Urban Contingency - 2018 - Health and Infrastructure

HEALTH AND INFRASTRUCTURE SYSTEM IN TRONDHEIM, WITH EMPHASIS ON THE ROCKEFELLER FRAMEWORK

Group: ​Danussia Baracho, Helene Lund-Johansen, Mathias Awusie Course: ​Urban Resilience (AAR5220)

1) GENERAL INTRODUCTION According to ARUP (2015), resilient cities are those capable of maintaining their basic functions, in order to allow inhabitants, especially the most vulnerable, to survive and thrive independent of the shocks they might face. Therefore, for a city to be resilient, it has to present a set of characteristics that consider the strength of its social, physical, organizational structures and strategic plan.

In the current report, the social and physical qualities, to be precise the health and infrastructure systems, within the context of Trondheim municipality will be analysed. The correspondent city's resilience will be studied in respect to the goals number three and eight of the Rockefeller Foundation’s City Resilience Framework.

The goal number three - ​Effective Safeguards to Human Health and Life - relates to how integrated and inclusive the health systems in a city are, and whether they effectively work on the prevention and addressment of diseases. Furthermore, it includes the capacity of emergency response services and its capability of meeting situations with peak on demands.

Whether and how a municipality carries out educative prevention campaigns influence in its level of resilience, as well as whether it has the adequate services to deal with the outbreak of a disease, for example. Vaccination and accessibility to other health services are also taken into account as an important part of a city's resilience.

The goal number eight - ​Effective Provision of Critical Services - includes all the infrastructure necessary to maintain people's basic needs on their daily activities, such as electricity and water supply, alongside with drainage system and waste management. However, not only the built systems are to be considered but also the natural ones, such as the natural terrain drainage and water resource spare capacity of absorbing heavy precipitation. In both cases, monitoring and maintenance are essential for a city to keep functioning in the most natural way possible, in order not to to suffer great disturbances from unexpected events of stress.

Diversity, redundancy and flexibility are fundamental features of an effective infrastructure system, in order to adapt to changes in demand in the case of a disruption in the urban context, and to increase the ability of city’s services to remain fairly stable, so that the population is still able to benefit of that provision, even during periods of shocks. If those characteristics are not found, the impacts of a possible disaster are likely to be much higher to people’s assets, meaning a longer time to recover and thus, low levels of urban resilience.

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2) GOAL 3 - EFFECTIVE SAFEGUARDS TO HUMAN HEALTH AND LIFE 2.1) Description of the goal Effective safeguards to human health and life is the third goal on which the Rockefeller Foundation focuses. The preservation of human health and life is an essential necessity because it plays a crucial role in determining how a country is able to harness the skills and the potentials of its citizens in order to fast-track its developmental agenda. Factors such as diet, literacy, socio-economic status, sanitation and lifestyle influence to a large extent the level of health of a population. The destruction that takes place in the environment also impact on human health through the loss of quality of life, loss of productivity and loss of income (OECD, 2001).

Adequate healthcare systems such as its infrastructure and the diverse set of its practices therefore become the critical ingredients required if any strides are to be made as far as the prevention of illness, the spreading of diseases and the protection of the population during emergencies are concerned. A critical component of an effective healthcare system that cannot be left unmentioned is the accessible and the affordable nature of the system where all manner of persons can access it when the need arises.

Furthermore, fashioning out appropriate policies and programmes in order to address health problems like injuries and addiction is vital to lessen the burden of ill-health. Again, the relevance of a robust, comprehensive, and well trained and motivated medical staff and procedures to guarantee that all individuals irrespective of one’s gender, race, status, religion or level of education have access to first class medical care and services before and even during emergencies can never be underestimated. The speed with which emergency services providers are able to respond rapidly to distress situation also helps to manage crisis or emergencies effectively and efficiently (ARUP, 2015).

Goal 3 places critical emphasis on robust healthcare services such as education, vaccination and epidemiological surveillance. In this report, we would like to turn our attention to the outbreak of epidemics in Trondheim and how it is managed, the vaccination system, the epidemiological surveillance system (MSIS) and the infectious control plan (Smittevernplan) that has been designed to address the challenges associated with the outbreaks of epidemics.

2.2) Methodology One of the indicators under Goal 3 of the Rockefeller Foundation Framework we have chosen to use in our work is effective emergency response services. ●

Effective Emergency Response Services: ​Effective response from the relevant stakeholders is the surest way to overcome an outbreak. ​The response services require that health workers and logistics will be made available in times of crisis to effectively manage the situation. Information sharing, teamwork, cooperation and effective coordination are the crucial ingredients that must be taken into account if any success is to be chalked.

