Background
As rapid urbanization creates complex environments that concentrate the risks and hazards of man-made and natural disasters, it also presents a vital advantage that must be exploited. Urban humanitarian emergencies by their very nature occur within the geo-political sphere of a governing body, the municipal government, and as such they are the responsibility of that body. It is the duty of municipal governments to prevent and prepare for and respond to humanitarian emergencies that may affect their citizens. Preparedness at the city level, therefore, remains a valuable area for development to mitigate the effects of humanitarian crises. Rapid urbanization now allows a greater proportion of the population to fall under a responsible municipal government and an opportunity to promote and advance urban planning around preparedness.
The Urban Health Equity Assessment and Response Tool (Urban HEART) is a tool for municipal governments to identify, analyze, and track health inequalities.1 It is accompanied by a collection of best practices for intervention in poor performing areas. Developed by the World Health Organization (WHO) Kobe Centre, it has been implemented throughout the world including Brazil, Indonesia, Iran, Kenya, Malaysia, Mexico, Mongolia, Philippines, Sri Lanka and Vietnam. Currently, it features indicators on both health outcomes and social determinants of health. The health outcome indicators are further broken down into summary indicators and disease specific morbidity and mortality indicators. The social determinants of health are sub-categorized by physical environment and infrastructure, social and human development, economics, and governance.
The current design of Urban HEART indicators allows cities to measure inequalities in a predetermined set of “standard” indicators that affect or reflect the health of its population. However, it currently does not include indicators on the prevention and preparedness of a city for a humanitarian emergency such as a natural or man-made disaster. Since any disaster poses significant health risks to the community, both from immediate trauma as well as from communicable and non-communicable disease in the aftermath, a city's capacity to respond to and mitigate the effects of a disaster is crucial to the future health of its population and remains a core responsibility for the government. Ensuring adequate planning and preparedness is the first step in responding to these inevitable crises.
The Urbanization and Humanitarian Access Working Group (UHAWG) aimed to develop preparedness indicators for humanitarian emergencies that could be incorporated into Urban HEART. The working group (WG) believes that this is a valuable tool that should continue to be scaled-up to cities across the globe. This objective allowed the WG to promote urban planning for humanitarian emergencies and scale up its adoption by city governments across the globe through a tool and program already developed by the WHO. These indicators could then provide a basis for cities to evaluate and improve their disaster preparedness. The discussion focused on key areas, discussed below, which the group thought should be included in an overall assessment of disaster readiness as modeled after exiting Urban HEART indicators.
The WG began work prior to the summit with a shared document in table format for group members to contribute their potential indictors, specific metric for the proposed indicator along with a column for comments from other group members on the proposed indicator. This pre-summit process led to a starting document with both potential indicators and points for discussion during the summit.
Common Themes
During the session, several common themes emerged as crucial to the development of new indicators. The WG decided that acknowledging the complexities of an urban environment is essential to any indicator. The immense size and structure of rapidly growing urban areas including mega-and meta-cities such as those with populations of 10 million and 20 million and those with excess density make it difficult to assess all of the resources available. For example, an assessment of health centers would need to account for not only the government services and major private hospitals but also the plethora of non-government organization (NGO) clinics and smaller independent clinics that may operate in a variety of neighborhoods. Given the diverse make-up of urban populations across a broad spectrum of socio-economic categories, the various services enumerated may not necessarily be available to all persons at all times or may not have a surge capacity capability. These services may only adequately reflect the resources for a sub-section of the population. Thus, a diverse array of topics must be included in the indicators.
Second, the WG noted a distinction between indicators of disaster early warning from those of disaster preparedness. Increasing rates of violent crime, reports of injuries and sexual violence may foreshadow a coming major conflict. In contrast, capacity of health centers to handle injured patients assesses ability to respond to such a crisis.
A final theme centered on ensuring the most accurate metric is used to for each indicator. For example, many current indicators rely on reporting percentages. In urban areas however, a small percentage of the population can represent a large absolute number of people. Indicators must include some measure of the absolute number of individuals and optimally, specific categories of people affected by a given gap.
