February 11, 2016

Rambam Medical Center in Haifa, Israel is home to the world’s largest fortified underground hospital. It provides shelter from conventional and unconventional threats for 2,000 patients and has become a global example of disaster preparedness.

By Katja Ridderbusch

HAIFA, Israel - Every morning when Liora Utitz parks her car on level minus three of the garage at Rambam Medical Center in Haifa, she feels a tiny thrill, a little chuckle of joy tickling in her throat. When she steps out of the comfortable dark of her car into the neon-lit garage. When she smacks the car door and a hollow echo bounces back from the thick walls. When her heels touch the shiny grey surface of the floor and the markings on the concrete columns glare in a garish green.

It is indeed the parking deck itself that makes Utitz happy every morning.  After all, it’s not just a regular parking garage. Cars are parked here only in peacetime. In times of war, the parking deck at Rambam, the largest medical center in the north of Israel, can be converted into a fully equipped hospital for 2,000 patients with four operating rooms; 85 intensive care beds; 94 dialysis stations; and a quarantine and infectious disease unit. The converted hospital also has a lab, a blood bank, mobile x-ray-machines, as well as a provisional childcare facility and a synagogue. An entire city in the underground, “a place where patients and staff can feel safe and secure,” says Utitz, senior nurse and coordinator for mass casualty and emergency preparedness at Rambam. “As safe as it can get in Israel.”

Rambam’s underground hospital is the largest fortified medical facility in the world. It’s been operational since 2013; final adjustments were made last year. So far, there hasn’t been a mass casualty event. However, Utitz is convinced that it’s only a matter of time before the new underground hospital will have to face the test of reality. “Here in Israel, violence is woven into our daily lives,” she says with a laconic shrug.

At Israel’s northern border, there’s a rising threat from Hezbollah missile attacks.  The radical Islamist militia, a close ally to the Syrian government, has been equipped by Iran with modern weapons. Its arsenal is comparable with that of a regular army, IDF sources recently said, adding that Hezbollah could fire as many as 1,500 missiles from Lebanon into Israel. Rambam has been put on high alert several times during the past few months.

Utitz, with a thick blond head of hair and a warm and firm voice, has worked as a nurse for over 30 years – in the emergency department, the intensive care unit, and the pediatric ward at Rambam, and also, in between, in a small kibbutz east of Haifa. She was appointed coordinator for disaster preparedness 10 years ago and helped plan the underground hospital from scratch.

Rambam’s fortified hospital is a child of war. In 2006, during the second Lebanon war, the north of Israel came under heavy fire by Hezbollah rockets. Many missiles hit Haifa and, in particular, the neighborhood of Bat Galim, where Rambam is located. The war lasted 34 days. “We were working under a firestorm,” Utitz remembers. Back then, Rambam only had a small shelter with room for about 100 patients and a few staff members. “We really felt unsafe and frightened,” she says. “The only comfort was that the staff was together, that we all lived in the same fear.”

Many of the Hezbollah missiles destroyed buildings and infrastructure around the hospital, but none hit the hospital itself. “Back then, we understood that for the next war, we could not rely on miracles, statistics or simply luck,” says Professor Shimon Reisner, associate director at Rambam, cardiologist, and a retired officer in the IDF medical corps.

In the months after the war, a team of Rambam executives, physicians and nurses looked at disaster relief facilities all over the world to collect ideas and inspiration for a fortified hospital. The breakthrough moment came when a Rambam team visited a Singapore hospital with a parking garage that could be converted into a small, makeshift emergency hospital for 400 patients. That’s when the idea was born: something like this had to be built in Haifa, but on a larger scale - bigger, safer and more technologically advanced.

Construction began in 2008 but was stopped several times due to water seeping into the site. Rambam’s fortified hospital has three levels. It is 56 feet deep and 26 feet below sea level. “It’s kind of a huge concrete box of about 650,000 square feet and surrounded by underground water,” Reisner explains.

The price tag for the giant underground fortress was $150 million, twice as much as a regular parking garage. It was paid for by the Israeli government and with private donations coming mostly from Israel and the United States.

The bunker hospital’s floor and walls are made from a specially coated, dirt-repellent concrete. Air condition units with particularly strong air filters are installed in the ceiling. In the walls and ceilings, dozens of kilometers of oxygen tubes are stored. The walls also hold water tanks, power generators and medical supplies.

