(introductory text...)

Mexico City
26 - 28 February 1996

This publication is also available in Spanish.

PAHO Identification No.: PAHO/PED/66.48

For further information about this or other publications on disaster issues, please contact the Emergency Preparedness and Disaster Relief Coordination Program, Pan American Health Organization, 525 Twenty-third Street, N.W., Washington, D.C. 2037, USA; Fax: (202) 775-4578; email: disaster@paho.org.

The printing of this document was made possible thanks to the financial support of the International Humanitarian Assistance Division of the Canadian International Development Agency (IHA/CIDA), the Office of U.S. Foreign Disaster Assistance of the United States Agency for International Development (OFDA/USAID) and the Overseas Development Administration (ODA) of the United Kingdom.

Conference Sponsors

Ministry of Health of Mexico
Ministry of Interior of Mexico
Mexican Institute of Social Security
Pan American Health Organization
Economic Commission for Latin America and the Caribbean
Secretariat of the International Decade for Natural Disaster Reduction of the United Nations Department of Humanitarian Affairs
World Bank Organization of American States

Foreword

Just over ten years ago, a powerful earthquake hit Mexico City, causing thousands of deaths and injuries. The health infrastructure suffered terrible losses. Patients and their families, physicians, nurses, and emergency health personnel were killed when hospitals collapsed; health services needed during this crisis could not function. We have seen these tragedies repeated in Chile, Costa Rica, Ecuador, El Salvador, Panama, and other countries prone to seismic activity.

It is not just earthquakes that have taught us these lessons. The Caribbean frequent!! suffers through hurricanes. In 1995, health centers and hospitals in the Eastern Caribbean were seriously damaged by Hurricane Luis; in many cases they were the same facilities that were damaged by Hurricane Hugo seven years earlier.

The health sector of these countries cannot allow such losses to be repeated' and the technical know-how exists to lessen the impact of such events on health facilities. There are strong economic reasons for applying disaster mitigation measures in new constructions and in existing buildings. However, when resources are scarce, budgets for maintenance are often the first to be cut; cost- or time-saving construction methods are used and choices are made that can he very costly in the long-term.

In 1990, PAHO/WHO began a program to strengthen national efforts to increase the disaster resistance of new and existing health facilities. Guidelines and pilot projects were developed to analyze the vulnerability of existing health facilities. In February 1996, at the invitation of the Government of Mexico, and with the support of numerous agencies, PAHO convened the International Conference on Disaster Mitigation in Health Facilities in Mexico City.

The objectives of the Conference were:

· To define concrete measures to reduce the impact of earthquakes and hurricanes on the physical plant, lifeline services, and equipment in health facilities in order to ensure that they continue to operate without interruption after a disaster;

· To establish regional goals that include identifying which existing hospitals have the greatest priority for vulnerability studies and necessary retrofitting, as well as applying mitigation standards in new constructions, from now until the year 2001;

· To contribute to the work of Governments of the Region in giving high priority to adopting disaster mitigation measures in health facilities, and assign, within national budgets, funds for these measures.

While there has been progress, much more needs to be done to convince decision-makers that reducing the health sector's vulnerability to natural disasters is an essential part of national planning. The Conference Recommendations presented in these Proceedings reflect the commitment of Governments, institutions, and individuals to work toward the goal of reducing the loss of life, material damage, and the social and economic disruption caused by natural disasters.

George A.O. Alleyne
Director
PAHO

Summary

WHY A CONFERENCE ON DISASTER MITIGATION?

Since 1960 natural disasters in Latin America and the Caribbean have caused the death of more than 180,000 persons and approximately US$ 54 trillion in property damages. The health sector has been particularly hard hit—hundreds have lost their lives when hospitals and health centers have collapsed in the most serious events, and health services interrupted when most needed.

As many as 50% of the more than 15,000 hospitals existing in the Region may he at high risk to natural disasters. A considerable number of these health facilities lack disaster mitigation programs, emergency plans, or the appropriate infrastructure for resisting powerful earthquakes and hurricanes.

This need not he the case. Health facilities can take measures to reduce the structural impact of natural disasters. The additional cost of building hospitals to seismic and wind resistance standards is minimal, making the failure to enforce such standards inexcusable. Providing structural reinforcement in existing facilities is, however, much more costly.