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Qualitative research method The qualitative research method was adopted as the methodological approach in the collection of the research data. Qualitative methodology is a kind of research method that seeks to explore the perception, viewpoints and understanding of various stakeholders on a particular phenomenon or development (Patton 1990 cited in Khan, 2014). It attempts to answer questions relating to ‘what’ and ‘how’ of a phenomenon, unlike quantitative methodology that is interested in answering questions relating to ‘how many’ and ‘how much’ of a phenomenon. This methodological approach became useful for this report because we wanted to broaden our scope and also gain deeper insight on the workings of the health and infrastructure system within the Trondheim municipality. Using this methodology, we were able to elicit information for example on who has access to vaccination, the step by step approach used in the management of an outbreak once it occurs and the surveillance activities that are carried out to monitor the occurrence of epidemics.

Sources of data Both primary and secondary sources were employed in the gathering of relevant data capable of answering the research questions. The primary data was obtained mainly from the interviews we conducted with the various research participants. The research participants we relied upon included the Vaccination Officers at the Trondheim Kommune Vaccination Centre. With respect to the secondary data, it was derived largely from articles, manuals, internet sources and reports. Also, a significant amount of the data was procured from the official websites of the Norwegian Institute of Public Health (NIPH) and Trondheim Kommune.

Data collection methods We employed the semi-structured interviewing approach in gathering the necessary information from our informants. Questions on occurrence of epidemics, accessibility of vaccines, inclusive healthcare, epidemiological surveillance, power outages and backup systems and information flow during outbreaks were some of the compelling issues we engaged the minds of our informants on. The interviews were conducted in a congenial atmosphere and it lasted between 15 to 20 minutes. Some of the interviews we recorded with our mobile phones whilst some were also handwritten. Follow up questions as a way of gaining deeper understanding on some of the issues our informants were talking about were explored.

On ethical grounds, we made the informants aware of our purposes and that their names would not be in the report if they preferred. Also, as a way of giving them strong assurance, we told them that the final outcome could be made available to them for their perusal if they would like to access to it.

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Figure 01 - Graphical representation of goals, indicators and research questions.

2.3) Findings The health system: Smittevernplan and MSIS Education is one of the relevant practices considered in a health services pack. Accessible informative manuals help the population in the prevention and addressment of epidemics. Information on some of the most common transmittable diseases is available in the Municipality’s website in the form of a manual named as Smittevernplan.

The definition for crisis, as presented in such manual is “an accident or other strain that goes beyond what is considered normal risk and normal load and which requires urgent action” (Trondheim Kommune, 2017, our translation). It is not clear, though, what could be understood as a “normal risk”; thus leaving that definition still uncertain.

The plan is revised once a year and assembles routines and guidelines on handling outbreaks, as well as an overview of local and state resources and references to laws and regulations. It contains a list of 21 transmittable diseases and respective explanations on their characteristics, infection method, incubation, symptoms, diagnostics, treatment and preventative measures, as well as measures in case of individual cases or outbreaks and vaccinations.

Regarding the epidemiological surveillance system, the MSIS (Norwegian Surveillance System for Communicable Diseases) is a paper-based system of notification forms, from the doctor who suspected or 4

detected an infected patient up to the level of the National Institute of Public Health. It is an integrated system that notifies different levels of health authorities. The process goes as follows (Figure 02): the doctor who receives from the lab at St. Olavs Hospital positive test results for a patient with determined disease has to fill up the MSIS form with the patient’s information (the patient’s identity is only revealed depending on the type of disease) and forward copies to the NIPH, to the surveillance authority in the municipality and to the patient’s journal. If the infected person resides in another municipality, the respective local medical authority also has to be notified. In case of an outbreak, the County Governor and the Regional Health Agency are also contacted. The NIPH also receives copies of the test results, directly from the laboratory.

Figure 02 - Representation of the notifications process.

In the Smittevernplan, the purpose of the registries is to continuously and systematically collect, analyse, interpret and report cases of infectious diseases, “thus laying the foundation for: 1. Describe the occurrence of communicable diseases over time and by geographical and demographic conditions; 2. Detect and help clarify the outbreak of communicable diseases; 3. Provide advice to the public, health personnel and management on infection control measures; 4. Evaluate the effects of infection control measures; 5. Drive, promote and provide a basis for research on the spread and causes of infectious diseases.”

