Disasters and Hospital Safety in Nigeria

Abstract

Nigeria has suffered from both natural and man-made disasters such as flooding, drought; civil unrest, genocide and insurgency; and the country is very important in the continent in terms of its population size, weak health systems and poor disaster preparedness. During disasters, hospitals play critical role by providing essential medical care to the injured in the communities. This paper assessed the relationship between disasters and hospital safety in Nigeria. The study is a narrative review using secondary literature from PubMed, Medline and Google scholar databases. The search words were disaster, Africa, Nigeria and hospital safety. Hospital safety index (HSI) is a global diagnostic tool that provides a snapshot of the probability of functionality of a hospital during disasters. It has structural, non-structural and functional factors in addition to environment and the health services network dimensions with 145 items that can be assessed and grouped into three safety categories- high (A), average (B) and low (C). Category A with score of 0.00-1.0, requires preventive measures to maintain and improve safety; category B with score of 0.36-0.65 measures are required in the short time to reduce losses; category C with score of ≤0.35 requires urgent measures to protect lives. Nigeria over the years has experienced flooding, epidemic, insurgency, fire outbreaks and gas explosion among others with serious impacts. The flood of 2012 alone caused 363 deaths, 2.1 million displaced persons, 18,282 injured and damages of $16.9 billion. The challenges include large gap between policy and implementation, poor knowledge and education on HSI, lack of hazards vulnerability and capacity assessment, hospital building code issues, corruption and poor post-disaster analyses. It is a wakeup call for synergistic action by the relevant stakeholders to reduce risk, protect health facilities and save lives in Africa in general and Nigeria in particular.

Full text

Corresponding Author‟s Email: dristifanus@yahoo.com
ABSTRACT
Nigeria has suffered from both natural and man-made disasters such as flooding, drought; civil unrest,
genocide and insurgency; and the country is very important in the continent in terms of its population size,
weak health systems and poor disaster preparedness. During disasters, hospitals play critical role by
providing essential medical care to the injured in the communities. This paper assessed the relationship
between disasters and hospital safety in Nigeria. The study is a narrative review using secondary
literature from PubMed, Medline and Google scholar databases. The search words were disaster, Africa,
Nigeria and hospital safety. Hospital safety index (HSI) is a global diagnostic tool that provides a
snapshot of the probability of functionality of a hospital during disasters. It has structural, non-structural
and functional factors in addition to environment and the health services network dimensions with 145
items that can be assessed and grouped into three safety categories- high (A), average (B) and low (C).
Category A with score of 0.00-1.0, requires preventive measures to maintain and improve safety;
category B with score of 0.36-0.65 measures are required in the short time to reduce losses; category C
with score of ≤0.35 requires urgent measures to protect lives. Nigeria over the years has experienced
flooding, epidemic, insurgency, fire outbreaks and gas explosion among others with serious impacts. The
flood of 2012 alone caused 363 deaths, 2.1 million displaced persons, 18,282 injured and damages of
$16.9 billion. The challenges include large gap between policy and implementation, poor knowledge and
education on HSI, lack of hazards vulnerability and capacity assessment, hospital building code issues,
corruption and poor post-disaster analyses. It is a wakeup call for synergistic action by the relevant
stakeholders to reduce risk, protect health facilities and save lives in Africa in general and Nigeria in
particular.
Keywords: Africa, Disasters, Hospital safety, Nigeria.
PUBLISHED BY:
Global Emerging Pathogens
Treatment Consortium
JOURNAL WEBSITE
www.getjournal.org
Disasters and Hospital Safety in Nigeria
Joshua *IA1; Stanley AM2; Igboanusi CJC 3; Oguntunde RO 4;
Muhammad-Idris ZK 1; Audu O5
1Department of Community Medicine, College of Medicine, Kaduna State
University, Kaduna State, Nigeria
2Department of Building, Faculty of Environmental Design, Ahmadu Bello
University, Zaria, Kaduna State, Nigeria
3Department of Public Health, 2 Division Medical Services and Hospital,
Headquarters, 2 Division, Nigerian Army, Adekunle Fajuyi Cantonment, Ibadan,
Nigeria
4University Health Services, Ahmadu Bello University, Zaria, Nigeria
5Department of Epidemiology and Community Health, College of Health
Sciences, Benue State University, Makurdi, Nigeria
*Corresponding Author: Istifanus A. Joshua
Department of Community Medicine, College of Medicine, Kaduna State
University, Kaduna, Kaduna State, Nigeria.
Phone: +2348037039752

