Protecting health facilities: design options for armed conflict and climate change disasters : Emergency and Critical Care Medicine

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Protecting health facilities: design options for armed conflict and climate change disasters

Groves, Heathera,∗; Kushner, Adam L.b,c; Gupta, Shailvia

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Emergency and Critical Care Medicine 3(1):p 1-3, March 2023. | DOI: 10.1097/EC9.0000000000000051
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Armed conflict and climate change disasters are 2 issues with an increasing impact on health facilities worldwide.[1,2] As climate change becomes an ever more apparent threat, the need for health facilities to plan for catastrophe intensifies. Terrorist attacks on health facilities during armed conflict are also increasing globally, and evidence exists that these soft targets can benefit from improved fortification of infrastructure. Designing hospitals to help withstand such catastrophes is now becoming crucial. Our aim is to investigate healthcare facility design interventions to help protect such facilities during times of disaster.

During armed conflict and disasters, health facilities play a critical role in saving lives and ensuring the well-being of affected populations. Health facilities must continue to provide care without interruption. For hospitals to remain functional during these emergencies, their structures must resist exposure and forces from many types of hazardous conditions caused by bombings, flooding, and high winds. The facility’s structure is critical to protect medical infrastructure, equipment, patients, and staff. A single fault in the design can cause a loss of critical functions including water, power, telecommunications, heating, ventilation, air conditioning systems, waste management, and fuel storage.[3]

Low- and middle-income countries are likely to incur more damage after disasters because of their increased vulnerabilities.[3] In addition, climate change increases the incidence of hazards that, in turn, increases the risk.[4] The combined effects of increased vulnerability and increased hazards place hospitals in low- and middle-income countries at a higher risk. New technologies and advances in engineering make it possible to help reduce possible damage to health facilities after seismic, flooding, and high-wind events.[5] The following interventions highlight design options to decrease the vulnerability of facilities. In many high-income countries, building codes often regulate design and construction in many hazard-prone areas, and those specifics are not discussed here.

Hospital design considerations

Health facility vulnerabilities can be divided into structural, nonstructural, and organizational components. Here, we will focus on mitigating structural vulnerability—damage to foundations, bearing walls, roofs, or other components that help support the building. An essential component of building vulnerability is its geographical location, and it is vital to review historical emergencies and disasters in a specific location. Any design planning for a health facility should incorporate a review of the risks (geological events and biological, technological, and societal hazards) and structural engineers’ assessment of structural elements to determine how hazards make the structural elements less safe.[3] Disaster experience has shown that current building code requirements are not always adequate[5] and that climate change is prompting the need to raise design standards to protect against stronger storms and rising sea levels.[6] As many locations are vulnerable to more than one hazard at a time, a multihazard design approach is ideal for considering similarities and differences in how hazards affect buildings.[5] Each of the following sections breaks down unique considerations for each hazard, and the concluding summary will discuss multihazard design options.


In the instance of flood risk, health facilities should refer to local hazard maps and past flash floods and build to exceed the minimum requirements to mitigate the impacts of flooding. If possible, designers should avoid selecting a site subject to flooding. Because this may not be an option because of the needs of a community living in a flood-prone region, designs should be implemented to reduce potential damage. The forces applied to buildings during floods are hydrostatic and increase with water depth; therefore, it is not ideal to have underground spaces in flood-prone areas. Reinforced masonry walls are the best at resisting these hydrostatic forces. Buildings need to be properly anchored to resist buoyancy forces and prevent building collapse. Any building should be elevated to above the 0.2% annual chance flood elevation (500-year flood) to minimize flood damage. Earthen fill is an option to help provide elevation to a building. Buildings should not be placed on structural fill in high-risk tsunami areas because waves and high-velocity flow can cause erosion and subsequent building collapse. Levees and floodwalls are possible solutions to hold back water. Levees and floodwalls should be designed with a significant safety factor for maximum flood depth because once overtopped or breeched, catastrophic flooding results. Floodproofing, such as applying a waterproof veneer or structural reinforcement of exterior walls, can be performed on underground floors. Avoiding the floodplain by elevation methods is preferred to floodproofing, even if buildings need to be designed with open foundations.[5]