(Trondheim Kommune, 2017, our translation)

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The plan emphasizes that, according to the Infection Act, such communication system allows guidance in the investigation and resolution of eruptions, which eventually would lead to the elaboration and implementation of the respective contingency plan.

As the system tries to identify places and periods of occurrence of epidemics, it helps to understand and discover probable sources of outbreaks, allowing the health system to get prepared for future cases and to inform preventive measures to the population and its staff in advance. Preparedness is one of the aspects of urban resilience, and in order to be prepared for a risk, it is necessary to comprehend why and how disasters happen. According to the plan, “MSIS notifications allow individual cases or outbreaks to be studied in conjunction, in order to predict the occurrence of major outbreaks, so infection prevention measures can be taken” (Trondheim Kommune, 2017, our translation).

However, in order to address diseases with rapidity, it is necessary first to identify priorities. The Risk and Vulnerability Analysis (ROS) assesses risk in order to prioritize illnesses that should be given more attention with vaccination programs and informative campaigns, for instance. It allows decision and management to be based on prioritizing efforts towards the areas that may be most critical to society, as stated: “We wanted to determine which of these diseases it would be relevant to have preventive measures for, which ones needed guidelines in general and what diseases there should be contingency plans for in emergency situations (...) We have chosen to concentrate on diseases that usually infect in Norway, and/or are usually transmitted in Norway” (Trondheim Kommune, 2017, our translation).

It is explained in the document that grading illnesses according to risk and danger has a purpose of prioritizing the ones that need specific risk mitigation measures through prevention and preparedness.

Figure 03 - Prioritization of diseases according to likelihood X gravity.

Source: Trondheim Kommune, 2017.

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The colors in the table (Figure 03) symbolize levels of risk that infectious diseases represent for Trondheim’s municipality. The green color indicates illnesses that are satisfactorily controlled under already implemented measures. In the yellow diagonal, are risky infections that should, as a minimum, be covered by the local contingency plan. The diseases in the red area should be addressed with special attention by local and central authorities and additional preventive work should be considered in order to reduce their manifestation. The level of likelihood crossed with the level of gravity of the disease shows that pandemic flu is the most catastrophic and likely to happen in Trondheim.

Some of the possible actions during the crisis management plan are represented here in a linear way (Figure 04), in an attempt to make a correspondence with different levels of response to hazard, but it does not mean that more than one action could not be taken at the same time or in a different order:

Figure 04​ ​- Main actions of the crisis management plan.

However, the manual acknowledges that there should be an attempt to address crisis from the lowest possible level. Decentralizing crisis management allows the problem to become more easily manageable, as it is brought to a reachable distance from local stakeholders, who can concentrate their efforts in their own regions. For that purpose, the crisis management plan establishes that the heads of local health units must deal directly with the crisis concerning to their own areas of responsibility, as much as possible, and activate the local contingency plan (Figure 05).

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CERTAIN HAZARD

CRITICAL / DANGEROUS

CATASTROPHIC

(risk of few and minor injuries)

(risk of serious injuries and/or deaths)

(deaths, need for evacuation)

- Unit manager notifies councilor

- Unit manager in consultation with Crisis Management Board

- Councilor starts crisis management process

- Councilor considers whether to take over or whether the unit manager will handle the incident

- Unit manager must be present or represented at the crisis site all the time (he/she is not deprived of liability to handle the situation on the spot)

Figure 05 - Responsible stakeholders according to the hazard’s gravity.

Besides the manual for handling infectious diseases, Trondheim is also supported by the Norwegian Immunisation Registry - SYSVAK, an electronic system that records an individual’s vaccination status and vaccination coverage in Norway. The manual plays an important role on informing the population on all procedures regarding self-prevention and crisis management actions; whereas SYSVAK is useful to keep track on people who have missing vaccines.

Outbreaks of epidemics Notwithstanding the robust healthcare system existent in the country, Trondheim’s system has recorded a number of infectious diseases or cases. The most notable cases recorded include mumps, measles, tuberculosis, hepatitis A, B and C, influenzas (swine-flu), legionellose, and giardia lamblia. In our interaction with one of the vaccination officers, she disclosed that the occurrence of some of these diseases come about when for example, some Norwegians travel to countries affected by these diseases and upon their return, they come with the diseases. In some instances too, she revealed that some immigrants who are coming from infected countries also bring the diseases into Norway and that some of these immigrants may harbour the symptoms, thus further spreading the disease and affecting locals.

