Pakistan: Rebuilding better through compulsory risk reduction designs

In 2005, a 7.6 magnitude earthquake struck a wide region of South Asia, affecting parts of Afghanistan, India and northern Pakistan. More than 73,000 people lost their lives and at least 150,000 others were injured. Almost half of the operating health facilities were completely destroyed and demand for emergency medical care was overwhelming This good practice example discusses 3 important lessons learned from the earthquake.

The event that prompted action

A 7.6 magnitude earthquake struck a wide region of South Asia on the morning of 8 October 2005, affecting parts of Afghanistan, India and northern Pakistan. The epicentre of the earthquake was located 95 km northeast of the Pakistani capital, Islamabad. In a matter of seconds, 85% of the infrastructure in towns such as Balakot was destroyed. Other cities such as the Kashmiri capital, Muzaffarabad, lost between 40% to 50%of its buildings. Strong aftershocks threatened structures already damaged by the initial quake. 

More than 73,000 people lost their lives and at least 150,000 others were injured. Demand for emergency medical care was overwhelming. The earthquake left an estimated 3.2 million people homeless.

At the time of the quake, 796 health facilities — ranging from sophisticated hospitals to small rural clinics — were operating in the area. Of that number, 388 (almost 50%) were completely destroyed. Thirteen of the destroyed facilities were hospitals, and four of these were regional or district referral hospitals. An additional 106 primary health clinics and 50 dispensaries were completely lost — and often these were the only sources of health care within a five-hour walking distance in the affected rural areas. The remaining facilities that were able to continue functioning were overwhelmed. Even if the area had not lost 50% of its capacity, the sheer number of seriously injured people that required medical care would have overwhelmed even the most sophisticated health system. Because of this, more than 14,000 persons were evacuated by helicopter to Islamabad for treatment — about 425 per day in the first month alone. And, in addition to physical damage to health facilities, the health sector itself was adversely affected, as many health professionals suffered direct losses, or worse, lost their lives.

Could lives have been saved?

If vulnerability assessments had been systematically carried out, if hospital disaster plans had been better prepared, tested and widely disseminated, and if health staff was better prepared in areas such as mass casualty management, many lives might have been saved and health facilities might have been able to function better, in spite of damage and the impact on health staff. The town of Balakot, which saw 85% of its infrastructure destroyed, including the hospital, is an example. In retrospect, it was learned that the town itself was built on unstable (unsafe) terrain. After the earthquake, the Government of Pakistan declared a 600-hectare area a “red zone”, meaning that no construction was allowed. Had earthquake vulnerability assessments been conducted beforehand, the risk would have been known and the existing hospital could have been retrofitted. In other instances, if proper triage systems had been in place, unnecessary evacuations — which separated many families already in a chaotic situation, forcing them to travel significant distances to search for injured relatives — could have been avoided.

Could lives have been saved? Most of the deaths were instantaneous and only could have been prevented if buildings had not collapsed. The earthquake struck on a Saturday morning, catching many people unaware at home. The majority of the houses that killed the inhabitants were poorly constructed with materials of inferior quality. As in almost all disasters, the majority of the affected people were poor.

Action taken

Rebuilding health facilities became a priority. To help ensure that a future disaster of this magnitude would not cause the same devastation, the Government of Pakistan introduced a series of disaster risk reduction and preparedness measures at local, provincial and national levels. One of these was the creation of the Earthquake Reconstruction and Rehabilitation Authority (ERRA). Under its programme “Knowledge and Capacity Building for Disaster Resilience: Earthquake-Affected Region in Northern Pakistan” UN/ISDR assisted ERRA in designing earthquake resistant buildings. Many of the designs, technologies and techniques introduced by the Citizen’s Foundation (a UN/ISDR implementing partner) were accepted and supported by ERRA as a standard to be followed by others. The standards were applicable and are being followed by many for housings as well as critical infrastructure (schools, health facilities, mosques etc).  The program was complemented comprehensively by awareness raising (through knowledge centres at grassroots level) and training programs for home owners, craftspeople, village elders, and line departments of the government.  The training included guidance on ensuring that heavy equipments or furniture such as racks/cupboards are fixed properly so that in case of earthquake they do not fall and cause damages. In the specific case of health facilities, ERRA looked at the geographical and population distribution of the health facilities that were scheduled to be rebuilt and concluded it was unnecessary to rebuild all pre-existing facilities. Rather, they chose to build back better by providing compulsory earthquake risk reduction designs for the 237 new basic health units, district and tehsil (sub-district) headquarter hospitals and rural health centres that are being rebuilt (download designs). Another 105 health facilities have been or will be repaired using safety and seismic retrofitting.

However, the construction and retrofitting of earthquake-resistant buildings require much more than building codes and guidelines. Enforcement measures are critical to ensuring that health facilities are actually built according to seismic standards rather than simply conforming to a “paper” design. Enforcement implies meticulous control of ongoing construction and retrofitting projects by an independent agency.

Lessons learned

The South Asia earthquake of 2005, like all disasters that cause massive damage and great human losses, created a real window of opportunity in terms of raising the awareness of national authorities on the need for disaster risk reduction in the health sector. In Pakistan, members of civil society also demanded that national, regional and local disaster mitigation and management strategies were developed based on lessons learned. The lessons learned include:

  1. Lack of public awareness about hazard risk management leads many people to react inadequately in the immediate aftermath of an earthquake. Training and capacity building for health staff in crisis situations increases the chances of saving lives and allowing health services to remain up and running. Health personnel at all levels must become agents of risk reduction, helping to identify health risks and promoting strategies to minimize the impact of disasters on the affected population.

  2. A decentralized disaster management plan needs to include all health facilities at the local level and provide them with the necessary means to ensure that health services remain functional in emergency and disaster situations.

  3. The design and construction of all new hospitals and health facilities must be earthquake proof as well as for other hazards. Almost 50% of health facilities in the October 2005 earthquake affected area in Pakistan were totally destroyed, causing a serious gap in health care delivery immediately after the earthquake, and in the medium to longer term.

More information is available from:

Altaf Musani
Regional Adviser for Health Action in Crises,
World Health Organization
Regional Office for the Eastern Mediterranean
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