Ten years after the 921 Earthquake:
Director, Department of Community Medicine, Jen-Ai Hospital, 483 Dong Rong Rd.,
Tali, Taiwan; E-mail: firstname.lastname@example.org
Chih-Chung Su, Superintendent, Jen-Ai Hospital, 483 Dong Rong Rd., Tali, Taiwan
The 921 Earthquake is the most catastrophic natural disaster that occurred in Taiwan in the most recent 60 years. The calamity left people with terror and insecurity. Conventional studies of the earthquake aftermath generally focus on emergency response systems, evacuation drills, emergency medical responses, new enhanced building codes and earthquake warning systems. Regrettably, the role of a quake-affected hospital facility, particularly a larger-scale, and its restoration are rarely discussed. In the 921 Earthquake, the Jen-Ai Hospital was the largest hospital in the Tali area. Though devastated by the disaster, the hospital was able to provide medical assistance to those who were injured. This paper reports on Jen-Ai Hospital’s response to the medical assistance and its quick reconstruction. It also shares their survival stories of recovery and reconstruction of their communities in hope of providing learning experiences for other hospitals located in disaster prone areas.
There were 10 catastrophic earthquakes in Taiwan between 1904 and 1999. The Richter Scale ranges of these earthquakes ranged from 5.5 to 7.3 and caused tens to thousands of deaths. The three most severe death tolls, involving thousands of deaths, happened in 1906, 1935, and 1999. All three epicenters originated from the main island (Chen, 2007). The 921 Earthquake occurred at 1:47 on September 21, 1999 in Chi-chi, Nantou and measured 7.3 on the Richter scale. According to the Ministry of the Interior (2008), the catastrophe was responsible for approximately 2,416 deaths, 11,443 injuries, and making more than 100,000 people homeless. Some 44,338 houses were completely destroyed, and a further 41,336 were severely damaged. The economic damage was estimated at NT$300 billion (US$9.2 billion).
Differing from Japan and the West Coast Region of the United States which are also on the quake-prone regions, Taiwan was fortunate to escape from major calamity in the most recent 60 years until the 921 Earthquake. As a result, Taiwan did not share the same experiences of dealing with earthquake calamity as Japan and the US. Emergency managers of Hanshin-Awaji ( Kobe) Earthquake and Northridge Earthquake discovered that buildings and constructions near the fault zones did not have sufficient seismic shock absorber systems to withstand any large earthquake attacks. The ability of a hospital to operate and to provide medical assistance after an earthquake attack is critical to the injured. Though the hospital buildings of Hanshin-Awaji and Northridge did not collapse after the Earthquakes attacked, their building structures could not escape damage completely (Ding, Shin, & Yu, 1999).
In the US, the 1971 San Fernando Earthquake destroyed most of the Olive View-UCLA Medical Center buildings, caused 3 deaths, and forced evacuation. The hospital later was reconstructed to meet the new building codes with the intent of maintaining functionality shall an earthquake strikes. It was approved to be successful and the buildings suffered only limited structural and nonstructural damage during the 1994 Northridge Earthquake. The hospital was fully operational shortly after the main shock. Because of this successful story of seismic hazard mitigation, Federal Emergency Management Agency (FEMA) strongly encouraged such a program. Subsequently, Federal and non-Federal agencies funded the Seismic Hazard Mitigation Program for Hospitals (SHMPH) to improve hospital building’s seismic performance. Its goal is to maintain a hospital’s functionality after an earthquake strikes and to minimize the cost to repair or to rebuild (FEMA, 1997).
