Monday, March 30, 2009


By M H Ahssan

World Health Day 2009 focuses on the safety of health facilities and the readiness of health workers who treat those affected by emergencies. Health centres and staff are critical lifelines for vulnerable people in disasters - treating injuries, preventing illnesses and caring for people's health needs.

They are cornerstones for primary health care in communities – meeting everyday needs, such as safe childbirth services, immunizations and chronic disease care that must continue in emergencies. Often, already fragile health systems are unable to keep functioning through a disaster, with immediate and future public health consequences.

This year, WHO and international partners are underscoring the importance of investing in health infrastructure that can withstand hazards and serve people in immediate need. They are also urging health facilities to implement systems to respond to internal emergencies, such as fires, and ensure the continuity of care.

Emergencies: global and local impact
Wars, cyclones, earthquakes, tsunamis, disease outbreaks, famine, radiological incidents and chemical spills – all are emergencies that, invariably, impact heavily on public health. Internal emergencies in health facilities – such as fires and loss of power or water – can damage buildings and equipment and affect staff and patients. In conflicts, reasons for hospital breakdowns include staff being forced to leave due to insecurity and the looting of equipment and drugs.

In 2008, 321 natural disasters killed 235 816 people – a death toll that was almost four times higher than the average annual total for the seven previous years. This increase was due to just two events. Cyclone Nargis left 138 366 people dead or missing in Myanmar, and a major earthquake in south-western China's Sichuan province killed 87 476 people, according to the United Nations’ International Strategy for Disaster Reduction (UNISDR). Asia, the worst-affected continent, was home to nine of the world’s top 10 countries for disaster-related deaths. Along with other weather-related events, floods remained one of the most frequent disasters last year, according to UNISDR. Conflicts around the globe have also led to great human suffering and have stretched health care services to the extreme.

Disasters also exact a devastating economic toll. In 2008, disasters cost an estimated US$ 181 billion – more than twice the US$ 81 billion annual average for 2000–2007. The Sichuan earthquake was estimated to cost some US$ 85 billion in damages, and Hurricane Ike in the United States cost some US$ 30 billion.

"The dramatic increase in human and economic losses from disasters in 2008 is alarming. Sadly, these losses could have been substantially reduced if buildings in China, particularly schools and hospitals, had been built to be more earthquake-resilient. An effective early warning system with good community preparedness could have also saved many lives in Myanmar if it had been implemented before Cyclone Nargis," said Salvano Briceno, the director of UNISDR.

Although only 11% of the people exposed to natural hazards live in developing countries, they account for more than 53% of global deaths due to natural disasters. The differences in impact suggest there is great potential to reduce the human death toll caused by natural disasters in developing countries – and that the key ingredient in these tragedies is human inaction.

This is only one part of the picture. There are many smaller-scale events that inflict an even greater toll in terms of human suffering, such as in the case of vehicle accidents and fires. Road traffic crashes kill 1.2 million people annually, or more than 3200 people a day, while a further 20–50 million people are injured or disabled every year. At least 90% of road and fire fatalities occur in low- and middle-income countries. There are also 300 000 deaths each year from fires alone.

Outbreaks of communicable diseases can spark emergencies that cause widespread death and suffering. In the 12 months up to 31 May 2008, WHO verified 162 outbreaks of infectious disease in 75 countries worldwide. More than a third of the outbreaks occurred in Africa. They included cholera, other diarrhoeal diseases, measles, haemorrhagic fevers and other severe emerging diseases.

"The risk for outbreaks is often presumed to be very high in the chaos that follows natural disasters, a fear likely derived from a perceived association between dead bodies and epidemics. However, the risk factors for outbreaks after disasters are associated primarily with population displacement (commonly linked to conflict)." Even a few cases of a given disease can give rise to the perception that the public faces a grave health risk, which can lead to major political, social and economic consequences.

Infectious diseases are major causes of death and illness in children in conflict settings, especially among refugees and the internally displaced.

How emergencies threaten health facilities and delivery of care?
Apart from their effects on people, emergencies can pose huge threats to hospitals, clinics and other health facilities. Structural and infrastructural damage may be devastating exactly at the time when health facilities are most needed. Health workers have been killed in collapsing hospitals. The number of other deaths and injuries is compounded when a hospital is destroyed or can function only partially. Health facilities should be the focus for assistance when disaster strikes but, if they are damaged or put out of action, the sick and injured have nowhere to get help.

The 2003 Algerian earthquake rendered 50% of health facilities in the affected region non-functional due to damage. In Pakistan's most-affected areas during the 2005 earthquake, 49% of health facilities were completely destroyed, from sophisticated hospitals to rural clinics and drug dispensaries. The December 2004 Indian Ocean tsunami affected national and local health systems that provided health services for millions of people. In Indonesia's northern Aceh province 61% of health facilities were damaged.

Despite international laws, health facilities continue to be targeted or used for military operations in conflicts. Health facilities in Bosnia and Herzegovina, Somalia, the Central African Republic and the Gaza Strip are among those that have been caught in the line of fire.

An emergency may be limited to the health facility infrastructure – for example, fire damage, power cut or loss of water supply. Chemical and radiological emergencies in or near a health facility can also disrupt the delivery of care. In addition, emergencies threaten health staff – the doctors, nurses, ambulance drivers and other staff working to save lives. When a hospital collapses, or an artillery shell destroys a ward or an ambulance, health staff are killed or injured. When staff are incapacitated and cannot do their work, health care is further interrupted.