Interventions to reduce nonstructural vulnerability—protecting equipment and medical supplies or ensuring the integrity of lifeline services, for example-can he carried out to a large extent by staff of the health facility with minimal capital investment.

WHO ATTENDED?

More than 500 representatives from governments; international, regional, and nongovernmental organizations; and the private sector of the Latin American and Caribbean countries met in Mexico City from 26 to 28 February at the International Conference on Disaster Mitigation in Health Facilities. The Conference was convened by the Pan American Health Organization, Regional Office for the Americas of the World Health Organization (PAHO/WHO), together with Mexico's Ministry of Health, Ministry of the Interior, and Social Security Institute the Secretariat of the International Decade for Natural Disaster Reduction (IDNDR) of the UN Department of Humanitarian Affairs (UN/DHA); the Economic Commission for Latin America and the Caribbean (ECLAC); the General Secretariat of the Organization of American States (OAS); and the World Bank.

The Government of Mexico hosted the Conference at the XXI Century National Medical Center in Mexico City. Several of the hospitals that form part of this complex were seriously damaged in the 1985 earthquake and have since been rebuilt or retrofitted. This mural commemorates the lives lost and heroic measures taken by the Center's medical staff and rescue workers in the aftermath of the disaster. (Photo: H. Molin, PAHO/WHO)

WHAT WAS DISCUSSED?

Presentations on disaster impact, vulnerability analysis, and mitigation strategies for health facilities included studies from Chile, Colombia, Costa Rica, Eastern Caribbean Islands! Ecuador, Jamaica, and Mexico. Government delegations presented progress reports on disaster mitigation objectives and practices in their national facilities. Technical Commissions met to discuss specific disaster mitigation strategies for earthquakes and hurricanes.

A highlight of the Conference and an expression of Mexico's commitment to ensuring that their hospitals withstand natural disasters, was the agreement signed by the Minister of Health of Mexico, Dr. Juan Ramón de la Fuente, and Dr. George Alleyne, Director of PAHO, whereby national and international committees will recognize the efforts and achievements made by national hospitals toward realizing safety standards.

OUTCOME

Conference participants approved "Recommendations and Goals," urging Governments and regional and international organizations to adopt policies to reduce the vulnerability of existing and planned hospitals to hurricanes and earthquakes. They also defined mitigation strategies in the design, construction, retrofitting, and maintenance of health facilities. These strategies will he presented for consideration to the political and technical decision-making levels of the health sector, trilateral and multilateral financing agencies, development planning organizations, professional schools, and other sectors, private as well as public.

A five-year plan for initiating or strengthening the disaster mitigation process in hospitals in each country was recommended. To the degree allowed by local political, economic, and organizational conditions, it was recommended that by the sear 2001 all "priority" hospital structures he able to withstand moderate- to high-intensity events without suffering functional damage and without danger of collapse. It was also recommended that the level of vulnerability to natural hazards and the level of preparedness be criteria for accrediting hospitals.

Arguably the most important result of the Conference was the personal commitment developed or strengthened among the participants to promote disaster mitigation strategies in new constructions and retrofitting projects. Participants requested PAHO to continue its disaster mitigation program in the areas of promotion, training, and regular evaluation of achievements in countries and territories of Latin America and the Caribbean.

Documents and case studies presented during the Conference may be requested, in Spanish or English, from the Regional Disaster Documentation Center, P.O. Box 3745-1000, San José, Costa Rica; Tel: (506) 257 2141; Fax: (506) 257 2139. They can also he viewed via the Internet: gopher://gopher.paho.org or http://www.paho.org/english/disaster.htm.

Agenda

Monday, 26 February

09:00-10:00
Plenary Session
Opening Ceremony

10:30-10:40
Objectives of the Conference and Work Methodology (PAHO/WHO)
Election of President and Rapporteurs
Drafting Committee

FIRST TOPIC: IMPACT OF DISASTERS

10:40-11:00
"Mitigation in the Countries of the Americas"
Dr. Eduardo Peña Triviño, Vice-President of the Republic of Ecuador

11:00-11:20
"Economic Impact of Disasters on the Hospitals of Latin America and the Caribbean"
Mr. Daniel Bitrán, ECIAC

