Building Disaster Resilient Hospitals
By Arunima Rajan
India has witnessed several natural disasters in the past decade, from tsunamis and landslides to typhoons and floods. Sometimes, it's sudden and violent, like an earthquake or gradual like a pandemic. Is it possible to build a hospital that can withstand such disruptive emergencies?
According to the Oxford Dictionary, a disaster is a sudden accident or a natural catastrophe that causes great damage or loss of life.
In addition to the lives lost each year due to natural hazards, the economic cost of natural disasters is also huge. While no nation is safe from such events, developing countries are more unsafe due to their incompetence to check the impact of disasters.
So, is it possible to ensure resistance against such incidents and ensure the safety of the occupants of a building? And, can we make buildings like hospitals safer, more reliable and secure?
Is resilient design prevalent in the Indian healthcare sector? The government of India's National Disaster Management Act, 2005 mandates all the hospitals in the country to prepare a disaster management contingency plan. This plan includes components of a disaster response cycle, i.e. response, rescue, recovery, risk: mitigation, reduction, prevention and preparedness.
The act also prescribes setting up coordination committees comprising administrative, medical and paramedical staff, who are given training about what the hospital must do in a disaster.
Almost a decade after WHO in 2015 and NDMA in 2016 issued guidelines specifically for hospital safety in the event of a disaster like earthquakes, floods and cyclones.
No Resilient Design Guideline in India
"Currently, there are hospital safety guidelines, Indian standard codes and standard operating procedures for disaster management hospitals, but there are no resilient design and planning guidelines for healthcare infrastructure in India. Infrastructure risk management caters to the nuances of mitigating the risks and vulnerabilities associated with it. However, it is important to note infrastructure resilience comprises of risk management, safety and its ability to adapt to the new normal. The construction industry has recently started to look into the macro aspects of building resilience, but no specific guidelines or policy framework has been prescribed for implementation,” says Ar. Niyati Gupta, a research scholar at the Department of Architecture, School of Planning and Architecture, New Delhi.
What is a Resilient Design?
What's Gupta's definition of resilience? “Hospital resilience is the measure of system's functional capacity to limit the damage of the facility and its building services (electricity, water supply, medical gas supply etc.) and mitigate the aftermath of a disaster through managerial functions and recovery or to adopt to a new function,” she adds. She also emphasised that resilience is the measurement of the entire system's capacity, which includes the community, built infrastructure, and services.
What does this mean in simple terms?
"The building or the system should resist or limit the damage to the critical infrastructure and services. It should have a mitigation mechanism to resist the aftermath of any disasters. It should also be able to recover from the minor losses of the shock. If everything fails, some backup/temporary infrastructure should be there to formulate a new functional capacity. Or in other words, the system should be able to adapt to the new setup and deliver medical services during an emergency," Gupta explains.
Gupta adds that when you build a structure in India, one has to take several approvals and clearances from nodal authorities like Development authorities and urban local bodies. "The built form and structure reports ideally follow the existing guidelines prescribed by the Bureau of Indian Standards and the by-laws of the region. The focus is often on the fact that the built structure shouldn't collapse in case of a disaster. One significant aspect missed out is the total quality management of the building—for instance, ensuring uninterrupted water and electrical services, cleaning of drainages to avoid dampness, indoor air quality checks, etc. Most of the risks like short-circuiting, power losses, lack of freshwater arises due to these lacunae. We need a robust measure for quality assurance, operations and management and facility management of the hospital building to check for resilience," she explains.
"We need to have smart hospitals, safe hospitals, resilient hospitals, patient-friendly hospitals and green hospitals in the country. Everybody knows these words, but no one knows the meaning or what to do about it, on the ground," says Prof. (Dr.) Anil Dewan, Head of Department of Architecture, School of Planning and Architecture, New Delhi.
Dewan recalls that after the Bhuj earthquake, a district hospital collapsed and rebuilt based on Base Isolation Technology, an aide of the New Zealand Government to the Government of India. The idea was a hospital must be functioning before, during and after an earthquake or any other natural or artificial disaster, which the hospital might encounter in its total lifecycle.