The main design concern with hurricanes/typhoons is the high wind speeds that create airborne debris, damage the roofs and windows, and damage rooftop equipment. In addition, water infiltration can become a problem when rooftop coverings are pulled off in the winds. Therefore, to make hospitals resilient in the face of hurricanes/typhoons, materials should be rated to resist wind and rain to the maximum expected level. Another consideration should be the ability of the building to withstand wind resistance. This can be an issue in the corners of roofs where wind forces can overcome the roof’s strength. Glass windows should be designed with impact-resistant glazing so that projectiles from the wind cannot break windows and spray patients/staff with shards. In addition, buildings should not be designed with brick veneer or roof slate because these materials easily break free and can become projectiles that cause even more damage.[5]

Armed conflict

Health facilities potentially exposed to armed conflict need to be prepared to protect their patients and staff. Recently, facilities in Syria and Ukraine were the targets of rocket and bomb attacks.[7,8] These facilities were not designed as military installations and sustained significant damage. One option to protect health facilities from such weapons is to build underground. This design was implemented in Syria, where caves and fully underground hospitals were built.[9] The cave hospitals require adequate ventilation to be used safely. The underground design provided a sense of safety for the staff and patients being treated. Of note, no patient or staff casualties were reported because of attacks on the underground structures.

Alternatively, buildings made of reinforced concrete can protect against blasts.[10] As blasts may hit nearby (and not on top) of a building, a circular design, which is better able to deflect blast waves, could be considered. A different design was constructed in the Netherlands, where a nuclear-proof facility was built under a medical center and can hold up to 300 patients.[11]

It has been noted that a hospital’s disaster plans mainly include educating staff and practicing training scenarios. A huge hurdle for preparedness could be overcome by constructing hospitals to withstand the disaster.[11] The following case study is an example of implementing such a process.

A case study: Rambam Hospital, Haifa, Israel

During the Second Lebanon War in July 2006, Rambam Hospital in Haifa, Israel, experienced multiple rocket attacks. The hospital had been prepared for singular disasters such as suicide bombings or poisonous gas but not for an ongoing assault of direct missile fire. Their early warning systems gave them time to reinforce their trauma and surgical units; however, the hospital was not built to withstand explosives, and only the hospital’s basement was considered safe during the attacks. Most of the hospital was unfortified and offered no protection against shrapnel or explosive fragments.[12] The hospital could not maintain full operational status nor provide care to the community.

After the end of hostilities, the hospital administration initiated an evaluation of the facility design. The quick and unpredictable escalation of hostilities in the region was a factor in their desire to improve function and delivery of treatment while under fire.[13] Because of this, they increased the fortifications for a new hospital. They constructed an emergency department that was fortified against chemical and conventional warfare. In addition, they built an underground facility to protect patients and staff during a continuous attack.[13] During peacetime, the new structure is used as a parking garage. However, in times of war, this structure can be converted into a 2000-bed hospital within 72 hours.[14] The underground hospital is sealed and self-sufficient—it was built 8 meters below sea level, can generate its power, and can store medical supplies, oxygen, and drinking water sufficient for up to 3 days.[15]

Multihazard approach

The goal of health facility design should be to protect against as many hazards as possible. While some design features may protect against one type of hazard, they could be harmful in another type of hazard. For example, underground facilities might protect from bomb blasts but be at risk from floods because of rising sea levels. Therefore, care should be taken to evaluate all design features before building. When design methods reinforce one another, the costs of multihazard design may be reduced, and performance improved. Increased risks of hazards due to climate change and increased inclusion of civilian populations/hospitals in modern warfare dictate that risk mitigation will need to be greater than baseline levels that have been used before. The HAZUS modeling tool from the US Federal Emergency Management Agency is an example of one of the many standardized tools that can help assess the risks of building hospitals in specific locations.[16] A multidisciplinary design team should be involved to evaluate project issues from start to finish.