11:20-11:40
Video presentation

11:40-12:00
Case study: "The Impact of the 1985 Mexican Earthquake"
Drs. Felipe Cruz Vega and Carlos Rojas Enríquez

12:00-12:25
Case study: "The Impact of Hurricane Luis on the Lesser Antilles"
Mr. Tony Gibbs

12:25-13:00 Observations, questions and answers

SECOND TOPIC: MITIGATION POLICIES AND STRATEGIES

14:30-15:00
Panel: "Policies and Strategies"
Moderator: Mr. Julio Kuroiwa
Ms. Vanessa Rosales, Structural aspects
Mr. Rubén Boroschek, Nonstructural aspects
Dr. Raúl Morales, Organizational aspects

15:00-15:30
Panel: "Vulnerability Assessment in Hospitals at Risk to Earthquakes, ECHO-PAHO/WHO Project"
Moderator: Ms. Belén Martínez Carbonell, ECHO
Ms. Julieta Giraldo, Colombia
Mr. Rubén Boroschek, Chile
Mr. Jaime Argudo, Ecuador
Mr. José Grases, Venezuela

15:30-15:50
Case study: "Reconstruction and Mitigation Programs in Jamaica post-Hurricane Gilbert"
Mr. Alfrico Adams

THIRD TOPIC: POLICIES AND FINANCING

16:15-17:00
"Role of International Development Financing Agencies"
Moderator: Dr. Daniel López Acuña, PAHO/WHO
Mr. Stephen O. Bender, OAS
Mr. John Bowlin, World Bank
Mr. Ricardo Bermúdez, USAID/OFDA
Dr. Luis Busco, Chile

17:00-17:30
Case study: "Legislation on Disaster Mitigation and Construction Codes in Colombia"
Mr. Omar Darío Cardona
Case study ''Construction Codes in the Caribbean (CUBIC)"
Mr. Jeremy Collymore, CDERA

17:30-17:50
Case study: "Disaster Mitigation in Existing and New Hospitals in Costa Rica"
Mr. Miguel Cruz

17:50-18:l5
Conclusions, organization of Technical Commissions

Tuesday, 27 February

09:00-13:00
Three parallel activities, as follows:

09:00-10:00
1. PLENARY

National Program on Hospital Certification for Disaster Situations in Mexico
Dr. Héctor Fernández Varela, General Director of Standards, Supervision and Development of Health Services, Mexico
Mr. Efrén Franco Díaz, General Director of Works, Conservation and Equipment of the Ministry of Health, Mexico

Reading of Agreement between Ministry of Health of Mexico and PAHO/WHO on Hospital Safety for Disaster Situations
Dr. Federico Ortiz Quezada, Director General of International Affairs of the Ministry of Health of Mexico

Signing of Agreement
Dr. Juan Ramón de la Fuente, Minister of Health, Mexico
Dr. George A.O. Alleyne, Director, Pan American Health Organization

10:00-13:00
Country and Organization reports

09:00-13:00
2. TECHNICAL COMMISSIONS
Commission 1. Design and construction of new facilities at risk to earthquakes
Retrofitting existing facilities at risk to earthquakes

Commission 2. Design and construction of new facilities at risk to hurricanes
Retrofitting existing facilities at risk to hurricanes

10:30-13:00
3. DRAFTING COMMITTEE

14:30-18:00
Continuation of meetings

Wednesday, 28 February

09:00-12:00
Visit to National Disaster Prevention Center-CENAPRED

14:00-15:30
Plenary Session
Technical Commission Reports - Discussion

15:30-18:00
Break - Optional Video session

18:00
Closing Ceremony

Recommendations and goals

Since 1960 natural disasters in Latin America and the Caribbean have caused the deaths of some 180,000 people and approximately US$ 54 billion in property damages. The health sector has been particularly vulnerable to these damages, so much so that hurricanes like "Gilbert" (Jamaica, 1988), and "Luis" and "Marilyn" (Antigua and Barbuda, St. Kitts and Nevis, St. Maarten, and other islands, September 1995) and the earthquakes in Mexico (1985), El Salvador (1986), and Costa Rica and Panama (1991) seriously damaged hospitals and health centers just when they were most needed to provide health services. ECLAC estimates that during the period 1985 to 1988 the health sector lost roughly US$1.9 billion.

