Executive summary

Hospitals and health installations in general are exposed elements that can suffer serious damage as a consequence of the occurrence of strong earthquakes. In other words the risk to health installations can be very high, which is why it is necessary to construct any new building in such a way that it is capable of resisting the kind of natural hazards that could occur in its area. It is also necessary to evaluate the vulnerability of existing buildings, in order to identify their weaknesses and to design and carry out the alterations or retrofittings that may be necessary.

In the last 20 years more than 100 hospital facilities, serving an estimated population of between 10 and 12 million people in 9 countries of the Americas, have been affected by earthquakes. Nearly one fifth of those installations collapsed or had to be demolished as a consequence of the damage suffered during disasters. This meant a great toll in human lives and the loss of more than 10,000 hospital beds. At current costs, the replacement value of those beds amounts to more than US$700 million. Such statistics underscore the need to review the design and criteria for the construction of hospital installations in earthquake-prone areas.

Hospitals require special consideration with regard to the mitigation of risks due to their complexity and occupancy characteristics and to their role during disaster situations, especially in the diagnosis and treatment of the injured and of outbreaks of disease. Hospitals may at any one moment find themselves full of resident patients, transitory patients, staff members, employees and visitors. In the event of disaster, a hospital must continue with the treatment of resident patients and serve the people injured in the disaster. To do this the personnel must know how to respond. The building and its equipment must also remain serviceable.

Most hospital authorities recognize these facts, and for that reason have prepared formal plans for the mitigation of disasters. However, all these plans suffer from the lack of organizational alternatives in the event of severe damage to, or paralysis of, the installations. Little attention has been paid to this, which is worrisome since in many places only one hospital provides medical care, and damage to such a hospital could cause an enormous crisis.

Good systems for organizing and mobilizing personnel, equipment and supplies within a safe environment are fundamental for an effective response to the disaster. This need for systematic arrangements underscores the critical nature and interdependence of processes, buildings and equipment. Deficiencies in any of these elements of the functional system of a hospital could induce a crisis in the institution.

Moreover, due to the importance and high cost of hospital installations, severe damage to them will not only affect the productive capacity of a country but also public finance due to the cost of rehabilitation and reconstruction.

A hospital building is composed of five basic areas, each of which has very specific functions, but which in turn must interact with other areas in ways that are vital if a hospital is to operate properly. The relations between such areas or sectors - Administration, Ambulatory Care Units, General Services, Outpatient Consultation and Emergency Services, and Inpatient Care Units - can be critical if the original design failed to consider their function and distribution in the case of a sudden influx of patients. A hospital can suffer a "functional collapse" as a result of this situation, which is recognized only at the time an emergency occurs. In addition to the above-mentioned areas, it is important to have an external services area, which plays a particularly important role in dealing with disasters.

A building can remain standing after a disaster but still be unserviceable due to nonstructural damage. The cost of the non-structural elements in most buildings is considerably higher than that of the structural elements. This is especially true of hospitals where 85% to 90% of the value of the installation is not in the support columns, floors and beams, but in the architectural design, mechanical and electric systems and in the equipment contained in the building. A relatively minor seismic movement may cause more non-structural damage than damage to structural components. As a result, the most vital aspects of a hospital, those that are most directly related to its purpose and function, are those most easily affected or destroyed by earthquakes. Conversely, it is easier and less expensive to adapt them and prevent them from being damaged or destroyed.

Many of the problems mentioned previously stem from deficiencies in the structural and non-structural safety of the building. The structural component should be considered during the design and construction stage, in the case of a new building, or during repair, remodeling or maintenance, in the case of an existing building. A good structural design is crucial if the building is to withstand a severe earthquake. The building may be damaged, but it is unlikely to collapse. If a hospital collapses even partially, it will be a liability for the community after the disaster and not the asset that it should be.

Unfortunately, in many countries of the Region of the Americas seismic-resistant construction standards have not been effectively applied and in others such standards have not taken into account distinctive specifications for the structures of hospital buildings. Thus, it is hardly surprising that every time that an earthquake occurs in the region the buildings hardest hit are precisely the hospitals, which should be the last to be affected. In other words, the structural vulnerability of hospitals is high, a situation that should be corrected totally or partially if enormous economic and social losses are to be avoided, especially in developing countries.