In an emergency, large dividing walls can seal off certain areas of the parking deck - hermetically, if necessary. Rambam’s fortified underground hospital is meant to protect from bombs and missiles, including biological, chemical and even nuclear attacks. Within 72 hours, according to the plan, the entire hospital can be moved underground and be self-sustained and completely functional for at least three days.

In order to evacuate the regular hospital in a speedy and organized fashion, the entire staff has to follow a strict and precise emergency protocol. Rambam organizes major mass casualty exercises and drills, often in collaboration with the IDF, up to eight times a year.

“Every staff member - every doctor, nurse, lab technician, IT worker, security guard or member of the cleaning crew – knows exactly what to do, what their role is at any given moment,” says Utitz. They know which department and which patients need to be evacuated and in what order. They also know which devices, medications, and supplies will be taken underground. During the drills, soldiers and volunteers play the roles of patients. "Only if we exercise again, and again, and again, can we improve upon the process, correct mistakes and streamline the flow,” Utitz says.

For decades, Israel has exported its expertise in mass casualty management, emergency response, and disaster preparedness. Rambam welcomes visitors from all over the world on a regular basis. Visitors have included government officials from China; engineers from the tsunami regions in Southeast Asia; and disaster relief experts from California and Louisiana, where earthquakes and floods are common threats.

One of the international visitors was Ret. Col. John McManus. McManus served in the U.S. Army for over 20 years, worked in field hospitals in Bosnia, Kuwait and Iraq, and now teaches emergency preparedness at Augusta University in Georgia. “Rambam is unique,” he says. “For one, it’s a perfect use of space. There’s no waste, no empty facility. What is a parking lot during peacetime becomes a hospital at war. That’s quite ingenious.”

He adds that, unlike most field hospitals or shelters, Rambam’s fortified underground hospital wasn’t just built as a makeshift area in order to triage mass casualty victims in the moment of an emergency, “but it has the capability to maintain patients’ care for a sustained amount of time.”

McManus points out that because of its historical and political situation, Israel is more willing than most other countries to invest upfront in emergency and disaster preparedness, “to proactively protect its citizens against different kinds of threats.”

That’s an expensive endeavor though. Rambam executives quote the price for self-protection at “many million dollars a year.”  The money goes for constant readiness. There are exercises and drills; facility maintenance; testing and repair of medical devices. The money is also used for continuously exchanging the water and oyxgen supplies, and for medications that expire.

“The motivation to invest heavily, continuously and long-term in a situation that may or may not happen is not very strong outside of Israel,” says McManus. Not in the United States, and not in Europe.

All preparedness aside, life 56 feet underground presents its own set of challenges. An open space within a closed world, that’s how Utitz describes the fortified hospital. She paints a graphic picture: "Life for the patients in the underground is very different than in the regular hospital. Beds are standing side by side. There’s no privacy.”

In this open space, a woman giving birth could lay next to a person who is dying; or a patient who receives IV chemotherapy could be next to a young soldier who just had a piece of shrapnel removed from his eye socket.

Besides mental challenges there are concrete medical hazards, such as a heightened risk of infection, as it would be difficult to keep the treatment areas completely sterile. Keeping the appropriate oxygen level in a room filled with more than 2,000 people all breathing the same air would be another challenge, and so would be an uncontrolled spread of a pathogen following a biological attack.

The four operating rooms in the underground hospital are reserved for extreme emergencies and urgent cases only, says Shimon Reisner. They are supposed to support the 12 operating rooms in the regular hospital that are also fortified. “However, if such an emergency happens, we can perform any needed urgent procedure in the underground hospital.” Even open heart surgery, says the cardiologist.

John McManus hopes that it won’t come to that, that the extreme emergency will not happen, at least not for a long, long time. Liora Utitz prefers to shield her hopes, be more pragmatic in her expectations. She just hopes that the emergency won’t happen all too soon. That she can enjoy the tiny thrill in her throat, in the morning when she parks her car in the parking garage at Rambam hospital.

This is the English translation of an article published in the German Jewish weekly “Jüdische Allgemeine” on February 11, 2016

© Katja Ridderbusch