Among the recorded cases, two recent cases of diseases that have stretched the system to its elastic limit have been swine flu and mumps. In 2009, Norway recorded its highest number of swine flu cases as about 1300 people were admitted and some 32 fatal cases also occurred (Voltersvik et al., 2016). With respect to the mumps, which occurred on September 2015 to January 2016, as many as 176 suspected cases were recorded within the Trondheim municipality, with a substantial number of affected people being students (Nordb​ø et al., 2016). Effective preparations were done in the case of the swine flu, as mass vaccination exercise was carried out on the 1-3 weeks prior to the pandemic reaching its peak, and thereby achieving high vaccination coverage of 45% (Voltersvik et al., 2016); but the same cannot be said in the case of the mumps, which caught the system unaware. This compelled the vaccination centre to call upon the retired 8

health workers as backup so that they could offer an additional support to overcome the challenge. It took a period of four months for the system to get restored in the case of mumps, whilst a period of eight months was spent as the recovery time for the outbreak of the swine flu.

Vaccination system The administration of vaccines may be free or paid, depending on the severity of the case. The decision to pay for a vaccine or not rest with the Norwegian Institute of Public Health (NIPH). One of the vaccination officers we interviewed made us aware that if it is an outbreak of an epidemics like the 2009 swine flu for example, the affected people will not have to pay for the vaccines. But for diseases like whooping cough, the affected people will have to pay for it themselves. Also, the following category of people are entitled to free vaccination at the Trondheim Kommune vaccination centre: ● ●

● ● ● ● ● ●

Children up to 18 years old in the Norwegian childhood vaccination program Persons with close contact with people who are chronic vectors with hepatitis B. This people include newborn babies, sexual partners, children in the same kindergarten if they are under three years old, people living in the same household Persons under 25 years old, who have one or both parents from endemic places with hepatitis B Drug addicts Homosexual men Persons with chronic kidney or liver diseases Persons with chronic bleeding disorders Students in medicine, operation, anesthetist, intensive care, midwife, dentistry, dental care and bioengineers

Effective communication channels have been developed so that people will not have to struggle to know when it is time for a particular vaccination exercise to be carried out. The following are the platforms available to people who are in need of vaccination: ● ● ● ● ● ● ● ● ●

Hospitals and health stations Health nurse at school Individual personal doctors Social media: Facebook (Figure 06), Twitter, Instagram Newspapers Television SMS Website of NIPH Flyktningehelse-tjenesten (working with refugees)

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Figure 06 - An announcement on Facebook about measles vaccination by the Vaccination Centre.

2.4) Proposals Trondheim seems to have an inclusive vaccination system, since foreigners have the same access to the free vaccines norwegians have. In addition, the health system sends information and notification via post, which is a good way to reach even those who might not have access to internet. However, the notifications for the foreigners still come in Norwegian language, which might hinder the actual access to informative campaigns, for instance. Immigrants or international students might feel discouraged to discover the purpose of the letter, at least at an immediate moment, which could also leave them behind when there are deadlines for procedures.

Therefore, a ​short-term proposal would be having an English version of the notifications, or a translator in the department who could check which letters refer to foreigners and do the respective translation. In that way, information would also be inclusive and come to non-norwegians in a more effective and direct way.

The second proposal regards the paper-based epidemiological surveillance system (MSIS). Although it is not specific to Trondheim context, since it is a national system, it was interesting to notice how there is still circulation of paper forms for handling emergency situations such outbreaks notifications, and in such a digital city like Trondheim. If the mailing services or the roads were affected by some kind of disaster, it would probably take longer to contact responsible authorities, while the speed of a disease is relatively fast.

In the Smittevernplan, it is stated that “a central register of all outbreaks of disease also provides a basis for increasing knowledge about causality and contagion measures, so that future outbreaks of disease can be better prevented” (Trondheim Kommune, 2017, our translation). Having an electronic platform would facilitate the updating and concentration of information into a system reachable by all levels of health authorities, available at any time.

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In addition, if MSIS forms were digital, the information would be spread in real time and emergency responses could be provided more quickly. In case of an outbreak, before the councilor is aware of the situation in order to start with the crisis management process, the forms will also have to pass through other stakeholders, which could cause some delay in the responsiveness. With the epidemiological surveillance being digital, there would be more integration between all health authorities and they could get updated simultaneously.

