE and 270 instructors and 630 end-users in MFR in the six countries where all the training programmes have been institutionalized. Emergency Response Plan and Drill: Many hospitals in Nepal are modifying their Emergency Response Plan from a rudimentary brief note to a full-fledged response plan considering earthquake as the worst-case scenario. Patan Hospital of Kathmandu and BPKIHS of Dharan are examples. NSET has supported both the hospitals in developing their emergency response plan and testing by conducting mass casualty management drills on an annual basis. Conclusion Methodologies exist for vulnerability assessment and reduction of earthquake disaster risk in hospitals and health facilities. These could be extrapolated to cover different types of natural hazards. Many institutions have implemented this knowledge, demonstrating technical, economic and social feasibility of risk reduction in health facilities. Despite this, disaster risk assessment and vulnerability reduction of health institutions is not yet in the high priority of health planners and policy-makers in developing countries in Nepal or elsewhere. Complacency prevails, leading to further exacerbation of the risk, for example by such practices as addition of another storey on an existing building that is not designed to take the extra load. In this context, the global Safe Health Campaign should start a new process of enhancing safety of all health-related institutions and facilities—hospitals and health centres to blood banks and primary health care centres in rural areas—to make them disaster resilient. This can be achieved by developing and implementing consensus strategies and actions for risk reduction. We
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really can gradually enhance disaster safety of our health facilities! Bibliography 1. Patton R, Thomas B, Basnet R, Guragain R. "A Report on Emergency Preparedness and Seismic Vulnerability of Bir Hospital", National Society for Earthquake Technology-Nepal (NSET), 2000. 2. World Health Organization Nepal (WHO), "A Structural Vulnerability Assessment of Hospitals in Nepal", 2002. 3. National Society for Earthquake Technology-Nepal (NSET), "Non-Structural Vulnerability Assessment of Hospitals in Nepal", 2003. 4. Disaster Health Working Group (DHWG) Nepal, "Emergency Preparedness & Disaster Response Plan." Part:1, 2001. 5. World Health Organization (WHO). "Protocol for Assessment of the Health Facilities in Responding to Emergencies", 1999. 6. New Zealand Standard (NZS), "Specification for Seismic Resistance of Engineering Systems in Buildings", NZS 4219:1983. 7. Federal Emergency Management Agency (FEMA). "NEHRP Guidelines for the Seismic Rehabilitation of Buildings", FEMA-273, 1997. 8. Federal Emergency Management Agency (FEMA). "Handbook for Seismic Evaluation of Buildings— A Pre-standard", FEMA-310, 1998. 9. Building Code Development Project (BCDP). "The Development of Alternative Building Materials and Technologies for Nepal", Appendix C: Seismic Vulnerability Analysis", 1994. 10. Structural Engineers Association of California (SEAOC). "Vision 2000—A Framework for Performance-Based Design", 1995. 11. Federal Emergency Management Agency (FEMA). "Prestandard and Commentary for the Seismic Rehabilitation of Buildings", FEMA-356, 2000.
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Amod Mani Dixit Executive Director, National Society for Earthquake Technology - Nepal (NSET), answered questions for FOCUS on the challenge of keeping health facilities safe in the South-East Asia Region 1. Why is keeping health facilities safe from disasters a challenge when it comes to disaster risk management? a. b. c. d. Because health facilities appear to get damaged the most by hazardous events, especially by earthquakes, in developing countries. Health facilities are the most needed facility following a disaster. At the same time, these facilities and systems are one of the most expensive to build and establish. The nonstructural components are expensive in health facilities, sometimes more expensive than the building in which the facility is housed. This fact is not well understood in this region. Despite strong evidence of the benefit of safe health facilities and systems, decision-makers are still not proactive in assigning high priority to strategy for disaster risk reduction in health facilities.
2.
Are countries in the South-East Asia region less receptive to the idea? a. Yes, unfortunately that is true. Despite the demonstrated fact of cost-effective risk reduction, especially nonstructural and functional vulnerability reduction, and the huge damage recent events of natural hazards have inflicted on health facilities including their occupants, vulnerabilities of health facilities are on the increase. The risk comes from locational vulnerability, structural and nonstructural vulnerability and functional vulnerability. Repeatedly we see hospitals adding on yet another storey on the top of an already vulnerable hospital building. Many times construction of a health facility does not follow the code for residential buildings, whereas the code standards for health facilities should be much higher than that of a residential building. However, there is a growing concern for the safety of health facilities and for ensuring their functionality during a disaster. The Hospital Preparedness for Emergencies, the training programme that NSET is implementing under the Programme for Enhancement for Emergency Response (PEER) in six countries, is immensely popular. Following a felt need, NSET has started the process of reorienting the HOPE curriculum to give it a multi-hazard focus.
b.
3.
Is it an expensive option for developing nations? a. Nonstructural and functional vulnerability reduction is not at all expensive. In fact, many of the actions, for example, the preparation and enactment of Emergency Response Plan for the hospital or fixing the cupboards or other nonstructural items, could be done at little or no additional costs. Structural vulnerability reduction requires good and detailed assessment and the mitigation options could entail significant monetary cost. However, given the potential risk of losing the facility to disaster, and the possibility of casualty to the medical personnel and the patients, and also the reduction in the capacity to treat following a disaster, the "do nothing" option becomes very costly in the long run. One has to remember that the assessment may allow improving the structural stability incrementally, which may make the proposition more attractive.
b.
