1. FEALAC Symposium on Pan-Oceanic Cooperation for Disaster Risk Reduction Bangkok, Thailand 9-12 November 2009 Patricia Bittner Pan American Health Organization Area on Emergency Preparedness and Disaster Relief Disaster Risk Reduction and Safe Hospitals: A Goal within our Reach

2. CONTENT General health effects of disasters The impact of disasters on hospitals and health services The loss of a hospitals is more than a health issue Safe hospitals and the Hospital Safety Index Partnerships…discussion

3. Disasters and health WHO defines health as a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity. It is difficult for disaster risk and good health to coexist!

4. Effects of disasters on the general population Loss of homes forces the displaced to seek temporary shelter. Needs of IDPs: basic supplies and sanitation, epidemiological surveillance. Locating disaster victims in temporary settlements should be the last alternative, spending money in other basic needs is more necessary. 180,000 persons in Managua, Nicaragua moved in with friends, relatives after 1972 earthquake

5. Effects of disasters on food and nutrition Food is usually locally available in sudden-impact natural disasters. Supply can be affected in slow-onset disasters (floods and drought) Food food shortages may occur when: Existing stocks or crops are destroyed Food distribution systems are disrupted

6. Effects of disasters on mental health Generally, anxiety and depression are not major health factors among survivors – most people find the strength to take care of immediate needs. Most cases can be treated with a minimum of trained staff. The issue is to diagnose and refer serious cases. Foreign medical teams are not the best equipped or prepared to deal with local or culturally sensitive situations.

7. Management of cadavers It is a myth to believe that dead bodies pose a major risk for disease. The bodies of victims of natural disasters in non- epidemic areas do not present a public health risk of cholera, typhoid, fever or plague. Even the carriers of communicable diseases are, in fact, a less serious public health threat than when they were alive.

8. Health impact varies by type of disaster Effect Hazard Earthquake High Winds (without flooding) Tsunami Flash floods Slow-onset floods Volcanoes Death ManyFewManyFewMany Severe injury ManyModerateFew Risk of communicable diseases Potential risk following all major disasters (probability rises as sanitary conditions deteriorate) Damage to health facilities Severe (structure and equipment) Severe Severe but localized Severe to equipment Severe Food shortages Rare due to economic or logistic CommonRare Population movements Rare due to heavily damaged areas Common but generally limited

9. Effects of climate change on health Source: WHO. Climate change and human health-Summary

11. One of the greatest risks to health is the impact of disasters on hospitals and health services More than 67% of the nearly 18,000 hospitals in Latin America and the Caribbean are located in areas at highr risk of disasters. Major disasters have left hundreds of thousands of persons without access to health care. In most cases, this was because the health facility simply could not function.

12. Prior to 1985, the safety of hospitals was not one of PAHOs main concerns, nor that of health managers in Latin America and the Caribbean. The trigger… Mexico City, 1985

13. Damage to health infrastructure El Salvador earthquakes 2001 Loss of 1,917 beds (39% of the countrys installed capacity. Preventive evacuation was costly and often based on unfounded fear. Field hospitals donated at great cost – money could have been better used elsewhere. HospitalBedsPost earthquake situation San Rafael (tertiary level hospital) 222Severe damage, partially operating outdoors Maternity Hospital 388Damage to obstetrics wing and elevators Rosales Hospital531Surgical center not functioning Primero de Mayo239Obstetric services evacuated San Juan de Dios San Miguel 398Operating outdoors San Pedro de Usulután 130Operating outdoors

14. Five hospitals (almost 25%) and 19 health centers (8%) destroyed. Damage to public hospitals and health centers, including replacement costs, estimated at US$53 billion. Damage to health infrastructure from tsunami in Aceh Province, Indonesia Source: World Bank, based on information from Indonesia Ministry of Health

15. Damage to health infrastructure Pakistan earthquake, October 2005

16. Not just a problem in natural disasters… Damage to health facilitiesLebanon, 2006

17. The loss of a hospital is a health issue… Disasters produce an intense demand for health services. In addition to treating disaster victims, hospitals must quickly resume treatment of everyday emergencies and routine care. The hospital network (laboratories, blood banks, etc.) are integral components of a nations public health system. The long-term impact of losing these services is difficult to quantify and therefore may be overlooked.

18. But the loss of a hospital or health facility is more than a health issue

19. Safe hospitals have symbolic social value; losing a health facility leads to a sense of insecurity and social/political instability. They are occupied around-the-clock with the most vulnerable population. Disaster-resilient hospitals must be able to protect the lives of patients and staff and continue to function. A social/political issue A public opinion survey carried out following the 2001 El Salvador earthquakes cited hospitals and blood banks as two of the three public facilities whose post-disaster functionality must be guaranteed.

20. Hospitals represent an enormous investment for any country. Destruction or loss of functionality pose a major economic burden. Direct economic losses involve more than the structure: the value of non-structural elements can be higher than the structure itself. Generally, it is much less expensive to incorporate risk reduction measures in the design of new health facilities than it is to retrofit existing facilities. An economic issue

21. UN/ECLAC estimates that damage to health infrastructure in Latin America and the Caribbean represented direct losses of US$ 3.12 billion between 1981-1996. An economic issue

22. Indirect costssuch as a decline in health and wellbeing of the population, the impact on overall recovery and a disincentive for future external investmentsare difficult to measure. An economic issue The direct and indirect costs of disasters far exceed what it would have cost to mitigate the damage to hospitals.