The elaboration of the electronic system would happen mainly in a ​long-term period, as this would also include the period of transition between both methods and the physicians would take some time to get used to the new platform.

2.5) Discussion A robust healthcare system comprises different but interlinked building blocks. In our analysis of the health system of Trondheim, we have attempted to concentrated on only a segment of it. The existence of the MSIS plays a vital role in the surveillance of infectious diseases through the regular and systematic collection, analysis and the reporting of the presence of infectious diseases to the responsible authorities for the necessary actions to be taken.

In spite of the existence of a well built system to take care of the health needs of the people, Trondheim has recorded a number of epidemic cases. Of the recorded cases, swine flu and mumps are the two diseases that have tested the system to its fullest extent. With reference to the swine flu, adequate preparations were put in place to accommodate the outbreak, however, the opposite is the case for the mumps, as it occurred at the blind side of the health authorities.

The vaccination system that has been set up to address the outbreak of epidemics may also be described as satisfactory because it is accessible and inclusive and every resident living in Trondheim has the right to it. Again, effective communication platforms have been utilised, thereby making it less cumbersome to get information about when a particular vaccination exercise will be carried out.

3) GOAL 8 - EFFECTIVE PROVISION OF CRITICAL SERVICES 3.1) Description of the goal The 8​th goal of the Rockefeller Foundation Framework is about provision of critical services and how this can be done most effectively. Both ecosystems and infrastructure plays an important role in handling the needs of the urban population (ARUP, 2015). These systems are important when it comes to vulnerable situations, hazards and natural threats, in order to keep the city functioning. It is important to develop and maintain natural and built infrastructure to be able to meet the threats of tomorrow and have the contingency ready (ARUP, 2015).

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The critical services rely on a well-planned and proactive management system. It is also important to have a variety of services provision for the inhabitants including redundancy (ARUP, 2015). Even though a city has the assets for handling critical situations, it is how these are managed, provided and distributed in the period of disturbance. If the city does not have well maintained and functioning systems and knowledge about central ecosystems and infrastructure, the government, stakeholders and inhabitants will not benefit from the assets (ARUP, 2015).

Ecosystems services are essential to cities. For example, when it comes to natural drainage, it can cause flooding if there is no infrastructure to handle it. Knowledge about how the water will affect the city is important to know when developing and building infrastructure in the city (ARUP, 2015). The framework states that to be a resilient city there is a need to implement continuous plans to make sure the managers of infrastructure are ready to maintain service provision and avoid disruption during disturbance and extreme events (ARUP, 2015).

By monitoring systems using technology there is possibility to actively control the ecosystems services and the infrastructure. This might lead to long-term robustness and flexibility because it is possible to quickly notice when there is a change. Therefore, rapid response to the change could lead to lower the damage (ARUP, 2015).

Goal 8 can be linked to hospital infrastructure and we have chosen to focus on the importance of power supply in a hospital. In Trondheim, the St. Olavs Hospital is situated at Øya close to the city centre and it is very accessible with public transportation. It can be hard to notice it is a hospital due to its architectural design, and the project has won many prizes due to its design (Arkitektur.no, 2018).

3.2) Methodology The Rockefeller Foundation Framework splits the goals into smaller indicators. In the next section, the selected indicators will be listed and after this, the research questions and the chosen data collection method will be presented.

The chosen indicator to goal 8: ●

Flexible infrastructure services. The importance of having adaptable infrastructure services that quickly can respond to changes. The service needs to be robust and diverse, and properly planned to serve the inhabitants.

Research questions for goal 8: ● ● ●

What happens if the hospital has a blackout and what kinds of backup systems do the hospital have?

Do the people working at the hospital know how to react and what to do in cases of blackouts?

How do they monitor their systems in order to be prepared if something unwanted happens?

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The methodology concerning goal 8 is based on written manuals and instructions, newspaper articles and interviews conducted with persons working at St. Olavs Hospital.

We have talked to different people working at the hospital, three nurses and one doctor. They all work at different departments. We also have talked to one person at the Customer Centre and the people that are in charge of the contingency plans. We again talked to one person who has been a patient at the hospital.

These interviews gave us an overview of how the power supply infrastructure is planned and monitored, and how they use the backup systems. There had been some challenges concerning getting in touch with the right people and, if given more time, we would have gone deeper into these issues and it would also have been interesting to talk to the network provider to hear their point of view on how vulnerable the network power supply is for St. Olavs Hospital.