Even if health facilities themselves are not affected during disease outbreaks and epidemics, their services and provision of safe care may be. Increased demands for services and a decreased workforce can impact on health care by disrupting communications, supplies and transport. Continuity of care is then in turn disrupted, including for chronic diseases like HIV and tuberculosis.

If measures to prevent and control infection are not effective, health-care facilities may act as "amplifiers" of outbreaks, generating cases of the disease among other patients or health-care workers and further decreasing the capacity to provide services.

Power cuts linked to disasters may disrupt water treatment and supply plants, thereby increasing the risk of waterborne diseases and affecting proper hospital functioning, including preserving the vaccine cold chain. A massive power outage in New York in 2003 was followed by an increase in diarrhoeal illness.

Why keep health facilities safe?
Safe health facilities in emergencies are a collective responsibility
Hospitals are more than just buildings. They are a vital asset at the heart of a community, the place where often life starts and ends. Due to the central role played by hospitals in our communities, we all share the responsibility of making sure they are resilient in the face of emergencies. Below are three reasons as to why we must make hospitals safe in emergencies.

1. Save lives, protect health
As they are occupied 24 hours a day, hospitals cannot be evacuated easily. They must remain working if their occupants – especially the most vulnerable such as newborn babies and patients in intensive care – are to survive. When the work of hospitals and other health facilities is disrupted or their buildings are damaged, both urgent and routine health care is interrupted and may be halted altogether – leaving the sick and injured without the care that they need.

Health "systems" rely on a range of public, private and nongovernmental facilities to work together to serve the community. In times of emergency, this is even more important. Hospitals, primary health care centres, laboratories, pharmacies and blood banks work with other non-health sectors, including energy, roads and transport, and the police to ensure the continuity of health services.

Health facilities are safe havens for people during an emergency. Hospitals and their staff must be regarded by all parties – particularly combatants during conflicts – as neutral and must not be subjected to any form of violence. Sadly, the provisions of international humanitarian law in this regard are often not respected. During emergencies, health facilities play a vital role. They:

provide emergency care to the injured (e.g. surgery and blood transfusions) and to the critically ill – as in outbreaks of communicable disease;
- collect and analyse data on illness and deaths in order to detect and prevent potential communicable disease outbreaks;
- deliver longer-term health care before and after an emergency. People need long-term nursing and medical care, maternal and child health services, rehabilitation of injuries, management of chronic diseases, and psychosocial support long after the emergency is over;
- provide immunization services to prevent outbreaks of communicable diseases such as measles that lead to the needless deaths of more children; and
provide other critical services – including laboratories, blood banks, ambulances, rehabilitation facilities, aged care facilities, and pharmacies.

2. Protect investment
The most costly health facility is the one that fails. Hospitals and health facilities are enormous investments for any country and their destruction or damage imposes major economic burdens. In some countries, up to 80% of the health budget is spent on hospitals and other health facilities. Rebuilding a hospital that has been destroyed virtually doubles the initial cost of the facility.

3. Safeguard social stability
Public morale can falter and political discord be ignited if health and emergency services fail during emergencies. Conversely, an effective emergency response and functional health service can reinforce social stability and cohesion. Hospitals are a haven for the public during conflicts and other emergencies due to their neutrality, impartiality and ability to protect a community's social and health capital.

Global efforts to make hospitals safe from disasters
Much has been done to ensure that health facilities can better cope with emergencies and to increase awareness of the vital role that health facilities play in emergencies. “Hospitals Safe from Disasters” is the theme of the 2008–2009 World Disaster Reduction Campaign, which focuses on natural disasters and the damage they can cause to hospitals in particular. The United Nations International Strategy for Disaster Reduction (ISDR), the World Bank and WHO are jointly involved in this campaign. WHO’s regional and country offices have been instrumental not only in helping to share best practices in health facility preparedness for emergencies but also in implementing such guidance and making hospitals and clinics more resilient and functional.

While much work has been done to raise the issue of emergency preparedness for health facilities and to build a "community" of people and parties dedicated to the cause, efforts remain sporadic and are neither sufficiently integrated into government development and emergency response plans nor properly harmonized with other sectors.

WHO's partners, including WHO's regional and country offices and ministries of health, are also leading the way in advocating how best to safeguard health facilities and their personnel and patients. The International Committee of the Red Cross, which advocates for the protection of health personnel and services in conflict settings, and its sister organization, the International Federation of the Red Cross and Red Crescent Societies, which works with communities on emergency preparedness at community level in natural disasters, play critical roles in making hospitals safe from disasters. Donors and financial institutions – including the World Bank, USAID and DIPECHO – have answered the call by offering funding to make health facilities safer.

WHO is devoting World Health Day 2009 to the theme of health facilities in emergencies – “Save lives. Make hospitals safe in emergencies” – to further strengthen the imperative that health facilities must be prepared to withstand emergencies so that they can treat patients both during crises and afterwards. The World Health Day campaign builds on the "Hospitals Safe from Disasters" campaign and calls for hospitals to be safer in all types of emergencies, including natural disasters, conflicts and outbreaks of communicable diseases.

World Health Day is more than just a one-day event. WHO, from its country and regional offices and headquarters, is continuously working with international and national partners to assist countries in preparing their health facilities and staff for emergencies. What 7 April 2009 marks is the launch of the next step of a campaign to build resilience into our health systems so that hospitals, clinics and staff can withstand the next crisis, whatever it may be, and provide the health care that their communities need in times of emergency.

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