In Latin America and the Caribbean there are just over 15,000 hospitals, as many as 50% of which are located in areas at high risk to natural hazards. Many of these facilities lack emergency plans and disaster mitigation programs or the appropriate infrastructure for resisting powerful earthquakes or hurricanes.

Concerned about the high risk that this situation poses to the health of the populations and economic well-being of the countries, delegates from Governments, representatives of governmental, international, regional, and nongovernmental organizations, and the private and scientific sectors of the Latin American and Caribbean countries met in Mexico City from 26 to 28 February 1996 at the International Conference on Disaster Mitigation in Health Facilities. This Conference was convened by the Pan American Health Organization, Regional Office for the Americas of the World Health Organization (PAHO/WHO), together with the Ministries of Health and Interior of Mexico, the Social Security Institute of Mexico, the Secretariat of the International Decade for Natural Disaster Reduction of the United Nations Department of Humanitarian Affairs (IDNDR), the Economic Commission for Latin America and the Caribbean (ECLAC), the General Secretariat of the Organization of American States (OAS), and the World Bank.

The participants decided to alert the Governments and international, regional, and subregional organizations of the need to adopt regional and national policies to reduce the vulnerability of existing or planned hospitals to hurricanes and earthquakes and other hazards, with the objective of helping to protect the lives of patients and health personnel and ensuring the availability of health care services.

RECOMMENDATIONS AND GOALS

1. The participants of the International Conference on Disaster Mitigation in Health Facilities, held in Mexico City from 26 to 28 February 1996, considering that:

1.1 The definition of health adopted by the countries in the WHO Constitution is: "a complete state of physical, mental and social well-being and not merely the absence of disease" and the prevention and reduction of damage due to natural hazards form an integral part of health;

1.2 The General Assembly of the United Nations has declared the decade of 1990-1999 the International Decade for Natural Disaster Reduction (IDNDR, Resolution 44/132) and adopted the "Strategy and Plan of Action for a Safer World" at the World Conference on Natural Disaster Reduction, held in Yokohama, Japan, in May 1994;

1.3 The high number of lives lost and the economic costs produced either directly or indirectly by the inadequate measures employed to protect health care facilities against the impact of hurricanes, earthquakes, and other hazards can be avoided;

1.4 The uninterrupted operation of health care facilities in the wake of a disaster, when the need for them is greatest, is extremely important, both socially and politically;

1.5 The program for disaster mitigation in hospitals, promoted by PAHO with the generous support of the Governments of Canada and the United States, as well as the pilot project for hospital vulnerability analysis conducted by this same Organization with the hacking of the European Community's Humanitarian Office (ECHO), have been very satisfactory and necessary;

1.6 Disaster mitigation measures should he carried out at the structural level of the physical plant (location, soil conditions, design, and compliance with and application of construction standards), the nonstructural level (equipment, installations, hazardous and pharmaceutical substances, furniture), and the functional level (physical distribution and training of human resources). It is important to guarantee the integrity of lifeline services outside of the hospitals or to create basic reserves to permit hospital autonomy;

1.7 Interventions to reduce nonstructural vulnerability (protection of equipment and supplies, better securing of furniture and equipment, planning for emergencies) can he identified and carried out by the staff of the health facilities themselves with minimal economic investment;

1.8 The United States Federal Emergency Management Agency, in its publication "Seismic Considerations—Health Care Facilities" (FEMA publication No. 150) states that: "The average increase in cost of health care facilities . . . should be less than 1.5 percent of the construction cost of the building which, of course, is only a part of the total project costs." The cost of protecting against high winds is generally less than protecting against earthquakes.

1.9 The greatest challenge will be to provide structural reinforcement for existing health care facilities, despite the relatively high cost such corrective reinforcement measures or structural adaptations may present, as well as to fulfill the need for highly specialized professional advisory services;

1.10 Regular maintenance and inspection of health care facilities, particularly in zones at seismic or meteorological risk are of great importance;

1.11 Health care facilities form an integral part of the communities they serve sharing hazards and many aspects of vulnerability, and disaster reduction projects and programs in communities also contribute to reducing risk in health facilities;