A vulnerability analysis could begin with a visual inspection of the facilities and with the preparation of a preliminary evaluation. Such an inspection makes it possible to identify areas that require attention. The report can be discussed with the consultants and the authorities in charge of the facility with a view to defining priorities and timetables for the work to be carried out. Once the retrofitting program has been designed, other reviews and studies should be carried out in specific areas identified as being in need of modification.

Mitigation of the impact of disasters by the adoption of preventive measures is a highly cost-effective activity in areas where disasters are frequent. For every dollar well spent on mitigation before a disaster occurs, much more will be saved in terms of losses prevented. Mitigation is not, in fact, a cost. In the long run it pays for itself. And it does so in real money, and in lives saved.

It follows from the above that functional, structural and non-structural interventions should be based on a very detailed work plan that includes keeping services going at each stage of the process. In the same way there must be coordination between administrative personnel, the medical staff, and the maintenance department of the hospital.

It is not possible to know the cost of reducing the vulnerability of a hospital unless there is a detailed design of the solution and of its implications. However, this does not preclude drawing up a plan in advance with enough precision to ensure that it will only require minimal adjustments as the work proceeds. Usually retrofitting costs are relatively high if they are carried out all at once. However, if the work is carried out by stages, it makes it possible for funds to be assigned more gradually and more in line with a hospital's maintenance budget.

All cases have so far demonstrated the high economic and social returns of improving the structural and non-structural behavior of vulnerable hospital buildings. The cost of retrofitting, although it may sometimes seem to be high, will always be insignificant compared to the services budget or to the cost of repairs or physical replacement. Some good figurative questions to ask in any given case might be, for example: how many scanners could be bought for an amount equivalent to the cost of a retrofitting? And how many scanners does the hospital have? The replies could yield surprising results, without taking into account all the other elements, equipment and goods that the building normally contains, not to mention the human lives involved directly or indirectly and, in general, the social cost of a loss of hospital services.

Consideration of risk in designing hospitals is a responsibility shared by the architect and the engineer. In particular, is should be emphasized that it is shared with regard to the physical relationships between architectural forms and resistant structural systems, and it would be ideal if every designer working in disaster-prone areas understood those relationships. Unfortunately, international educational methods and practice have tended to reduce incentives for promoting this broad approach in the designer's way of thinking since training for new architects is separate from that given to new engineers and, in many cases, they remain separate in practice. As it happens, some architects, by intuition or because of their intellectual background, have an excellent sense of structure, but there are very few of them, and this understanding on their part tends to occur despite their education and practice, rather than as a result.

The loss of life and property caused by earthquakes can be avoided by applying existing technologies and without going to enormous expense. The only thing that is required is the will to do it. Since around two generations are required before the current inventory of buildings in most communities gets replaced, as much attention must be paid to the structural improvement of existing buildings as to the design and construction of new buildings. At this time there exist very few technical limitations to designing and constructing buildings that will resist hurricanes, earthquakes, or other natural hazards. It is possible to minimize risks and damage if preventive measures are incorporated into the design, construction and maintenance of new health installations.

By way of conclusion, the following, briefly summarized, recommendations emerge from this study:

· In all facilities where health services operate, vulnerability and risk analysis of the buildings and their essential hospital equipment should be carried out.

· The procedures governing the purchase of hospital equipment should include a requirement that it meet risk reduction specifications.

· Hospital disaster preparedness plans should be revised with a view to including vulnerability analysis procedures and modifications designed to improve existing installations.

· Construction codes should be compulsory in the design and construction of health sector buildings.

· The administrators, builders and maintenance staff in the health services should have a basic knowledge of the architectural and engineering requirements that their installations should meet in order to be able to withstand the impact of possible natural disasters.

· Hospitals should keep in a safe place information and updated diagrams illustrating the architectural and engineering features of their buildings and technological systems.