As armed conflict and climate change disasters are increasing globally, we recommend that efforts to assess and mitigate damage resulting from both types of disasters be prioritized. Mitigation plans and disaster managers are critical for planning and preparing for major disasters. Any infrastructure designs must consider as many scenarios as possible. To do this, we must also answer the question of how to balance the need to secure sites to protect from armed conflict along with the changing realities brought upon by climate change. Any answer must include input from clinicians as well as architects, engineers, and safety personnel working together to address current realities and anticipate future needs. The ensured functionality of hospital structures is key to the ability to provide care during disasters and limit mortality.

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

All authors participated in the writing of the manuscript.



Ethical approval of studies and informed consent

Not applicable.




1. Ewbank C, Stewart B, Bruns B, et al. The development of a surgical care and climate change matrix: a tool to assist with prioritization and implementation strategies. Ann Surg. 2021;273(2):e50–e51. doi:10.1097/SLA.0000000000003980
2. Cavaliere GA, Alfalasi R, Jasani GN, Ciottone GR, Lawner BJ. Terrorist attacks against healthcare facilities: a review. Health Secur. 2021;19(5):546–550. doi:10.1089/hs.2021.0004
3. World Health Organization. Hospital safety index: guide for evaluators. 2nd ed. World Health Organization & Pan American Health Organization; 2015. Accessed March 10, 2022.
4. Gori A, Lin N, Xi D, Emanuel K. Tropical cyclone climatology change greatly exacerbates US extreme rainfall-surge hazard. Nat Clim Chang. 2022;12:171–178. doi:10.1038/s41558-021-01272-7
5. U.S. Deptartment of Homeland Security, FEMA. Design Guide for Improving Hospital Safety in Earthquakes, Floods, and High Winds: Providing Protection to People and Buildings. Accessed March 24, 2022.
6. United States Environmental Protection Agency. Climate Change Science. Future of Climate Change. Accessed March 12, 2022.
7. Fallon K, Kievel N; Saving Lives Underground: The Case for Underground Hospitals in Syria. Accessed March 20, 2022.
8. BBC News. Ukraine war: Maternity hospital hit by Russian air strike. Accessed March 14, 2022.
9. Marres G, Bemelman M, van der Eijk J, Leenen L. Major incident hospital: development of a permanent facility for management of incident casualties. Eur J Trauma Emerg Surg. 2009;35(3):203–211. doi:10.1007/s00068-009-8230-1
10. U.S. Department of Homeland Security, Federal Emergency Management Agency. Buildings and Infrastructure Protection Series Reference Manual to Mitigate Potential Terrorist Attacks Against Buildings. Accessed March 22, 2022.
11. Haverkort JJ, de Jong MB, Foco M, et al. Dedicated mass-casualty incident hospitals: an overview. Injury. 2017;48(2):322–326. doi:10.1016/j.injury.2016.11.025
12. Bar-El Y, Reisner S, Beyar R. Moral dilemmas faced by hospitals in time of war: the Rambam Medical Center during the second Lebanon war. Med Health Care Philos. 2014;17(1):155–160. doi:10.1007/s11019-013-9517-x
13. Bar-El Y, Michaelson M, Hyames G, Skorecki K, Reisner SA, Beyar R. An academic medical center under prolonged rocket attack—Organizational, medical, and financial considerations. Acad Med. 2009;84(9):1203–10. doi:10.1097/ACM.0b013e3181b18bd6
14. Rambam Healthcare Campus. Sammy Ofer Fortified Underground Emergency Hospital. Accessed March 9, 2022.
15. Design Build Network. Rambam Health Care Campus Underground Hospital. Accessed March 9, 2022. https://www.designbuild-
16. Federal Emergency Management Agency. Hazus. Accessed March 22, 2022.

Armed conflict; Climate change; Disaster preparedness; Hospital design

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