2 Urge all countries and institutions to:

2.1 Take into account that each country has the primary responsibility for protecting its population and infrastructure from the impact of natural disasters, as formulated in the "Strategy and Plan of Action for a Safer World," adopted at the World Conference on Natural Disaster Reduction, held in Yokohama, Japan, in May 1994;

2.2 Declare the adoption of concrete measures to mitigate the impact of natural phenomena on the physical plant, lifeline services, and equipment in health care facilities as a high health, social, and economic priority, and as an integral part of disaster prevention and emergency preparedness plans;

2.3 Define guidelines, integrated plans and programs for disaster mitigation in existing hospitals and other health care facilities, as well as those in the planning phase, mustering the political will and resources necessary to prevent facilities designed to improve health from causing loss of life and injuries when natural hazards strike, and to ensure their uninterrupted operation in emergencies;

2.4 Take into account the recommendations made by the Technical Commissions on earthquakes and hurricanes during the Conference;

2.5 Review the working documents "Role of International Development Financing Agencies," "Economic Impact of Natural Disasters on Health Infrastructure," and "General Policies on Consideration of Natural Disasters in Proposals for Investment in Health Infrastructure" as technical and scientific guidelines for the formulation of this strategy and its respective work plan;

2.6 Ensure that the planning, design, construction, alteration, and maintenance of health facilities be carried out by multidisciplinary, professional teams to guarantee proper investment in health facilities.

3. Recommend to the countries at risk to hurricanes and earthquakes that they continue, strengthen, or initiate the disaster mitigation process in health facilities between the years 1996 and 2001, for which it will be necessary to establish an annual schedule for reaching objectives, to be determined in accordance with constraints and possibilities of local political, economic, organizational, technical, and logistical conditions. The following is proposed

3.1 Formally identify which of the existing health care facilities are of greatest priority, for the study and adoption of measures to reduce the impact of hurricanes or earthquakes;

3.2 Adopt legislation and standards regulating the characteristics of the investment in order to avoid structural collapse and nonstructural damages that would the safety or functionality of the hospital in the event of a disaster;

3.3 Consider geological and hydrometeorological hazards as determining factors in decision-making when planning health services, and introduce disaster mitigation measures into the design and construction of new health establishments or into the remodeling and expansion of existing facilities;

3.4 Carry out structural vulnerability studies and design retrofitting for those health care facilities which have been classified as "priority" in accordance with accepted norms and procedures, given the present state of technical knowledge;

3.5 Ensure that existing hospitals in areas exposed to natural hazards meet the standards and regulations governing nonstructural safety in case of disaster;

3.6 Include measures for nonstructural mitigation against earthquakes and/or hurricanes, as appropriate, in all plans for maintenance, inspection, remodeling, and upgrading of existing hospitals;

3.7 Identify budgetary resources and have mitigation plans to protect the lives of patients and health workers in hospitals classified as "priority" and where vulnerability studies have been made.

By the end of the year 2001:

3.8 All hospital structures considered "priority" will he able to withstand moderate- to high-intensity events without suffering functional damage and the maximum established probable event for their designs without danger of collapse, within the useful life defined for their location, and will protect the life and health of their occupants and maintain essential health care services;

3.9 The level of vulnerability to natural hazards, as well as the level of preparedness, will he criteria to he considered in hospital accreditation;

3.10 Necessary allotments will he assigned to carry out measures to reduce vulnerability of health facilities within the budgets of all public and private institutions in the health sector.

4. Recommend to the regional and subregional organizations that they:

4.1 Consider the recommendations of the "International Conference on Disaster Mitigation in Health Facilities" in the agenda of subregional meetings of Ministers of Health and at other gatherings during 1996, so that they are adopted as policy;

4.2 Request PAHO/WHO to serve as a facilitator to promote the exchange of information and mutual support for disaster mitigation in health facilities, in the health sector, among other sectors, and regional and subregional agencies among the countries of Latin America and the Caribbean, taking advantage of the development and experience that some countries have already attained in this area;

4.3 Encourage and promote the development of training and research in universities and institutions of higher learning as a means to maintain efforts to reduce the impact of disasters on the health sector;

4.4 Strengthen the ongoing education and training of health workers in the mitigation of structural, nonstructural, and functional damage, as well as disaster preparedness;

4.5 Follow up on schedules for disaster mitigation in health facilities in order to assist countries to comply with established goals;