Areas of Proposed Metrics:
1. Health Outcomes
2. Physical Environment and Infrastructure
3. Governance and Response Capacity
4. Social and Human Development
5. Economics
6. Local Disaster Planning
1. Health Outcomes
Acute stressors such as a disaster place an immediate strain on the chronically underdeveloped health system in many rapidly urbanizing environments. The existing health of the population and the capacity of the system influence the health outcomes of those adversely affected by the event. The WG believed that both structural and functional indicators of the healthcare system should be included. Outcome indicators of health should supplement standard structural indicators such as hospital bed capacity, human resources and drug supplies. For example, under-five mortality, overall mortality, or vaccination rates could be potential functional measures that offer insight into the existing state of a health system. Disparities in these rates within or between cities represent areas where the functionality of the existing system can be improved by investigating the determinants of that outcome rather than focusing on structural measures alone.
The development of health indicators could also include an assessment of existing mechanisms for reporting various forms of violence. Specific forms of violence against particular communities and gender-based violence are important to identify during major conflicts and thus methods of monitoring these are integral to preparedness. Such systems are crucial for the management of this violence during a disaster. Indicators in this area could both assess disaster readiness and have potential early warning applications as discussed in above.
2. Physical Environment and Infrastructure
Given the heterogeneity of urban physical infrastructure and geographic impact of some disasters, humanitarian emergencies will affect the existing physical infrastructure in variable ways with different consequence for different sections of the city. Poor infrastructure, inappropriate land use and lack of structural standards can exacerbate a population's vulnerability to a disaster.Reference Arnold2,Reference Wamsler3 Thus, the pre-existing physical environment has a significant influence on disaster outcomes. The WG determined it was crucial to include an assessment of the existing infrastructure and the physical environment of a city when evaluating disaster preparedness. There is a range of potential indicators that could be considered in this category including durable housing, sanitation infrastructure, and roads. These assessments are also context specific with variable definitions of what constitutes durable and thus may require contextualization or an agreement on a universal standard.
Similarly, the population's current access to services is as important as the assessment of the physical infrastructure and thus defining these resources in terms of access rather than simply physical existence is another method for evaluating preparedness. Access to services and resources such as sanitation, safe water, electricity, and fuel reflect existing preparedness as well as, or sometimes better than, an enumeration of the facilities.
The WG also identified shelter as a major priority during any humanitarian crisis. The physical layout and legal environment of property rights of a city influence the availability of temporary shelter, as a piece of land will be required. Thus, an emergency plan with pre-identified land available for setting up temporary shelter with an estimation of the capacity for that land should be considered for an indicator. It could incorporate information on the legal status of the land and its suitability for temporary relocation such as access to basic service provision, transportation and security.
3. Governance and Response Capacity
There was a general consensus among the WG participants that the existing environment of governance structures and policies related to interactions with donors, aid agencies and international organizations involved in humanitarian relief are important determinants of humanitarian response. In addition, mechanisms for large aid organizations to coordinate with local organizations that work with vulnerable populations or on baseline disparities in basic services such as child health, water and sanitation and immunizations need to be developed. Indicators that represent this form of enabling environment could include mechanisms and policies the government has to coordinate with such organizations and channel donor aid.
Fundamentally, basic response capacity measures such as the number of emergency response vehicles and personnel would need to be integrated into preparedness plans. The indicators to reflect such response capacity can draw from the numerous disaster preparedness plans and recommendations already developed by many local and national governments throughout the world. In addition, some measurement of the capacity of the private sector to assist in a response should be included as it may be a valuable resource for many goods and services such as volunteer trucks and basic amenities as seen during the flooding in New Orleans from Hurricane Katrina. In many developing economies the private sector is already responsible for many basic services traditionally provided by government.
4. Social and Human Development
Existing levels of social development and cohesion have a profound influence on the impact of a disaster and how the post-disaster relief phase plays out. Many different measures could be used to assess the existing level of social development. Many of these measures, however, also fall into other basic health or security indicators as they serve a dual role. For example, rates of child malnutrition could be used to reflect the developmental status of an individual city or neighborhood within a city. The WG also discussed the role security and rates of violent crime play in development. Similarly, increases in the rates of small arms within civilian hands could be another potential warning sign. The best indicators to reflect these ideals still need to be determined but will likely draw from existing measures of development and social cohesion.
