Protectors or perpetrators.

To The Editor: World Health Day is celebrated globally every year on 7 April, to mark the Anniversary of the 1948 founding of the World Health Organization (WHO). The aim of celebrating this day every year is to raise awareness on a key global health issue. The theme of World Health Day 2009 is – “Save lives. Make hospitals safe in emergencies”, which focuses on the importance of investing in health infrastructure and that is able to withstand natural hazards, conflicts or a deteriorating situation and that is able to serve and protect people in immediate need [1]. Events around the world will highlight successes, campaign for safe facility design and construction, and build momentum for widespread emergency preparedness. Health facilities, large or small, urban or rural are critical life-lines to the community in case of emergencies and the safety of these centers become crucial in the successful management of any disaster [1]. They can be affected by natural calamities such as earthquakes, floods, hurricanes, landslides, volcanic eruptions, wild fires, avalanches, drought, and rock falls. Man-made events such as fires, gas leaks, explosions and terrorist attacks can also destroy them [2].

In spite of the great advancement in science and technology, natural calamities are ill-fated incidents, on whose occurrence man has little control. The intensity and timing of these disasters can expose the vulnerability of the emergency services even in the most advanced nations. Hurricane Katrina which hit the southern coast of the United States on August 8th, 2005, claimed more than 1,800 lives, and caused damages to the extent of 81 billion dollars [3]. The out-of-control bushfires that swept through Victoria, Australia in February, 2009, killed more than 200, left thousands homeless, destroyed entire communities and transformed forests into ash. While the fury of Hurricane Katrina caught the emergency services in New Orleans and Florida on the wrong foot, the deadly combination of scorching temperatures, low humidity and strong winds saw firefighters in Victoria waging a losing battle to control the blazing flames [4]. The Global Warming and greenhouse effect also contribute to the increase in incidence of more frequent and stronger hurricanes and intensity of drought and heat waves, besides the spread of disease such as malaria [5, 6]. Recent studies report that the climate changes due to global warming may be irreversible [7].

Hospital and other health services are the front-line defense and immediate solace to the populace in any emergency, and their operation at optimum capacity is therefore crucial during that period. When health facilities are damaged and stop functioning, it is a double blow to a devastated community which is deprived of even basic emergency care. Several recent natural calamities (Table 1) have raised questions on the resilience of health facilities. The WHO and UN/ International Strategy for Disaster Reduction (ISDR), World Disaster Reduction Campaign, advocate the concept of “Safe Hospital”-as that- “Which will not collapse in disasters situations, killing patients and staff; can continue to function and provide critical services when they are most needed; is organized, with contingency plans in place and a health workforce trained to keep the network operational” [8]. The primary objectives to insulate our health facilities from disasters, and render them fully functional in emergencies are summarized in Table 2.

Table 1

Disasters which exposed vulnerability of health services

year	Place	Consequences
2001	Gujarat (India)	3812 health facilities were destroyed when an earthquake of 7.7 magnitude struck.
2003	Algeria	An earthquake left 50% of the health facilities in the affected area non – functional due to the damage.
2004	Aceh (Indonesia)	The tsunami destroyed 30 of the 240 health clinics in and seriously damaged 77 others.
2004	Sri Lanka	The tsunami also ruined 92 heath facilities including 35 hospitals
2005	Pakistan	An earthquake destroyed 49% of health facilities from sophisticated hospitals to rural primary clinics and drug dispensaries
2008	China and Myanmar	Myanmar's Cyclone Nargis and China's magnitude 8.0 earthquake devastated more than 50% the health facilities

Table 2

Objectives for better functioning of health facilities in emergencies

1	Applying existing technologies and bringing new innovations to ensure the health structures are built to withstand the impact of disasters.
2	Ensuring that the equipment and supplies of these health facilities remain intact in case of an emergency.
3	Synchronizing the functioning of different departments within the hospitals.
4	Improving the preparedness and safety of health workers.
5	Making sure that the victims of disasters have direct and rapid accessibility to hospitals.
6	Involving communities and improving coordination with other sectors and experts from other fields such as urban planners, architects, engineers to bring not just awareness, but more importantly action.
7	Not imposing any restriction on both the local and international media coverage of the disaster.
8	Having an unequivocal and unpretentious foreign policy to seek aid from international agencies, NGOs, and other governments.
9	Restricting visits by politicians, and other dignitaries during relief operations.
10	Life is precious. Invest in health for the present and future generations.

Determining the Hospital Safety Index is a new concept developed by the Disaster Mitigation Advisory Group (DiMAG) for assessing and managing risk in the health sector. The DiMAG is an informal, multidisciplinary group of Latin American and Caribbean experts that provides advice to Pan American health Organization (PAHO)/ WHO and its member states on a variety of issues related to disaster and risk reduction in the health sector. Calculating the Hospital Safety Index is now considered to be the ”gold standard" for assessing the probability that a hospital can remain functioning in emergency situations. Table 3 summarizes the core features of the Hospital Safety Index [9]. Based on the computed score a hospital is placed in either one of the three categories of safety: Category A, Category B or Category C. Health facilities in Category A: can protect the life of their occupants and likely to continue functioning in disaster situations; In Category B: can resist a disaster but in which equipment and critical services are at risk; In Category C: where the lives and safety of occupants are deemed at risk during disasters. Calculating the safety score can thus be an introspection to identify the areas which require immediate attention, and interventions to improve safety in emergencies, can be implemented.

Table 3

Features of the Hospital Safety Index

1	A rapid, reliable and low cost diagnostic tool that provides a quick overview of the resilience of hospitals.
2	Easy to apply by a trained team of engineers, architects and health professionals.
3	Evaluation team uses the standardized “Safe Hospitals Checklist” to assess the level of safety in 145 areas of the hospital including structural, nonstructural and functional components.
4	The obtained scores are entered into an Excel spreadsheet (the Index Calculator), and automated formulas tabulate the results.
5	The final Safety Index score places a health facility into one of the three safety categories: High, Average and Low.

Man – made events, and reckless, imprudent policies can also destroy health facilities and paralyze their functioning. War is a man-made disaster that has brought untold misery to humanity. To quote Mahatma Gandhi-“ What difference does it make to the dead, the orphans, and the homeless, whether the mad destruction is wrought under the name of totalitarianism or the holy name of liberty and democracy?” [10]. The recent Israeli aggression into Gaza killing children, innocent civilians, health workers, and damaging health facilities is something the entire world should be ashamed of. Heart – rendering scenes from inside Gaza's Al-Shifa Hospital is a blot on humanity [11]. The bombing of hospitals in Northern Province of Sri Lanka has destroyed the entire fabric of the health services in the affected regions [12]. Cama Hospital of Mumbai, India came under gunfire during the Mumbai terrorist attacks of November, 2008. A hostage like situation was created in the hospital and as many as five members of the hospital staff were killed [13]. In Sudan's Darfur region, the nongovernmental organizations (NGOs) and health workers are obstructed in their work in the war-ravaged country (Al Jazeera News Channel, 30th March, 2009).

Hospitals and health facilities safe from disasters are everyone's right. They are also everyone's responsibility. An earnest and collective effort from Governments, United Nations, international and regional agencies, NGOs, health institutions and the health workforce, universities, schools and professional organizations, financial institutions, and the donor community can go a long way to protect our hospitals from disasters (1). It's the “basic minimum” one can contribute to see a happy and prosperous world. Let us play the role of “protectors ” not “ perpetrators ”. We owe it to all humanity.