In Japan, the Hanshin Awaji earthquake caused damage to 193 medical facilities. Due to the severe damages, many hospitals could not continue to provide medical services, even result in closures of outpatient clinics. To ensure the functionality of hospitals in quake-prone areas, seismic hazard mitigation programs for hospitals are encouraged, especially in an aging society such as Hyogo. Ten months after the main shock, the Hyogo Prefecture Magistrate asserts the importance of four administrative aspects of the Earthquake: 1.) disaster emergency medical systems, 2.) dedicated volunteer disaster relief system, 3.) establishment of World Health Organization (WHO) in Kobe, and 4.) the health park concept. The considerations of establishing WHO Kobe Center and health park concept are: the Great Hanshin-Awaji earthquake disaster happened in an aging society, death of the population over 60 years of age accounted for 53%. There were thousands of people seeking for the temporary refuge and more than 30% of them were more than 65 years of age (Chan-Liao, 1999).In Taiwan, the Jen-Ai Hospital was classified as a general hospital before the 921 Earthquake, treated 730,000 outpatients, 58,400 emergency patients, and 15,600 inpatients (with surgical procedures) annually. The hospital was equipped with 488 beds, not including beds in the intensive care unit . Occupancy was 429 beds when the earthquake occurred. The hospital team included a total of 1,210 employees and physicians. Though the hospital was severely damaged by the earthquake, with the help and support from the staff, the hospital was able to perform to its utmost capability. As a result, the damaged lifeline emergency medical alert system and the facility were fully restored within four days. While ensuring the structural integrity of a hospital is vital to effective response, it is also essential to ensure that staff are available to use the facilities and respond promptly and effectively to meet the medical needs of survivors. This paper includes discussion of how the hospital staff responded to the disaster and their dedications to their responsibilities.
The Jen-Ai Hospital buildings were built with concrete and steel reinforcing bars on a base area of 4,930 square meters, nine floors above ground level and three underground levels. In 1993, they were built according to the Taiwan's building codes for the moderate quake zone. The 921 Earthquake caused damages on the northern columns and wall structures on the fifth and sixth floors. The safety rating was rated as “Warning.” Department of Radiology was located on the ground floor first level of the building. Valuable medical assets such as computed tomography, magnetic resonance imaging (MRI), angiographic room, special and routine X-ray machines escaped from any damages. The generators located on the ground floor three were able to operate to supply power to intensive care unit (ICU) and operative room (OR) enabling emergency operations.
The president of Jen-Ai Hospital, Dr. Jen Liao, was a former president of Taichung City Medical Association, that had long-term international exchanges with Hyōgo Medical Association. Shortly after the 921 Earthquake occurred, Hyōgo Medical Association shared their experiences in quake response with the Jen-Ai Hospital. The response of Jen-Ai Hospital to the 921 Earthquake experienced three phases: 1.) the emergency phase, 2.) the rescue and relief phase, and 3.) the recovery phase.
Phase One: Emergency Period (within 72 hours)
A. Medical Assistance
The 921 Earthquake occurred at 1:47am. Within an hour after the main shock, all non-critical patients were removed from all floors and evacuated to the uncovered parking lot across from the hospital building with the help of all hospital employees, family members, and neighboring residents. As for the critical patients on the third floor, they remained at where they were due to the needs of medical equipments and supplies. At 1:52am, all on-duty medical staff members were grouped into groups: a.) emergency triage, b.) trauma care, and c.) in-patient.
Around 1:55am, huge influx of patients was received at the temporary emergency medical station at the parking lot. From 02:20-02:40 am, the president and vice-president of the hospital and chief nursing officer arrived at the facility to evaluate the building structure and determined that it was safe to set up an emergency care unit at the first floor to assist with all the injured patients. At 04:40 am, medical personnel from six other hospitals namely Taichung Veterans General Hospital, Chengching Hospital, Chung Shan Medical University Hospital, China Medical University Hospital, Kuang Tien General Hospital, and Taichung Hospital, came to assist with the emergency care. At 08:00 am, most of the physicians, nurses, pharmacists, technicians, administrators and volunteers returned to the hospital, nearly 93% of the personnel were present by this hour.
At 08:30 am, seven hours after the main shock, President Liao and executive managers examined the safety of staff and the conditions of damaged building structure in order to take immediate actions to provide medical assistance and to rebuild the hospital buildings. First action to take was to group all staff and medical personnel into three groups. Extra manpower was provided to the emergency room to assist with the injured patients. Second action was to send a medical team to station at the most severely damaged building in Tali city in order to provide immediate medical assistance. Thirdly was to contact TCT Architectural Resources and other related resources to run a post-quake evaluation for the building damages and to set out plans for restorations. Last action was to continue paycheck issuing during hospital’s reconstruction period to provide comfort and financial security to the staff.