3.3) Findings The findings section will be divided in two parts. The first part will shortly describe some blackout events that happened during 2017 from the newspapers perspective. The last part will be based on the manuals we got from the hospital and interviews we have had with the nurses, doctor, one patient and administration in the hospital.

Blackouts in December, 2017 Hospitals should provide the citizens necessary and sound healthcare also during crisis and extraordinary events such as during power cuts and blackouts.

In December of 2017, St. Olavs Hospital experienced two power outages, on the 6​th and 19​th of December (Baumberger, 2017; Lein and Wangen, 2017). The reason for the first power outage was an error that occurred on the transformer stationed at west of Høgskole park. This error led to some 27 000 people without power supply, including St. Olavs Hospital (Baumberger, 2017). The other blackout was a disturbance in the power supply network (Kleiven, 2018). According to a newspaper article, in Adressa, the hospitals reserve solutions for power to immediately get switched on. There was no danger to people’s life and health, but the hospital had several delays because of the blackout.

In southern Norway there have been several problems with the power supply due to large amount of snow covering trees that falls over the power lines. Many houses have been without power for almost a week (Weiby et al., 2018). Even though this kind of blackout had not happened in Trondheim for this long period, there might be a possibility since it happened in the south.

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Interviews: The leader of technical infrastructure at St. Olavs Hospital The entire technical infrastructure, including power supply, is monitored by the automation system. This system has a visual alert in addition to notification (Figure 07). The power supply system at St. Olavs is monitored 24/7 by a technical guard.

Figure 07 - From this screen the technical guard monitor the power supply at the hospital 24/7. Foto: V. Kleiven

The electrical system at St Olavs is divided in three:

Figure 08 - Visualisation of the power supply system at St. Olav’s hospital.

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Figure 09 - The three-divided power supply system at St. Olav Hospital.

Despite the complexity of the system, the hospital experienced an average of one blackout per year in the last 5 years, but there was no lives in danger because of this.

The emergency generators driven by diesel have different capacity according to how much they are used and for how long. This can be summarized in the Figure 10:

Load on emergency generator

Liters per hour

Liters per day

Total operating time

50 %

675 L

16200 L

2,95 days

75 %

924 L

22176 L

2,16 days

100 %

1230 L

29520 L

1,62 days

Figure 10 - Operation time for three emergency generators at maximum fuel reserve (48 000 liters). Based on manuals from St. Olavs hospital, given by the leader of technical infrastructure.

During the two blackouts in December the systems functioned perfectly and reacted as they should.

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Nurses and doctor The nurses and the doctor replied that there are no established training programs concerning how to react during a blackout. One of them said she did not have any training concerning how to react when there is a power outage. Another nurse also replied that she did not have any formal training on this ever since she started working at the hospital, but only some random training and some part of workshops touched this matter.

The doctor also replied that the hospital offers a large online course portal for the workers, with its own database, containing guidelines for all kinds of problems, including blackout. He explained further that a couple of the courses are mandatory such as the fire course, but the course on blackouts is not. The doctors need to use their working time to go through the guidelines by themselves and he acknowledges that this is not something he prioritizes, due to lack of time.

Only one of the nurses mentioned that they have an emergency cover/book, and she knows there are procedures in the large online course portal, but she is unsure whether it includes strategies concerning power outage.

None of the people interviewed knows whether they test the emergency systems and can not remember whether they have participated in such a test. The doctor mentioned that the hospital has regular disaster exercises where they train on how to receive many injured people or on terror attacks towards the hospital. He said that he assumes they perform scenarios with power outages, but he had not participated and cannot remember if that was ever done. All the people interviewed, however, assume that the emergency systems will kick in immediately if a blackout occurs and it can be relied upon completely without any hitches. They again said they are all aware that the hospital has emergency generators, but they do not know how long they can last or how they are monitored. Another backup system or solution mentioned by one of the nurses is that there is existence of medical air and O2 flasks which are ready for use in case of emergency.

When it comes to improvements, one of the nurses said she would like if there were more training concerning blackouts when recently employed at the hospital. The doctor says he would like to know more about what a blackout has to say for the operation of the hospital and for the patient safety, as well as what it means in the practice of his work if the network is down and of which features are taken care.

Two of the nurses were working at the hospital during the blackout in December. One of them said she perceived it as peaceful and controlled. However, the other nurse also said it took surprisingly long time before the emergency generator kicked in, but she thinks it possibly broke down earlier at the intensive department. The doctor on his part replied he was at work on that very day but the blackout did not affect his work.