Are there good examples of innovative design in India? "AIIMS is a good example. IIT Delhi retrofitted the premier institute of the country. Japanese government built Tribhuvan University Teaching Hospital, a public hospital in Nepal. The disaster-resilient design of the hospital saved the lives of many during the earthquake in 2015," explains Dewan.
Hospitals have unique requirements
Dewan highlights a crucial point about the resilient design of a hospital. "If there's a fire in a hospital, it's not just enough that the patient is rescued. Along with the patient, his life support system, ventilator, life-saving drugs also need to be transported outside the building. One cannot ask the patient to run outside the building if there's a fire. There should be medical supply, electrical supply, and human resources to manage and operate this equipment. Only then a patient will survive. Otherwise, he won't survive. So only having a fire escape will not work for a hospital situation," he adds.
Emergency Preparedness= Lives Saved
Is it possible to remodel hospitals built several decades ago? "There are measures to retrofit the existing structure. But it is an expensive process, and there are limitations. Sucheta Kriplani Hospital, one of India's oldest hospitals, underwent a series of renovation and retrofitting processes. For a hospital to be resilient, it's not enough that the building doesn't collapse. All the other functions, as well as services of the hospital, should also be operational," explains Gupta.
Are there resilient design institutes in India? No. But there are both public and private think tanks and research institutions which are working towards developing disaster resilient infrastructure in India. Policy framework at the level of built-environment is still at a very contextual stage. National Disaster Management Authority has its institution for training and disseminating information, called the National Institute of Disaster Management. At a government level, it's the institution solely responsible for formulating policies regarding the resilient design of public buildings and healthcare infrastructure in the country. Another example is the Coalition of Disaster Resilient Infrastructure (CDRI), a collation of different countries, UN agencies, and many other multilateral development organisations. CDRI was founded to promote the climate resilience of new and existing infrastructure systems.
Why invest in resilient design?
Resilience is an iterative process, says Niyati Gupta. "There many excellent examples from the Federal Emergency Management Agency (FEMA), Department of Homeland Security in the US. FEMA's benefit-cost analysis toolkit prescribes a method through which the hazard mitigation cost benefits can be determined. It is claimed that investments made in resilient infrastructure can save up to 1.5 times the expected economic losses. It's similar to investing in the energy efficiency of the building, wherein the add on cost will be 10-20% more than the actual cost, but futuristic savings are much more than the investment. Investment in resilient design and planning of structures has direct accountability to the lives saved", explains Gupta.
Resilient Design Process
What are the steps involved in resilient design? Do designers use a toolkit to do a risk assessment of hospitals?
"Right now, there is no such toolkit prescribed by the government of India. But there are certainly other methods. For example, there are many disaster-resistance codes and standards. It might not give a holistic picture of resilience per se, but it outlines structural standards of the buildings against disasters like earthquakes, cyclones, floods, landslides etc. In addition to the codes, there are guidelines prescribed by the NDMA to withstand any extreme weather event like urban flooding, avalanche heatwaves, et cetera.," explains Niyati Gupta.
So would a firm or an architect look at past natural events which happened in that area? Anil Dewan points out that designers usually use tools like micro-zonation plans of the area, vulnerability atlas, hazard mapping, which kind of gives the risk associated with a particular location.
India does not have a risk assessment tool for hospitals specifically, but there are NDMA 2016 hospital safety guidelines for earthquakes. WHO has provided a hospital safety index which enlists both structural components and non-structural components. They have a very exhaustive list of all these indicators for the structural and non-structural part of the hospital. Through this index, risk assessment can be performed for low, medium, or high-risk hospital building areas.
Steps Involved
For building any hospital, a detailed site assessment is required. The designer assesses the hospital's location and superimposes it with the hazard maps. It also weighs the geological, climatic, demographic and vulnerability profile of the region. After considering many such nuances, a detailed project report, design basis report, tender documents are conceived. It is only after the due assessment; client interaction and area programming concept design are proposed, which reflects the building type and configuration on sit.
For new construction of the hospital campuses at the stage of the floating tender document, measures related to site assessment, hazard mapping, vulnerability mapping risk assessment, the energy efficiency of the building and most importantly, resilient design and planning have to be specified. Only when it is specified since the inception of the project by the client, only then a tender can float, and thereby the architect can work towards resilient infrastructure. Hence, the notion of resilient design and planning has to be emphasised in the client's brief.