Phase Two: Rescue and Relief Period
A. Community services and community care
Water, gas and electricity supplies were disrupted due to damages caused by the earthquake. During the first four days, the utility supplies were limited and the hospital cafeteria was unable to provide sufficient meals for the patients and staff. Volunteers from the community helped with preparing meals to resolve the inadequate meal supply issue. Purchasing and pharmacy were also able to obtain external support and supply immediately. The unconditional support and help from the community shown the hospital staff great compassion and humanity of the community.
In addition, the six years old boy who was rescued from the Tali Kim Paris Building after 88 hours of rescue mission boosted all medical staff’s faith and hope in humanity. The hospital decided to give back to the community and sent a mobile medical team to the rescue centers to continue providing free medical services to the community for a month. A cash donation of NT$3,500,000 (about US$ 109,375) and a medical supply worth of NT$1,520,000 (about US$47,500) were also donated to the Tali City Hall. Furthermore, all hospital staff committed themselves to volunteer one day per year to serve the community and this has become the hospital tradition. This tradition has continuously providing medical services to the community health center.
The reconstruction projects of the hospital were executed within 24 hours such as building safety evaluation, debris cleanup, repair or enhancing structure, projected completion date and interior renovation, and so forth. All projects were completed within fifty-one days as scheduled.
Phase Three: Recovery Period
A. Natural Disaster Experiences and Preparedness
"Experience" has been the driving force for human learning and growth. The experiences of natural disaster and education of preparedness are important to the future planning and preparedness. Because of this understanding, Jen-Ai Hospital had taken following actions to prepare the disaster management planning. First of all was to obtain copyrights of “Hanshin-Awaji Earthquake Medical Record of Hyogo Prefecture” from Kobe, Japan, and translated into Chinese adding the response of Jen-Ai Hospital to the 921 Earthquake as reference. Secondly, the hospital held seminars on the first and third anniversary of the 921 Earthquake to discuss medical response and assistance to natural disaster. Lastly, exercise medical drills as how to deal with large influx of patients and written emergency response guidelines. The guidelines include response procedures, emergency location and flow chart, and evacuation plans of each individual department. The disaster mitigation and emergency response plans were also posted on the hospital website.
B. Promoting Tali Community Health Center
The Executives of Jen-Ai Hospital was devastated by the great damages that the 921 Earthquake caused to the Tali community (nearly 200 deaths, 3,000 injuries, and 7,400 houses damaged or destroyed), and its impacts on the individuals, families, and society as a whole. The following year, the Jen-Ai Charity Fund established Tali Community Health Center. The goal was to collaborate with local organizations and to gather resources to assist community members to cope and to promote their well-being to build a healthy community. The Community Health Center was promoted and supported by the Jen-Ai Hospital. The business operation can be categorized into three phases. Details are described as follow:
Phase 1: The first three years of operation
It was focused on the Health Promotion and Public Relations Committees. Health Promotion Committee consists of Jen-Ai Hospital and other eighty clinics in the Tali area. The purpose of the Committee is to continue providing medical services to the community residents and to care for their well-being such as monitoring the development of Posttraumatic Stress Disorder (PTSD), diabetes, high blood pressure, etc. Another mission was to establish Tali Community medical records electronically. The Public Relations Committee consists of neighborhood representatives and community organization presidents. Meetings were held regularly to discuss the needs of the community and to plan accordingly.
Phase 2: Promoting training on the importance of exercise and healthy
The mission of this phase was to help community members to have a better understanding of the importance of exercise and healthy diet. First of all, projects were designed for those domestic women who care for their families. Training them with healthy cooking tips could directly benefit their family members. And then, the Jen-Ai Charity Fund recruited those project participants as volunteers for more community projects, such as smoking health risks, Life-Care Training Projects for Adolescents, health workshop, and establishment of website for the Tali Community Health Promotion Center.
Phase 3: Sustainable management
This is the time for sustainable management. The mission of this phase is to carry on projects that have been performing in the Phase Two, and starts new projects. Three new projects are promoted such as decrease incidence of metabolic syndrome in community, breast cancer awareness and prevention, and free medical publications.
In order to get a view from staff members, the authors interviewed their colleagues who have been working in the Jen-Ai Hospital for over 11 years, to ensure that they were part of the 921 Earthquake response team. Interviews emerged four themes promoting posttraumatic growth: executive response and decision, loyalty and teamwork, disaster preparedness, and employee care.
Executive response and decision:
Leadership is vital to rescue missions during a calamity. At the early stage of the 921 Earthquake, the quick response of the Jen-Ai Hospital executives, including reaching out to seek for assistance in building emergency medical networks in the Tali area, searching for information of disaster response and learning from hospitals in Hyogo, Japan, and taking immediate actions on hospital reconstruction planning, etc, had helped to speed up the recovery.
Loyalty and teamwork:
Most of the staff including physicians, nurses, pharmacists, technicians, administrators, even volunteers returned to the hospital to help, nearly 93% of the staff was present six hours after the main shock. They demonstrated high standard of responsibility and portrait an excellent teamwork. During the hospital reconstruction period, paychecks were issued continuously according to the schedule. By doing so, it not only provided financial security and comfort to the staff, but also promoted staff’s continuous loyalty towards the hospital. Furthermore, secured income would help to relieve and to reduce stress caused by the catastrophe and helped staff to focus on recovery both body and mind.
The 921 Earthquake had brought attention to the executive management the importance of familiarizing themselves to the building structure and non-structure such as electronic equipments, ventilation, electricity and water supply. It is also important to understand the needs of disaster preparedness and its contingency plan and exercise medical drills regularly.
Human resource is a valuable asset to an organization. An article from Journal of Japan Municipal Hospital Association indicates that 40% of the nurses still suffered from the psychological impact of Kobe Japan Earthquake, ten years after the disaster (Kawamura, 2006). Kawamura asserts the importance of employee care in both their competency and psychological well-being.
Crisis can be a favorable turn. The 921 Earthquake caused great economic and societal losses to the Taiwanese people. It also reminded them the importance of disaster preparedness. The purpose of this paper is to benefit other organizations and hospitals in the quake-prone areas and provide hospital disaster response experiences as references for disaster preparedness and emergency management plans. The authors suggest that hospital administration shall include disaster preparedness and seismic hazard mitigation guidelines as part of their operational target goal. Examples are risk assessment and management skills, disaster preparedness funds, disaster medical assistance training, and employee care. The concepts of medical and health services have changed its focus from medical treatment to preventive health care. Because of the 921 Earthquake, the Jen-Ai Hospital has changed its mission statement and established the Tali Community Health Promotion Center to give back to the community. After the 921 Earthquake, Taiwan has re-defined the quake-prone areas and implemented new seismic hazard mitigation programs for hospitals to apply to new building codes (Hsu, 2007; Chuang, Yao, Hsu, et al., 2002). The valuable medical services are vital to disaster rescues. Government should evaluate all hospitals’ capacity of seismic hazard mitigation and prioritize the hospital list for improvement. Also, government should follow the example of FEMA to establish seismic provisions and funds in order to repair and strengthen hospital buildings to be quake-proof. To ensure the functionality of hospitals after an earthquake strikes, it is necessary to sustain quake-proof hospitals.For the past ten years, the Jen-Ai Hospital has strongly believed in community welfare and included community care in its operation. The hospital has registered in Taiwan HPH network of “WHO Collaborating Center for Health Promotion in Hospitals and Health Care” to become a member, and obtained “HPH membership Certificate 2009-2012” in 2009. The hospital continues to provide medical services to the community and to promote preventive health care through the Community Health Promotion Center. It is ready to grow with the Tali community.
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Massey University, New Zealand
23 December, 2010