4.6 Support the countries in the development and use of data hanks and experts in mitigation;

4.7 Support the efforts of the countries to include risk assessment in the health sector.

5. Urge international agencies to:

5.1 Include the presentation of these Recommendations in the agenda of their respective Governing Bodies for approval;

5.2 Include risk analysis with respect to natural hazards as part of the criteria for the approval of loans or grants for hospital construction or retrofitting;

5.3 Strengthen their technical cooperation on the subject, promoting the development and dissemination of methodologies that will he utilized and the standards that will be applied when carrying out risk analyses with respect to natural hazards in troth the health sector and the planning of economic development;

5.4 Support and promote the linkage between loans and grants aimed at improving structural and nonstructural safety, and the organized response of priority health care facilities.

Recommendations from the technical commission on mitigation measures for hurricanes

27 FEBRUARY 1996
MORNING SESSION

The Commission has produced the following recommendations:

1. Governments should mandate the use of appropriate building codes and include special provisions for hospitals.

An importance factor of 1.5 on design forces is to he used in the construction of health facilities in hurricane zones, as well as special inspection procedures, including strict quality control, from the design stage to completion of construction.

2. Nonstructural elements of the building envelope, e.g., windows and cladding, are to be designed to similar levels of safety as those applied to structural elements. In addition, all glass used should he laminated or storm shutters should be provided.

3. Each country is to form a national technical advisory group or commission to develop and advise on mitigation measures for health facilities. This group should include hut is not limited to:

a) Technical personnel involved in health care as well as maintenance departments of the Ministry of Health;
b) Government technical personnel and project management agencies responsible for hospitals;
c) Representatives of professional institutions of engineers and architects.

4. The additional costs of design for increased wind-forces and new standards for nonstructural elements should be absorbed in project costs.

5. Where appropriate, wind and/or hydro-meteorological studies are to be conducted to support design of health facilities.

(Note: Technical considerations are expected to be covered by construction codes to be selected)

AFTERNOON SESSION

1. The Commission takes the same position as voiced in point 3 of the morning's proceedings with the following additions:

a) The group or committee as indicated in point 3 of this morning's proceedings will focus on health;
b) It is to he expected that the health sector would act as a catalyst for other sectors.

2. The considerations to he taken into account in determining the order priority of hospitals for retrofitting against hurricanes are:

· location of the hospital;
· level of hurricane hazard and history of occurrence;
· area of influence of the hospital, based on the population it serves;
· level of care it provides (local, regional, national/teaching);
· age of the hospital;
· type of construction under consideration, whether it meets hurricane ha/arc standards;
· degree of vulnerability;
· cost factor;
· organization for disasters (plan available?);
· training of personnel.

3. For the preparation of projects to retrofit priority hospitals subject to potential damage by hurricanes, the following requirements should be met:

· technical assistance should he obtained from specialized agencies;
· standardization of procedure manuals should he achieved to negotiate international loans;
· priority should be granted by financing agencies to hospital retrofitting;
· national funds are to he allocated as counterpart for this purpose.

4. The formulation and drafting of invitations to tender for the design and execution of projects must clearly stipulate the need for specific expertise in design for hurricanes and other natural hazards.

5. As the construction of a new hospital or major retrofitting are rare occurrences in any given island, it is extremely important to clearly define the organizational structure for decision-making. In the pre-construction programme, there should he two clearly defined intervals for client review, discussion, and decision-making following any necessary amendments. These intervals would follow the consultant's inception report and the preliminary design submission.

6. PAHO should develop a rating and accreditation system for preparedness for hurricanes and other natural hazards, or should encourage the Health Ministries to jointly develop such a common rating. Such a system would provide goals and incentives for individual hospitals, so as to further accelerate the mitigation activities.

Recommendations from the technical commission on mitigation measures for earthquakes

27 FEBRUARY 1996

During the Technical Commission for Seismic Mitigation convened at the International Conference for Disaster Mitigation in Health Facilities, health professionals, engineers, and architects analyzed design, construction, and operational aspects of new health facilities and retrofitting existing ones in terms of effective disaster mitigation measures. The recommendations made by participants aim at the formulation of hospital mitigation plans, understanding hospital mitigation as those measures taken before a disaster occurs to reduce to a minimum human and material losses, reducing physical, organizational, and functional vulnerability to ensure that the hospital continues to function during and after a disaster.