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3.4) Proposals Short-term recommendation: Training and information for the nurses and doctors on how to react and what to do in case of blackouts.

Since the fire course is compulsory for every employee at the hospital, it would have been convenient to have some 5-10 minutes education at the end of the course on the issue of blackouts, concerning information and training on how to react and what to do during blackouts.

Long-term recommendation: Simulate what will happen if they lose power supply for a whole week.

They should identify what is the most critical service at the hospital, and how much power supply they need to have in periods of extreme events, such as a blackout that would last for a longer period. Lack of diesel supply should be included in the scenario. They should also estimate how long the supply of medical air and O2 flasks will last.

3.5) Discussion We have barely touched the surface of how the electrical system of St. Olavs works. It is very complicated and we have had short time, but we managed to get some good answers from the daily workers at the hospital and the leader of technical infrastructure.

From the interviews, newspaper articles and the manuals given to us by the hospital staff, we can observe that the hospital has a functioning backup system to handle power outage. St. Olavs Hospital has a resilient and flexible electrical infrastructure system. They test their systems regularly and they monitor them 24/7. The tripartite power supply system is resilient and has proven that it works when there is a blackout. Yet the systems might be vulnerable, due to the fact that they are automatic and technical; the complexity can be a weakness. The supply of medical air and O2 flasks provide a less vulnerable backup system since they do not rely on electronic systems. We recommend St. Olavs to do a scenario where they analyse what happens if they face diesel shortage. Even though Norway is an oil driven country it would be interesting have a simulation if Trondheim runs out of diesel sources and start questioning how much diesel they need to distribute basic services to the citizens in Trondheim and how much diesel they need to cover the most important departments of the hospital for one week without normal power supply, or how long the supply of medical air flasks last, for example.

The doctors and nurses do not know any structured routine when it comes to power outage. One can ask whether there is a need for the nurses and doctors to get training on this, because of the good working power system. Apart from the monitoring and the adaptable electrical infrastructure, we recommend that the doctors and nurses have information and training on how to react and what to do in case of blackouts, and what to do if the emergency generators do not work. To save time the hospital could arrange this subject in the mandatory fire course that every employee at the hospital is obliged to attend.

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4) CONCLUSION Trondheim’s health system seems to have been strategically planned. Many reports are available online providing loads of information that is publicly accessible, besides its inclusive vaccination system and well prepared staff. Prioritizing attention to the most risky diseases, but being well informed and prepared for all kinds of epidemics keeps city’s resilience on the high level. It was quite challenging to think on suggestions and improvements, since we have not identified serious gaps that could represent significant obstacles in the health network; but since resilience is a process, there is always a possibility of some improvement.

Even the most developed countries might have moments of weakness, but resilience is manifested when those moments do not last too long and are replaced with quick and smart strategies to overcome a difficult situation. When Trondheim had its mumps epidemics and the vaccination office realized there was no sufficient personnel to work on the protection of the healthy and treatment of the infected, and relied on a strong social asset for contacting retired nurses to help, it showed there is a vast sense of community and that the responsibility towards the ill still remains with the willingness of the nurses to assist.

What could be understood as a weakness though, is when relying too much on backup systems, as the generators in the hospital for example, discourages training for a possible, even though not likely, situation of real blackout if a failure on the generators system happens. It is necessary to think on all the possibilities and have at least a minimum idea on how to proceed.

In addition, having a paper-based notification system means to believe that the deliveries will occur safely and it also discards the risk of fire, for example, which would lead to loss of all registries. An important factor for effective emergency responses is the high speed of information and connectivity. Creating a digital system would auxiliate in this task, when all stakeholders would be aware of outbreaks instantly.

All in all, the process of building a resilient urban environment is never-ending. It is essential to critically evaluate the current systems and think of different hypothesis to check possible gaps. If the unexpected happens, new processes and strategies are to be created, with the same risk of becoming quickly outdated again.