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INTRODUCTION
Africa has made remarkable strides, with annual
growth averaging 4.5 percent over the last 20
years, foreign direct investment increase of seven-
fold, life expectancy increased by six years and
school enrollment rise to 74 percent. Infant and
maternal mortality rates have decreased by 26 and
22 percent respectively in the last decade [1].
However, the positive development gains are
threatened by climate and disaster risks that
impact 10 million people on average every year in
Africa since 1970 [1]. A vicious cycle of poverty
and ill health is the reality for many African
countries. Almost half of the population of Sub-
Saharan Africa (SSA) live on less than one dollar a
day [2]. The continent shoulders a disproportionate
burden of the world‟s communicable diseases,
including the highest number of people living with
HIV (22.5 million in SSA) and the highest rates of
HIV-TB co-infection [2]. The main communicable
disease causes of morbidity and mortality are
diarrhoeal diseases, acute respiratory infections,
measles and vector-borne diseases (dengue,
yellow fever, Crimean–Congo haemorrhagic fever
and typhus) [3]. Africa is the home of 60 per cent of
the world‟s malaria-sufferers and witnesses 90 per
cent of the world‟s malaria deaths [2]. Malaria is
endemic in over 80% of areas affected by natural
disasters [3].
Disasters cause severe impact on social and
economic development in many African countries,
and the burden falls disproportionately on
vulnerable populations, namely the poor, ethnic
minorities, old people and people with disabilities
[1,4]. Various risk factors for human vulnerability to
disaster-related morbidity and mortality include low
income, low socioeconomic status, lack of home
ownership, single-parent family, older than 65
years, younger than 5 years, female sex, chronic
illness, disability, social isolation or exclusion [4,5]..
Africa has had both natural and man-made
disasters, with serious consequences. The Natural
disasters in the continent are predominantly hydro-
meteorological and climatological. Epidemics such
as Lassa fever, Ebola virus disease, plague,
measles, meningitis, dengue and COVID-19, also
comprise a large proportion of disasters in the
region [1,6]. Many parts of the continent are prone
to flooding. For example, heavy rains in Congo and
Northern Angola increasingly lead to massive
flooding in the areas banking the Zambezi River.
This was illustrated by the mega floods of 2000
and 2001 in Mozambique, which drew the world‟s
attention through television images of a woman
giving birth in a tree [2]. Such floods not only drown
people, livestock and homes, but also lead to a
great upsurge of waterborne diseases, such as
cholera, shigellosis, typhoid fever, among others
[3]. Leptospirosis is associated with flooding and
the increased proximity of rats to humans [7,8].
Economic Community of West African States
(ECOWAS) policy recognises that over 75 per cent
of the population of West Africa live in areas that
are regularly affected by natural hazards such as
floods, droughts, cyclones or earthquakes. It also
recognises that the level of vulnerability determines
whether these hazards will become disasters [2].
Nigeria is an important country in the Africa
continent and it has been suffering from natural
disasters such as flooding and man-made
disasters such as insurgency and ethno-religious
crises, among others. Hospitals have been
destroyed and health workers targeted in some
cases, compounding the health challenges,
especially in a country where the health system is
weak and human resources for health is poor. This
bad pre-disaster situation is usually worsened
when disasters occur. These include high social
and financial costs with the associated human
tragedy. Human vulnerability has been shown to
be responsible for the increased catastrophic
effects of disasters [9]. This paper assesses the
situation of disasters and hospital safety in Nigeria
in particular.
DISASTERS, DISASTER SEVERITY INDEX AND
HOSPITAL SAFETY
A disaster is defined as a serious disruption of the
functioning of a community or a society involving
widespread human, material, economic or
environmental losses and impacts, which exceed
the ability of the affected community or society to
cope using its own resources [10]. Disaster
impacts may include loss of life, injury, disease but
also other negative effects on human physical,
mental and social well-being, together with
damage to property, destruction of assets, loss of
services, social and economic disruption and
environmental degradation [10]. Disasters are
often classified according to their speed of onset
(sudden or slow), their cause (natural or man-
made), or their scale (major or minor).
Disasters may cause ill-health directly or
through the disruption of health systems, facilities
and services, leaving many without access to
health care in times of emergency. They also affect
basic infrastructure such as water supplies and
safe shelter which are essential for health [4]. The
public health impacts of disasters are many and
cannot be over-emphasised. Disaster severity
index (DSI) is used to quantify the impact of
disasters and it is calculated as number of persons