The group recommends:

1. That it is necessary to mitigate the impact of earthquakes in health facilities through an effective reduction of structural, non-structural, and functional vulnerability. These elements are described as follows:

Structural elements: Include all those elements that support the structure of a building (beams, columns, foundations, supporting walls, etc.).

Nonstructural elements: Include all those elements that do not support the structure of a building and its contents, such as: architectural components (ceilings, windows), electrical and water connections, mechanical equipment, laboratory and medical equipment, and supplies.

Functional and organizational aspects: Include design of physical space (site selection, better distribution of external and internal space, etc.), and organization (emergency plans, drills, multidisciplinary teams, etc.).

2. That mitigation concepts should he present from the moment of formulation of the project, troth for new buildings and modifications of existing ones.

3. That vulnerability of a hospital should he considered from a global and multi-disciplinary perspective, focusing on design, construction, and operation of the hospital.

4. That even though the decision for implementation of disaster mitigation measures is mainly political, the technicians must provide for the decision-makers an estimation of the level of vulnerability in relation to intervention costs.

5. That countries should promote specific recommendations for the construction of safe health facilities, since current regulations do not include provisions to guarantee the functionality of the hospital after an earthquake.

6. That accreditation of hospitals should include vulnerability evaluation.

7. That countries should request PAHO to continue its program on disaster mitigation in health facilities in the areas of promotion, training, and regular evaluation of achievements. There is an urgent need for the experiences in several countries with mitigation projects to he compiled and disseminated in the Region.

8. That disaster mitigation and vulnerability reduction for health facilities should he promoted in universities and professional associations.

9. That the design of health facilities should include seismic risk analysis! soil and site conditions, and estimates of expected losses. Experience has shown that the inclusion of these factors does not increase project costs by more than 5%.

10. That cost should not be the main factor when deciding upon design of new projects or reinforcement of existing facilities. The terms of reference should include technical and safety criteria.

11. That the need for retrofitting existing hospitals should be based on a cost/benefit analysis in relation to an acceptable level of risk.

12. That priority criteria in selecting hospitals for vulnerability reduction should include: risk level, hospital complexity, and population served. The use of hospitals classified as "high risk" should be limited as long as mitigation measures are nut implemented to protect the lives of their occupants.

13. That countries should try to obtain credit and grants from financial institutions, to he used in prevention and mitigation activities for health facilities.

14. That governments and institutions should provide funds for maintaining health facilities to avoid deterioration and consequent increase of vulnerability.

15. That financial institutions should require countries to include minimum disaster mitigation criteria in the preparation of investment projects for health infrastructure.

Conference documents

The following Conference documents are available from the Regional Disaster Documentation Center, P.O. Box 3745-1000 San José, Costa Rica, or can be accessed through the Internet at gopher://gopher.paho.org.

Technical Documents

"Economic Impact of Natural Disasters on Health Infrastructure," by Daniel Bitrán Bitrán, ECLAC.

"Role of International Development Financing Agencies," by Stephen O. Bender, OAS.

"General Policies on Consideration of Natural Disasters in Proposals for Investment in Health Infrastructure," by Vanessa Rosales, PAHO.

Case Studies

"Establishment of a National Plan for the Reduction of Seismic Effects on Health Systems," by Ruben Boroschek K., Maximiliano Astroza I., Claudio Osorio U., Dept. Civil Engineering, University of Chile.

"The Response Capability of Hospitals in Seismic Disasters: Non-Structural Aspects," by Ruben Boroschek K., Maximiliano Astroza I., Claudio Osorio U., Dept. Civil Engineering, University of Chile.

"The Mexico Earthquake, September 1985," by Dr. Felipe Cruz. Vega and Dr. Carlos A. Rojas Enríquez.

"Hospitals Under the New Colombian Legislation on Seismic Protection: Demonstrating Political Commitment to Risk Mitigation," by Omar Darío Cardona.

"Impact of Hurricanes on Health Facilities," by Tony Gibbs.

"Reconstruction and Mitigation Programs in Jamaica post-Hurricane Gilbert," by Alfrico D. Adams.

"Seismic Risk and Reinforcement of Hospitals in Costa Rica," by Miguel F. Cruz.