Feature Emergency Medicine

Urban building collapse: what are the health implications?

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5256 (Published 22 August 2014) Cite this as: BMJ 2014;349:g5256
  1. Patralekha Chatterjee, journalist, New Delhi
  1. patralekha.chatterjee{at}gmail.com

Mass deaths after the collapse of the Rana Plaza in Dhaka in 2013 were met with global outcry, alerting the world to collapse of buildings as a huge problem in South Asia. Patralekha Chatterjee reports on continuing difficulties

A string of disasters in India’s big cities has sparked public fury and focused attention on what causes buildings to collapse. In early July one person died when a building under construction collapsed in downtown Mumbai. In June, a crumbling four storey building in New Delhi collapsed killing 10, including five children, and injuring several others. Also in June, an 11 storey structure under construction in Chennai failed, resulting in the deaths of 61 people.

A total of 3074 structures (including houses, other buildings, and bridges) collapsed in India in 2013, up from 2764 the previous year, according to the National Crime Records Bureau.1 In 2013, building collapse was responsible for the death of 1379 people and a further 384 were injured.

A report in the Economic and Political Weekly considered the Chennai collapse, noting that investigators, supervised by the police, had found that the construction site was on “unsafe ground.”2

Several people have been arrested, but the report pointed out, “The tragedy . . . is not just the loss of life, but often employees’ lack of knowledge of laws that entitle them to compensation through a grievance redress mechanism.” This is compounded by government indifference and collusion with employers, the article says, hampering efforts to prosecute under, for example, the Workmen’s Compensation Act or the Building and Other Construction Workers Act.

Rana Plaza

The problem is not confined to India. In April 2013 the Rana Plaza, a multistorey building built on swampy ground near Dhaka, collapsed killing more than 1130 people, most of them garment workers, and sparking global outcry.3

“The main cause of collapse was industrial electricity generators and factories in the top floors,” says Professor Khondker Abdul Awal Rizvi, former director of the National Institution of Traumatology of Orthopaedic Rehabilitation in Dhaka, one of the specialty care hospitals that provided immediate surgery and treatment for the injured. “Other reasons were factors like faulty design, use of substandard materials, faulty supervision, and failure to take proper action by the local administrator when a crack was detected,” he says.

In 1985, the roof of Dhaka University’s Jagannath Hall caved in and 40 students were killed. Rizvi blames poor maintenance: “We have some old buildings in old Dhaka and other parts of the country. Poor people use them as homes and are unable to maintain the building. Common problems are failure of the government to enforce building codes and safety rules.”

Preventing building collapse

Structures that collapse are generally either old and decrepit or new buildings that violate building codes. A lack of oversight contributes to both.

The problem is not the lack of building standards but lax enforcement. India’s national building code dates from 1970. It specifies minimum safety levels with regard to fire protection, structural standards, emergency evacuation measures, and so on. Standards were revised in 2005 to unify all such regulations,4 but some states have not adopted the revised code. Building laws are often the responsibility of local authorities that have overlapping jurisdiction, leading to inadequate implementation. And there is little monitoring of whether appropriate materials are used.5

Chandrashekhar Prabhu, a Mumbai based architect and housing activist, told The BMJ that “unauthorised constructions, sub-standard quality of design and construction material, lack of financial capacity to repair” can lead to collapse. Corruption is an aggravating factor.6

How do builders get away with it? The short answer is because people are desperate, land prices are high, and most people are willing to live anywhere and take risks.

Medical response

The region has an acute shortage of professionals to deal with the large numbers injured when buildings collapse. India has fewer than 30 000 orthopaedic surgeons for its 1.2 billion people—one per 400 000 population.7 Bangladesh, with 150 million people, has only 600 orthopaedic surgeons, according to Rizvi. Many people with serious injuries die before they are rescued, and those who manage to survive generally have “extreme exhaustion, dehydration, and acute starvation in addition to mutilating limb injuries,” explains Amit Gupta, additional professor of surgery at the J P N Apex Trauma Center in New Delhi.

Gupta says that often “amputations need to be performed at the site itself in order to extricate the victim, as removing heavy debris might be impossible or would make the rest of the collapsed structure unstable.” But this has to be done by an expert medical team trained to do on-site amputations safely and swiftly under often dangerous circumstances.

The National Disaster Response Force, India’s nodal agency for emergency reaction, has a mandate for search and rescue only for multiple or major incidents, such as earthquakes or cyclones, but often responds to building collapse. Although it often partners with specialist doctors and nurses from institutions such as the J P N Apex Trauma Center, one agency cannot attend to every disaster in a country as vast as India.

Bringing patients to a facility that can provide the right care quickly is a challenge. Not all Indian states have the free 108 ambulance telephone number. Gujarat is the only state to have legislation specifically dealing with emergency medical services (EMS), says Gupta, and there are no standards for ambulance paramedics. Access to trauma care services can also be delayed because of a lack of resources and trained staff for both acute and rehabilitative care, which has led to poor outcomes.

Rajasekaran Shanmuganathan, an orthopaedic surgeon working at Ganga Hospital, Coimbatore, periodically treats victims of building collapse. “Many of them have spinal fractures and are paralysed for life. Many have completely crushed limbs that require amputation,” he says. “The victims are usually poor people who have to work to feed themselves. Delay increases death and disability. Patients are usually taken to the nearest government hospital or small hospitals where inadequate care is given. After a delay of a few hours to [a] few days, they are shifted to tertiary trauma centres like our hospital. By that time, the opportunity for reconstruction is lost. If there is a provision for these patients to come directly to big trauma centres, the results will be far better because of the high technology available in specialised centres.”

Shanmuganathan says that municipal corporations “must have a robust mass disaster action plan.” India needs to create units that are well versed in treating such multiple injuries, he says, and the government should list hospitals capable of dealing with such situations in each area.

The way forward

India’s television channels, myriad newspapers, and increasingly powerful social media have publicised building collapse. The judiciary is also stepping up to the plate.

On 4 August the Madras high court asked the Tamil Nadu government to report on the poor quality of design and construction materials that led to the collapse in Chennai in June. The court has directed that the report be submitted by 28 August.

Venkaiah Naidu, the country’s new union urban development minister, has said that the central government is preparing a 25 point agenda to check illegal structures and building violations. It will be circulated to all state governments to implement along with local guidelines.

Institutions such as the J P N Apex Trauma Center, set up as one of the specialty centres in the All India Institute of Medical Sciences (AIIMS) are also helping to improve care. The centre, which opened in 2007, has 210 beds, 50 faculty members, 100 resident doctors, over 500 nurses and other support staff.

“With a footfall of about 60 000 injured victims last year this trauma centre is one of the busiest in the country. As a part of AIIMS it has a mandate not only to provide state of the art care but to build capacity and do research. The aim is to develop a model trauma care system for India which is cost effective and can be emulated,” says Gupta.

The centre’s recent initiatives include several short term courses on different aspects of trauma care. The centre also collaborates internationally. The question is whether centrally funded centres of excellence can improve the situation for trauma patients elsewhere in the country.


Cite this as: BMJ 2014;349:g5256


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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