5. Economics
The structure of urban economies is incredibly complex with large informal markets interacting with the formal economy. The WG noted that this offers unique challenges and opportunities in disaster preparedness. Knowledge of the economic system allows a city to effectively respond to challenges. Knowledge of all available supply chains could facilitate access to goods following a disaster. As discussed above, private sector capacity, if measured and understood before hand, can be utilized during disaster response. The prevalence of basic services supplied to urban residents by the private sector including water, sanitation and even basic healthcare makes this sector relevant to the relief and recovery phase.Reference Eisenman, Cordasco, Asch, Golden and Glik4
6. Logistical Planning
The final area the WG identified as contributing to disaster preparedness relate to the city's existing disaster plans. The metrics could begin with a simple assessment if such a plan exists. A second important component would be assessing the presence of budget resources allocated to researching, updating, distributing and executing the plan.
The plan itself could include a multitude of components, some of which could be used as indicators of the robustness of the plan. The WG suggested that examining the disaster plans of multiple cities for common key components should strengthen the final list of indicators. This process would also be consistent with Urban HEART's commitment to validating indicators. Some of the possibilities identified by the WG include assessing the presence of plans to transport people and resources in and out of an urban area. This includes the existence of maps and predetermined road routes that can be used, the identification of drivers and vehicles that can be relied on, and mechanisms to get large quantities of goods in and out of the area. Knowledge of and plans accounting for the distribution of populations within a city could be an important indicator. Previous experiences have shown that vulnerable populations disproportionately bear the effects of disasters,Reference Leitmann5 and that this risk will worsen in the future.Reference Burkle6 Identifying these populations and their susceptibility to various types of disasters, then developing plans to assist them is particularly important to disaster planning.
Future Directions
The power of integrating preparedness for complex humanitarian emergencies into urban planning is immense and must be harnessed. While we might focus on the complexities of humanitarian response an equal measure of time, effort and resources must be placed on preparing for these emergencies by academia, aid organizations, governments and international agencies. The Urbanization and Humanitarian Access Working Group (UHAWG) discussions provide a starting point for future development of indicators on disaster preparedness for Urban HEART. Metrics on disaster preparedness would allow urban areas to evaluate their existing capacity for response and design targeted interventions to improve on their preparedness. The exact indicators still need to be further developed and refined. They will then need to be assessed to ensure they meet the principles of Urban HEART, which include ease of use, operational feasibility, generalizability and sustainability.1 The Harvard Humanitarian Initiative and UHAWG along with the WHO will continue to develop and refine these indicators for final integration with the help of the WG over the coming year. Once developed and evaluated, these indicators have the potential to significantly expand the scope of the Urban HEART project, and may offer a standardized way for cities to improve their preparedness for the future humanitarian emergencies that will inevitably strike urban areas.
Acknowledgment
We thank the other participants from the 2011 Humanitarian Action Summit who participated in the working group discussions and shared their experiences and insights.
Appendix: Urbanization and Humanitarian Access Working Group (Alphabetical order)
Working group leader: Ronak Patel
Rapporteurs: Laura Janneck and Shada Rouhani
Working group members: Richard Brennan, MBBS, MPH (Former Health Director, IRC); Nan Buzard, MPA (Director, International Services, American Red Cross); John Damerell, MSc (Project Manager, Sphere Project); George Deikun, (Director, UN Habitat, Geneva); Elizabeth Kimani, PhD (African Population & Health Research Center); Paul Kong, JD (ICRC, Washington, DC); Jostacio Lapitan, MD, MPH (WHO Centre for Health Development, Kobe, Japan); Hani Mowafi, MD; MPH (Boston University; Harvard Humanitarian Initiative), Monica Onyango, PhD, RNM (Department of International Health, Boston, University); Anjali Pant, MD, MPG (Global Emergency Medicine Program, Weill Cornell Medical College); Amit Prasad, MPA/ID (WHO, Japan); Lilly B. Schofield, BS, MSc (Concern Worldwide, Kenya); Natalia Valeeva, MD (IMC Regional Medical Director); Tricia Wachtendorf, PhD (Disaster Research Center, University of Delaware).
Abbreviations:
HEART = Health Equity Assessment and Response Tool
UHAWG = Urbanization and Humanitarian Access Working Group
WHO = World Health Organization
WG = Working Group