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c.
Certainly, incorporating disaster risk reduction measures during construction of new health facilities will be much less expensive than subsequent retrofitting.
4.
Is there enough evidence to justify the expense that the implementation of the concept would incur? a. Yes, the case of Patan Hospital in Kathmandu Valley, Nepal demonstrates the cost-effectiveness in terms of expenses versus achieved incremental safety against earthquake hazard. The main thing is to start doing it! Cost is no reason not to start the risk reduction work!
5.
What does multisectoral cooperation mean in the context of safe hospitals? The stakeholders of safe health facilities are a. central and local governments; b. academia (for teaching and research) c. emergency response systems such as the police, army, Red Cross; and d. the private sector and the local communities.
6.
Do communities have a role to play in this aspect of disaster risk management? a. Sure, the very first responders come from the community; hence, they play a big role. This role should be emphasized, especially for engaging them, by telling them that the community also is the source of the future victims. Communities can assist the emergency health response by doing light search and rescue, triage of the victims at the site, security and crowd management at the site. However, they need to be trained in advance for effective delivery of their services. In mitigation and risk reduction, no initiative will be effective unless there is community acceptance of the intervention. What the community accepts is much more important than what could be considered as necessary by decision-makers or scientists.
b.
c.
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The last decade has seen a paradigm shift in disaster management. Which are the evolving developments in disaster risk management? a. A visible effort in developing Disaster Risk Management (DRM) strategy including re-structuring of the institutional, legal and policy mechanisms to incorporate new and evolving concepts and paradigm shifts. Institutionalization of DRM at central to local levels. Significant achievements in capacity building and disaster awareness including Collapsed Structure Search and Rescue and Medical Response, Incident Command System and so on. Development of different strategies and plans for disaster reduction and emergency response. Increasing the number of disaster drills at various levels. Emergence of methodologies for effective DRM in developing countries, successful and replicable programmes such as School Earthquake Safety Programme, Municipal Earthquake Risk Management Programme, Community-based Disaster Risk Management Programme, Programme for Hospital Preparedness for Emergencies (HOPE), National Emergency Preparedness and Response Planning and so on. adixit@nset.org.np
b. c. d. e. f.
Safe health facilities and uninterrupted health services during disasters
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What are disaster-safe health facilities? • Those that will not collapse when a disaster strikes • Those in which patients and staff will not be killed because of the collapse • Those that will continue to function and provide services to the community in the wake of a disaster • Those that have contingency plans in place • Those that have trained workforce to keep the health facility operational in an emergency How is it possible to protect health facilities from disasters? • By taking into consideration all health facilities, such as primary health care centres, blood banks, laboratories, warehouses and emergency medical services • By including risk reduction in the design and construction of all new health facilities • By selecting and retrofitting the most critical of the existing health facilities • By involving professionals from all health disciplines, engineers, architects, managers and maintenance staff in identifying and reducing risk • By involving the widest range of professionals and health workers in building resilience of communities to disasters What are the different levels of protection to which a health facility can be built? • Life Safety: is the minimum level of protection and is the most commonly used in construction of health facilities. • Investment Protection: is the level designed to protect all or part of the infrastructure and equipment, although the facility may itself stop functioning. This level ensures that the facility can resume operations within a reasonable timeframe and cost. • Operations Protection: the most costly level. It includes life and investment protection and tries to ensure that the facility will remain functional after a disaster. Which are the components of a health facility that determine its safety? • Structural elements: beams, columns, slabs, load-bearing walls, braces or foundations. • Nonstructural elements: these enable the health facility to operate. They include water heaters or storage tanks, mechanical equipment, shelving, cabinets and lifelines. What is a functional collapse of a health facility? • This occurs when those elements that allow a hospital to operate on a day-to-day basis are unable to perform because the disaster has overloaded the system. The elements include physical spaces, medical and support services and administrative processes.
South-East Asia Regional Office Dr Poonam Khetrapal Singh Deputy Regional Director Editor-in-Chief Editorial Team Dr Roderico H. Ofrin Dr B.K. Verma Ms Rashmi Saksena Ms Trine Ladegaard Mr T. Gangadharan Mr S. Sornakaleeswaran
Bangladesh: Dr Kazi A.H.M. Akram Bhutan: Mr Norbhu Wangchuk DPR Korea: Dr Shafik Nagi India: Mr A.K. Sengupta Indonesia: Dr Vijay Nath Kyaw Win Maldives: Ms Laila Ali Myanmar: Dr Maung Maung Lin Nepal: Mr Erik Kjaergaard Sri Lanka: Dr Hendrikus Raaijmakers Thailand: Dr Arun Mallik Timor-Leste: Dr Luis Dos Reis Designed by: FACET Design
Emergency and Humanitarian Action Regional Office for South-East Asia World Health House Indraprastha Estate New Delhi-110002, India Tel: 00-91-23370804 Fax: 23370197, 23379395 Email: eha@searo.who.int Visit us at www.searo.who.int/eha
World Health Organization (2008) FOCUS is a magazine that is published twice a year. by the WHO Regional Office for South-East Asia in New Delhi India. This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors.