Author(s): Angelo Verzoni. Published on December 5, 2019.

Burn Treatment

Deadly hospital fires are frequent occurrences around the world. Experts say economic globalization is driving new approaches that could change that.


In September, eight newborn babies died when a fire ripped through the maternity wing of a hospital in the small city of El Oued, Algeria. The potential cause was a defective electric mosquito zapper, according to an Algerian state health minister. The fire was the second at the facility in the past 16 months. In May 2018, a blaze at the hospital caused “significant damage but no casualties,” according to Agence France-Press.  

The maternity ward fire was one of three deadly hospital fires that made headlines internationally in September alone. On the same day the Algerian hospital burned, two people were killed and more than 45 others were injured in a fire in a hospital in South Korea. Also that month, 11 people, mostly elderly patients, died in a hospital fire in Rio de Janeiro, Brazil. Then, in October, five people died in a fire that tore through a hospital in eastern China.  

While there are no comprehensive statistics kept on the number of fatal hospital fires that occur globally, academic studies and news reports suggest that they’re frequent—especially compared to the situation in the United States, where hospital fires are rare and essentially never deadly. 

“Fire happens with alarming frequency and [with] potentially devastating consequences in hospitals around the world,” a study published in the Journal of Clinical Anesthesia in 2014 found. The study included a list of hospital fires that had been reported in newspapers globally from 2004 through 2013. From 2011 to 2012, fires in hospitals in India dominated the headlines, according to the study, including one that killed 93 people in the city of Kolkata in December 2011. In 2013, three hospital fires with over 35 deaths were reported—two in Russia and one in China. In 2018, South Korea experienced its deadliest fire in nearly a decade when smoke and flames ripped through a 98-bed hospital in the southern part of the country, killing more than three dozen people. Experts say the key reason behind this deadly trend is a lack of code use and enforcement at hospitals around the world. 

But things could be changing. In the past several years, experts say new approaches to hospital oversight—the kind of measures that provide US-based organizations with more control over fire and life safety—have emerged worldwide. 

“We’re seeing the globalization of the economy, and health care is included in that,” said William Koffel, a fire protection engineer who serves on several NFPA technical committees. Koffel’s Maryland-based fire protection engineering consulting firm, Koffel Associates, specializes in health care facility design, and it has worked on a number of projects overseas. “There are health care organizations in other countries that are reaching out to consultants in the US because they’re interested in having their facilities operated and managed similar to a hospital in the US,” he said. “There are also a number of hospitals outside the US that are now being managed by US health care organizations. I think both of these trends certainly have the potential to grow in the future.”

‘Learning from our mistakes’

Statistically, virtually nobody dies in hospital fires in the US.

That’s according to data from an NFPA report published in 2017. From 2011 to 2015, less than one death occurred on average each year in fires in hospitals in the US, the report says. Hospital fires simply don’t happen that often. US fire departments respond to roughly 1,100 such fires each year, compared to about three times that number in schools.

But this wasn’t always the case. Some of the world’s deadliest hospital fires occurred in the US in the 20th century, such as the Cleveland Clinic fire that killed more than 120 people in Cleveland, Ohio, in 1929, and the St. Anthony’s Hospital fire that took 74 lives in Illinois in 1949. As recently as the 1980s, over 8,000 fires occurred in hospitals in the US annually. 

“In the United States, we have a history of killing people in nursing home and hospital fires,” said Robert Solomon, a fire protection engineer at NFPA. “But we’ve learned from our mistakes.”

The building safety deficiencies that drove the high death tolls in past US hospital fires, such as a lack of compartmentation to prevent smoke spread and the absence of fire sprinklers, have largely been eliminated from American facilities, Solomon said. And that’s due to the fact that in the US, a ro
bust, multilayered system of code enforcement has emerged that keeps hospitals in compliance with modern codes and standards that include NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities Code

Even by US standards, hospitals—and other health care facilities—are subject to a unique and especially rigorous enforcement process compared to other occupancy types that has created the level of safety that exists in hospitals in the US today.

“An office building, for example, may get inspected every year or so by fire engine company personnel from the local jurisdiction, whereas in a health care facility you have local jurisdiction enforcement in addition to a state agency coming in for licensure purposes, a validation survey process from representatives of the [federal Centers for Medicare & Medicaid Services], and the accreditation process,” Koffel said. 

Solomon said the hospital accreditation process has essentially become the “fourth entity” of hospital oversight in the US, in addition to oversight from local, state, and federal agencies. “To remain an accredited hospital, there are private organizations that look at everything from infection control to continuing education for doctors to fire and life safety,” he said. “If the facility isn’t in compliance with the applicable codes and standards, that accreditation can be threatened, which could mean insurance companies won’t pay for treatment services at that facility, or Medicare and Medicaid funding for patient treatment and care may be jeopardized.” 

Experts say such a robust and multilayered system of oversight generally doesn’t exist in other countries—and that’s the main problem.  

“Internationally, I don’t think there’s the same level of inspection that we see in the US,” Koffel said. “From the work we’ve done and facilities we’ve seen outside the US, not as much time is spent ensuring code compliance and you tend not to have those multiple layers of inspection.” 

What sets international hospitals apart?

One way the fire problem in hospitals outside of the US can be further understood is by examining the NFPA Fire & Life Safety Ecosystem, a framework of safety comprising eight components that must function together in order to be effective: government responsibility, development and use of current codes, referenced standards, investment in safety, skilled workforce, code compliance, preparedness and emergency response, and informed public. 

Failures in any of these components can lead to devastating fires in hospitals and other occupancies. In international hospital fires, it’s often the components related to building construction, codes and standards, and emergency preparedness and management that tend to fail. 

“Hospitals in low- and middle-income countries often lack strict building codes, certification processes, and regulatory oversight,” said Robyn Gershon, an occupational and environmental health and safety researcher at New York University’s College of Global Public Health. “Everything from poor construction to a lack of emergency preparedness within the hospitals can lead to adverse outcomes in staff, visitors, and the most vulnerable population—patients—during fires or other emergencies.” 

A breakdown in the code compliance component of the Ecosystem was specifically cited after the September blaze that killed 11 people in a hospital in Rio de Janeiro. 

“The hospital did have an approval certificate issued by the fire department,” Anderson Queiroz, NFPA’s representative in Brazil, told NFPA Journal in an article on the incident and other recent, deadly fires in the country (“Brazil Burning,” November/December 2019). “But the department doesn’t make regular inspections to check whether already-approved facilities continue to comply with the code. … It’s not uncommon for there to be a lack of maintenance of certain fire protection systems or a change of the facility’s layout without the necessary updates to the design of fire protection systems. There’s a lack of accountability to make sure facilities that are already approved continue to comply with the code.”

In September, 11 people died—mostly elderly patients—when a fire ripped through Badim Hospital in Rio de Janeiro, Brazil. Code compliance failures were believed to have contributed to the deadly outcome. (Reuters) 

Experts say similar scenarios play out at hospitals globally. While there may be individual organizations that set out to construct health care facilities overseas using codes like NFPA 101 and NFPA 99, there are often few, if any, checks and balances in place in these countries to ensure that certain details aren’t overlooked during the construction process or that compliance will continue over time.

“I would suspect that even if facilities are using NFPA 99 and NFPA 101, the systems and equipment are not maintained and the requirements of the codes are not well enforced, either during construction or after the hospital is up and running,” said Rich Bielen, the NFPA staff liaison to NFPA 99. “If those codes were being vigorously enforced, we wouldn’t be seeing the fires we’re seeing.” 

A good example, Solomon said, is a fire that swept through Jazan General Hospital in Saudi Arabia in 2015, killing 25 people. “It was built using some of the fundamental provisions of NFPA 101,” he said of the facility, which was constructed in 2012. “But there were deficiencies that ultimately proved fatal.” 

Koffel delivered a presentation on the incident at the 2018 International Summit and Exhibition on Health Facility Planning, Design, and Construction. In it, he pointed to the main factors that contributed to the fire’s severity, which included inadequate smoke compartmentation, foam plastics left behind after construction, fire pumps failing to work properly, and corridor clutter—deficiencies that could have been identified and potentially corrected through a more rigorous enforcement process in the Middle Eastern country.

But making US codes and standards work in some international health care facilities can be harder than it seems, if not impossible—even in an area with a relatively robust regulatory environment. 

Jason D’Antona, a veteran electrical engineer who specializes in health care facility design and management and sits on several NFPA technical committees, explained how in the US, we’ve had decades to mold our safety regulations based on the layout of hospitals, which is based on how clinical care is best delivered. In other countries, he said, if that clinical care model is different, the layout of these facilities can be different, which means you can’t just implement codes like NFPA 101 and NFPA 99 without making adjustments—the pieces wouldn’t fit together.

“It’s a holistic system,” said D’Antona, who currently serves as the director of engineering for Boston-based Partners HealthCare and has worked on health care facility projects in the Middle East, Africa, and Haiti. “In the US, our sprinkler layout is the way it is because the clinical units are laid out the way they are based off the clinical care model. Where I see breakdowns is if you try to implement things piecemeal.”

In some of the world’s least developed countries, a total lack of awareness seems to exist around the codes and standards that address the threats to fire and life safety in health care facilities. 