23. What is a Safe Hospital? …a health facility whose services remains accessible and functioning, at maximum capacity and in the same facility, immediately following a large-scale disaster or emergency. The key issue is in the level of protection!

24. Levels of Protection I.Life Protection (patients, health personnel and visitors) II.Investment Protection (equipment, furnishings and utility services) III.Operational Protection (maintain or improve the facilitys capacity to function).

25. This is a problem that can be solved... Clear mandate exists: Hyogo Framework for Action Tools are available to reduce risk Technical publications on vulnerability reduction in health facilities Courses on Hospital Disaster Planning Advocacy print and audiovisual material The Hospital Safety Index

26. What is the Hospital Safety Index? Rapid, reliable and low-cost diagnostic tool Easy to apply by a trained team of engineers, architects and health professionals Values entered in a spreadsheet (mathematic model) Four components: Location, Structural, Non-Structural and Functional 145 items or areas are assessed Three categories of safety: High, Average and Low

27. What the Checklist Evaluates Location in relation to hazards (geological, hydro- meteorological, environmental etc.) Structural safety (history of the buildings, structural systems, construction materials etc.) Non-structural safety (electrical, communications water supply systems etc.) Organization and management (disaster plans, EOC, preventive maintenance, etc.)

28. SAFE HOSPITALS CHECKLIST Geographic location (mark with an X where applicable). 1.1 Hospital location Request the hospital team to provide the map(s) showing hazards at the site of the building. Safety Level Note: ranking indicates the level of SAFETY, NOT risk. NO HAZARD YES LOW AVERAGEHIGH 1.1.1 Geological phenomena Earthquakes Rate the safety level of the hospital in terms of geological and soil analyses. Volcanic eruptions Refer to hazard maps to rate the safety level of the hospital in terms of its proximity to volcanoes and volcanic activity, lava and pyroclastic flow, and ash fall. Landslides Refer to hazard maps to rate the safety level of the hospital in terms of landslides caused by unstable soils (among other causes). Tsunamis Refer to hazard maps to rate the safety level of the hospital in terms of previous tsunami events caused by submarine volcanic or seismic activity.

29. Non-structural safety 3.1 Critical systems Safety Level Electrical systemLOWAVERAGEHIGH Generator has capacity to meet 100% of demand. Verify that the generator begins to operate within seconds of the hospital losing power, covering power demands in the emergency department, intensive care unit, disinfection and sterilization unit, surgery, etc. Low =0–30%; Average = 31–70%; High = 71–100% Performance of generator tested regularly in critical areas. Low = > 3 months; Average = 1–3 months; High = < 1 month. Generator protected from potential damage due to natural phenomena Low = No; Average = Partially; High = Yes.

30. Scoring Calculator 2.1 History of facilitys safety CONTROL Safety Level LOWAVERAGEHIGH 1 Has has been prior structural damage to the hospital as a result of natural phenomena Determine whether structural reports indicate that the level of safety has been compromised. If no natural phenomena has occurred in the last 30 years, do not fill in any box – leave blank. Low = Major damage; Average = Average/moderate damage; High =Minor damage. BLANK 2 Was the hospital built and repaired using current safety standards? Verify whether the building was repaired, the date of repairs, and whether repairs were carried out using current standards for safe buildings. Low = Standards not applied; Average = Standards partially applied; High = Standards fully applied ERROR 1 1 3 Has the hospital been adapted or remodeled or modified affecting the structural behavior of the building? Verify whether modifications were carried out using current standards for safe buildings Low = Major remodelling or modifications have been carried out; Average = Average/moderate modifications; High = Minor changes or no remodelling or modification was needed. OK 1

31. Category Unlikely to function Likely to function Highly likely to function Total Structural 7.5024.3818.1350.00 Non-structural 10.3610.988.6730.00 Functional 6.936.926.1520.00 Total24.7942.3732.94100.00 Assessment of a Health Facility

32. Safety of Non-structural Elements

33. The Result Preventative measures are suggested at some point, as the health facilitys current safety levels can cause acceptable damages, which nevertheless reduce the overall safety level of the installation. Category A0.66 – 1 Necessary measures are required at some point, as the health facilitys current safety levels can potentially put at risk patients and staff during and after a disaster event. Category B 0.36 – 0.65 Urgent measures are required immediately, as the health facilitys current safety levels are not sufficient to protect patients and staff during and after a disaster event. Category C 0 – 0.35 What should be done?CategorySafety Score Result for this facility: Category B

34. Role of the Safe Hospitals Evaluators Advocacy Preliminary meetings with senior managers to explain the rationale and purpose of the Safe Hospitals Initiative and the assessment. Assurances of confidentiality of the results. Interpretation of the results Able to explain the basic methodology of scoring the instrument. Able to analyze the results, identify and justify priorities based on these.

35. The good news… The knowledge exists to assess vulnerability and reduce risk in health facilities. Well-built or retrofitted hospitals have continued to function following disasters. The health sector is working hard to improve the safety health facilities. Two realities … One choice

36. The Hyogo Framework for Action The Hyogo Framework for Action 2005-2015 (HFA) included the following measure of commitment to and success of national risk reduction: Integrate disaster risk reduction planning into the health sector; promote the goal of hospitals safe from disaster 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 services.... next steps with FEALAC???