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killed plus the number affected divide by the total
population multiply by 100.
During times of disaster, hospitals play an
integral role within the health-care system by
providing essential medical care to their
communities [11]. To enhance the readiness of
health facilities to cope with the challenges of a
disaster, hospitals need to be prepared to initiate
fundamental priority action [11]. The role of the
hospital in maintenance and promotion of public
health is more important in times of crisis because
the hospitals also act as public shelters and a ray
of hope for the affected population in the crisis
[12].
Hospitals are complex and potentially
vulnerable institutions, dependent on external
support and supply lines. During a disaster, an
interruption of standard communications, external
support services, or supply delivery can disrupt
essential hospital operations and even a modest
unanticipated rise in admission volume can
overwhelm a hospital beyond its functional reserve.
However, resilient health systems based on
primary health care at community level can reduce
underlying vulnerability, protect health facilities and
services, and scale-up the response to meet the
wide-ranging health needs in disasters [4].
WHY SAFE HOSPITALS SHOULD BE
PRIORITY?
Health facilities, especially hospitals, are critical
assets for communities on day-to-day basis and
when disaster strikes. Yet they and health workers
are often among the major casualties of
emergencies, with the result that health services
cannot be provided to affected communities when
they are most needed [13].
Studies showed that during accidents and
disasters, the need for medical attention is highest
in the first 24 to 48 hours and 85 to 95 percent of
survivors are those that were rescued and received
effective medical aid in the first 24 hours [14].
Acts of violence, including direct attacks, have
increased the threats to the security of hospitals,
health workers, patients and health services [13].
Measures to ensure the safety, security and
functionality of health infrastructure are needed at
both national and community levels. Hospitals are
also important symbols of social well-being. A
Safe Hospital programme is an essential
component of a country‟s strategy for disaster risk
reduction and, in particular, emergency and
disaster risk management for health [13] and
resilient hospitals will be able to provide essential
services to affected people and it can mitigate the
risk of injuries during and after disasters [15].
World Health Organisation (WHO) and
partners have been promoting safe hospital
programmes for over 20 years through global,
regional and national policy commitments,
technical guidance and support to countries and
partner organizations in WHO‟s six regions [2].
Recent developments that are aligned with Safe
Hospitals have included a greater focus on security
measures to protect health workers and facilities in
areas of conflict, violence and criminality, and
initiatives to improve the energy efficiency and
waste management practices of „‟green“ or „‟smart“
hospitals [13].
The Hyogo Framework for Action 2005-2015
makes specific reference to “promoting the goal of
„hospitals safe from disaster‟ by ensuring that all
new hospitals are built with a level of resilience that
strengthens their capacity to remain functional in
disaster situations and implement mitigation
measures to reinforce existing health facilities,
particularly those providing primary health care”.
The World Health Assembly and WHO Regional
Committees have passed resolutions with member
states pledging to make their hospitals safer.
HOSPITAL SAFETY INDEX
A hospital safety index (HSI) is a rapid, reliable and
low-cost diagnostic tool that provides a snapshot of
the probability that a hospital or health facility will
continue to function in emergency situation. It
takes into account structural, non-structural and
functional factors in addition to environment and
the health services network. It is easy to apply by a
trained team of engineers, architects, builders and
health professionals, and it has allowed safety to
be gradually improved upon. It is an important first
step towards prioritizing a country‟s investment in
improving safety. It protects the lives of all
occupants, the investment in the infrastructures
and the functionality of new facilities and those
identified as priority facilities in the health service
network. 145 items or areas are assessed and
then subsequently categorized into one of the
three safety categories- high (A), average (B) and
low (C). Category A with score of 0.00-1.0,
requires preventive measures to maintain and
improve safety, while category B with score of
0.36-0.65 measures are required in the short time
to reduce losses. Category C with score of ≤0.35
requires urgent measures to protect life of patients,
visitors and hospital staff [13].
The Hospital Safety Index not only estimates
the operational capacity of a hospital during and
after an emergency, but it provides ranges that
help authorities determine which facilities most
urgently need interventions [12]. The failure of non-