The 2014 study published in the Journal of Clinical Anesthesia found this to be the case in India, where hospitals frequently experience fires made worse by oxygen-rich air. “The National Fire Protection Association publications NFPA 53, [Recommended Practice on Materials, Equipment, and Systems Used in Oxygen-Enriched Atmospheres], and NFPA 99 list recommendations [for limiting oxygen concentration in the air in hospitals], which are not followed in Indian hospitals,” the study says. “In fact, very few of these hospitals in India are aware of the existence of any international codes and standards for [oxygen] handling.”

Brazil and Saudi Arabia images: AP/Wide World. All others: Getty Images.

Addressing the problem  

One way fire and life safety at international hospitals seems to be improving is through the globalization of health care—specifically, the involvement of US-based organizations in these facilities, whether it’s a US hospital opening or advising a facility overseas or an international hospital contracting with a US fire protection engineering consulting firm. While there are no statistics to prove this is the case, anecdotal evidence supports it and nearly everyone interviewed for this article said they had noticed increased efforts like these over the past five to 10 years.

“The US health care system gets criticized a lot, but we are by far the people others ask for help,” Brett Spencer, partner and managing director of Boston Consulting Group’s health care business, told Hospitals & Health Networks magazine in September 2016. The magazine said the demand of US health care expertise was “strong and growing in many regions of the world, particularly the Middle East” at the time. “The Middle East has always been interested [in US health care]. In Southeast Asia and China, I think it has to do with the significant rise in the upper middle class. They aren’t wealthy enough to fly to the US for care, but they want more than they can get from the public health service,” Spencer said. 

D’Antona said not much has changed in the past three years. He, too, identified the Middle East as well as China as the markets most ripe for US health care intervention heading into the future. “They look very aspirationally toward our health care systems,” he said. 

About six years ago, Hamad Medical Corporation, the largest hospital chain in the tiny Middle Eastern country of Qatar, reached out to two US-based fire protection engineering firms asking for help improving fire and life safety at their facilities, Koffel said. Koffel’s firm was one of those companies, and it sent employees on the nearly 7,000-mile trek to study Hamad’s facilities. 

“We surveyed all of their hospitals the same way we would survey hospitals in the US,” he said. “Then we told them they had to do the same thing that’s done in US hospitals—identify all their problems and create a plan for improvement.” 

Another trend that’s helping fight the fire problem in international hospitals is US-based health care organizations opening their own hospitals or partnering with existing hospitals overseas. 

In 2017, the Baltimore Sun reported on this trend, noting that Massachusetts General Hospital in Boston had announced it was helping Jiahui Health in Shanghai open a hospital. The Cleveland Clinic opened a 364-bed hospital in Abu Dhabi in 2015, the Sun said; the clinic also managed Sheikh Khalifa Medical City, a 586-bed acute-care hospital in Abu Dhabi, and had recently bought a health care facility in London. Additionally, the Mayo Clinic and Partners Harvard Medical International had also expanded to other countries, the Sun reported, and Baltimore’s own Johns Hopkins Hospital had 19 projects occurring overseas at the time the article was published. 

The Cleveland Clinic runs this 364-bed hospital in Abu Dhabi, which opened in 2015. (Cleveland Clinic)

As for why hospitals are doing this, the Sun pointed to the altruistic motive of wanting to save lives and improve patient care in other countries, as well as the financial benefits such projects can have for US health care organizations. Many US hospitals have found themselves bleeding money in recent years as insurance companies increasingly deny reimbursement for nonemergency care at hospitals, driving patients to nonhospital facilities like urgent care centers. But in non-US markets, US-based hospitals can profit from their name alone. It’s similar to how large hotel chains like Marriott, based in Maryland, have long profited off the appeal of their brand in other countries. “Most people would rather go to a hospital with a name they know, like Johns Hopkins or Cleveland Clinic,” Koffel said. 

But the trend can also have the indirect effect of improving safety at international hospitals. 

These facilities are often approved by international health care accreditation organizations such as the Illinois-based Joint Commission International (JCI). According to a 2017 copy of its accreditation standards, JCI requires a hospital to establish and implement “a program for the prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and nonfire emergencies.” 

JCI accreditation is “an important indicator of the high quality of care that is being provided, including the environment of care,” said Gershon, the NYU researcher. Right now, there are about 1,000 JCI-accredited hospitals in more than 65 countries outside of the US. “As more hospitals become accredited, we will see improvements in hospital emergency management—similar to what we’ve seen in the US over the years,” she said. 

But Gershon was quick to point out that cost and government action will serve as barriers to this foreseen advancement. It all comes back to the Ecosystem, and the fact that safety in international hospitals won’t be achieved through just one avenue. It can only be achieved through “sizeable investments in personnel, training, accreditation, equipment, infrastructure, and, most importantly, policies and procedures,” Gershon said. “Political will and financing is needed for all of these elements to come together.”

ANGELO VERZONI is staff writer for NFPA Journal. Top photograph: Getty Images.