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5) REFERENCES ARUP, 2015. ​City Resilience Index​. Online: ARUP and the Rockefeller Foundation. https://assets.rockefellerfoundation.org/app/uploads/20171206110244/170223_CRI-Brochure.pdf (Accessed: 13.02.18) Arkitektur.no, 2018. ​Rapport St. Olavs hospital​. Available at: https://www.arkitektur.no/st-olavs-hospital?tid=158202​ (Accessed: 23.02.2018) Baumberger, B., 2017. ​Store deler av datasystemet til St. Olavs hospital var nede​. Available at: https://www.adressa.no/nyheter/trondheim/2017/12/19/Store-deler-av-datasystemet-til-St.-Olavs-hospitalvar-nede-15780600.ece​ (Accessed: 16.02.2018) Direktoratet for Samfunnssikkerhet og Beredskap (DSB), 2017. Available at: https://www.dsb.no/globalassets/dokumenter/rapporter/kiks-2_januar.pdf​ (Accessed: 16.02.2018) Khan, S. N., 2014. Qualitative research method - phenomenology. ​Asian Social Science​, ​10​(21), pp.

298-310.

Kleiven, V., 2018. From the interview with the leader for technical infrastructure.

Lein, Ø. and Wangen, J. S., 2017. ​Over 27 000 kunder var uten strøm​. Available at: https://www.adressa.no/nyheter/trondheim/2017/12/06/Over-27-000-kunder-var-uten-strøm-i-Trondheim15709081.ece​ Accessed 16.02.2018 Nordbø, S. A., Krokstad, S., Christensen, A., Borge, K. S. and Sagvik, E., 2016. Mumps outbreak among vaccinated students in Trondheim, Norway in 2015. ​Journal of Clinical Virology​, ​82​, pp. 58.

OECD, 2001. ​Human health and environment.​ Available at: http://www.oecd.org/health/health-systems/32006565.pdf​ (Accessed on 25.02.2018) Trondheim Kommune, 2017. ​Smittevernplan​. Available at: https://www.trondheim.kommune.no/globalassets/10-bilder-og-filer/11-politikk-og-planer/planer/temapla ner/smittevernplan-trondheim-kommune-revidert-juni--17-8-1.pdf​ (Accessed: 17.02.2018) Voltersvik, P., Aqrawi, L. A., Dudman, S., Hungnes, O., Bostad, L., Brokstad, K. A. and Cox, R. J., 2016.

Pulmonary changes in Norwegian fatal cases of pandemic influenza H1N1 (2009) infection: A morphologic and molecular genetic study. ​Influenza and other respiratory viruses​, ​10​(6), pp. 525-531.

Weiby, H., Pevik, C. and Wirsching, A., 2018. ​Tung snø på trær og linjer – mange strømløse på Agder​.

Available at:​ ​https://www.nrk.no/sorlandet/tung-sno-forer-til-strombrudd-pa-sorlandet-1.13909626 (Accessed: 18.02.2018)

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6) FIGURES LIST Figure 01: Graphical representation of goals, indicators and research questions. From the authors.

Figure 02: Representation of the notifications process. From the authors.

Figure 03: Prioritization of diseases according to likelihood X gravity. Source: Smittevernplan, 2017.

Figure 04: Main actions of the crisis management plan. From the authors.

Figure 05: Responsible stakeholders according to the hazard’s gravity. From the authors.

Figure 06: An announcement on facebook about Measles vaccination by the Vaccination centre. From the authors.

Figure 07: From this screen the technical guard monitor the power supply at the hospital 24/7. Photo: V. Kleiven.

Figure 08: Visualisation of the power supply system at St. Olavs Hospital. From the authors.

Figure 09: The three-divided power supply at St. Olav hospital. Based on manuals from St. Olav’s hospital, given by the leader of technical infrastructure. From the authors.

Figure 10: Operation time for 3 emergency generators at maximum fuel reserve (48 000 liters). Based on manuals from St. Olavs hospital, given by the leader of technical infrastructure. From the authors.

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7) APPENDIX 1 Questions sent to Vaccination Office: 1)​ What would be the immediate procedures in a case of epidemics? a)​ Do you think the infrastructure is enough to respond an emergency situation? b)​ Are there sufficient well trained staff?

2)​ Who has access to free vaccination? a)​ How do people get to know about it?

3)​ Has the system faced any difficulties before? a)​ If yes, how long did it take to return to a normal situation? How did you deal with that?

4)​ What kind of improvements have you observed in the vaccination system in Trondheim?

5)​ How often do people report on these epidemics 6) What kind of education do you give people on these known outbreaks and how often do you educate them 7) Have you recorded any deaths from an outbreak of an epidemic. If yes, what made you unable to save such people (faulting the health system) 8)​ Do you foresee the occurrence of specific outbreaks and you prepare towards it 9)​ What surveillance activities do you carry out to monitor the occurrence of specific epidemics

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8) APPENDIX 2 A sample of the MSIS paper form

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