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structural elements does not usually put the
stability of a building at risk, but it can endanger
people and the contents of a building [12].
Health systems are composed of public,
private and nongovernmental facilities which work
together to serve the community; these include
hospitals, primary health care centres, laboratories,
pharmacies and blood banks. Safe hospitals
programmes ensure health facilities are safely built
to withstand hazards, remaining operational in
emergencies [4].
THE NIGERIA SITUATION
Nigeria had experienced various degrees of
disasters over the years of which flooding and
epidemic are the natural ones. Others such as
road traffic accidents, oil spillage fire outbreaks
and terrorism are man-made and are avoidable. In
most cases, whether natural or artificial, Nigeria
has always been caught unawares because there
had not been any efficient disaster management
system in place and as such each time disaster
strikes, it usually results in significant human and
animal lives and economic losses to the country.
Flooding which is a recurring disaster in Nigeria is
usually caused by either climatic or non-climatic
factors, thus leading to river, flash, urban and
coastal floods among others [16]. In the history of
flooding in Nigeria, the worst experience was
recorded between July and October 2012 when
363 people lost their lives, 2.1 million people
across ten states were displaced and 18, 282 were
injured [17]. In 2012, floods in Nigeria caused
combined damages and losses of $16.9 billion, or
1.4 percent of GDP [17]. Armed banditry, terrorism
and ethno-religious crises have also resulted in
loss of lives and properties including houses,
hospitals and clinics in Nigeria.
The issue of hospital safety is a global
phenomenon but unfortunately, there are lots of
challenges in Nigeria. These include the large gap
between policy commitment and implementation,
lack of detailed vulnerability and capacity
assessment in hospital setups, development and
revision of building codes for hospitals in relation to
emerging disasters, lack of continuous training and
re-training of health workers in response to
disasters, lack of evaluation and learning lessons
from past disasters. Others include, assessing the
safety of existing health facilities, development of
national policy and programmes on hospital safety,
developing partnership between health facilities
and the communities, poor reduction of
vulnerability of persons and individuals to disaster
as a public health priority e.g. through poverty
reduction, non-inclusion of conflict resolution
mechanisms and peace education in school
curricula and lack of application of multidisciplinary
approach in hospital safety, among others[18].
According to the World Health Organization-
Western Pacific Region, the African Region has
the lowest density of physicians, nursing and
midwifery staff, and pharmaceutical personnel [13].
This means that the impact of disasters in Nigeria
will be catastrophic since these are the personnel
that treat the injured, maintain environmental
sanitation, and provide preventive, protective and
promotive health services. Nigeria being the most
populous black nation on earth with some fragile
demographic, socio-economic and health indices
will also have negative consequences in an event
of a disaster[19]. There have been documentations
that when health services and hospitals fail due to
disaster (from structural or functional reasons),
people die and suffer needlessly both during the
disaster and long into the future [20]. Health sector
damage can cause devastating secondary
disasters.
Hospitals are safe from disasters when health
services are accessible and functioning, at
maximum capacity, immediately after a disaster or
an emergency. Safe hospitals will protect the lives
of patients and health workers, make health
facilities and health services function in the
aftermath of emergencies and disasters (when
they are most needed) and improve the risk
reduction capacity of health workers and
institutions, including emergency management
[20]. As such, every Nigerian should be made
aware of the importance of the issue and be
committed to helping ensure that hospitals and
health facilities are resistant to natural hazards
[20]. Hospitals are the setting in which health
workers work tirelessly to ensure the highest level
of service; and home to critical health services
such as public health laboratories, blood banks,
rehabilitation facilities or pharmacies [20].
Hospitals and health facilities represent an
enormous investment for any country and their
destruction imposes major economic burden and
its consequences.
CONCLUSION
The relationship between disasters and hospital
safety is very important in Africa in general and
Nigeria in particular as natural and man-made
disasters continue to cause deaths of humans and
destruction of hospital structures and equipment,
among others. The structural and non-structural
requirements should be taken seriously by
government in terms of policy, practice and
development both at African regional level and

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national level in order to reduce the losses and
disruption of services during disasters.
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