Starting with Sphere

In the months leading up to the Humanitarian Action Summit of 2011, the first official gathering of the UHAWG, group members started their discussion around the first of two major objectives of determining how the Sphere Standards may apply or need to be modified for new and complex urban landscapes. The Sphere Standards are a set of minimum standards and guidelines based on human rights and developed to guide theaid and assistance community during humanitarian crises.⁴ Many of these standards, however, are not met by urban slums at baseline. Additionally, urban settings are entrenched in relatively stable formal and informal networks with pre-existing governing and political systems that are often opaque to the new arrivals as well as the expatriate humanitarian community. Unlike setting up rural refugee camps with disrupted local networks and lack of strong outside governance, working in cities necessitates engaging with these forces and this complexity.

Working on a shared document prior to the summit, the working group went through each of the 2004 Sphere Standards and commented on the relevance to and possible adaptation for urban settings. Working group members also commented on how to approach adapting the Sphere Standards to urban settings, including what new data is needed and what contributing factors need to be considered. The majority of the standards were thought to be relevant in urban settings and many required no modification, but several required adaptation to be relevant to the urban environment. Discussion around possible adaptations opened up recurrent themes that needed to be addressed.

Many Standards are Not Met at Baseline

One of the most apparent challenges for humanitarians working in urban settings is that conditions in most slums and informal settlements during non-emergency times are well below the minimum standards set by Sphere. This reality poses several questions:

• • Should the quantifiable standards be different for urban settings?

• • Do cities have forms of compensation that alleviate some of the negative consequences of exceeding the limits seen in camp settings?

• • Is it possible to achieve Sphere Standards in urban slums?

• • Are the limitations of space and density able to be feasibly overcome without forcibly moving populations?

• • Are some of these standards inappropriate for urban settings, considering the local circumstances?

• • Are there more appropriate alternative standards that should be developed?

• • Should the Sphere standards be aimed at governments to guide development or should new standards be developed for the urban environment in the non-emergency setting?

Potential Variation in Quantifiable Standards

The UHAWG consistently identified the need for new data to guide recommendations on adaptation in order to answer the above questions. The quantitative standards in Sphere, and most studies that have looked at health indicator relationships to mortality, have been based on data from refugee camps.Reference Spiegel, Sheik, Gotway-Crawford and Salama^5.Reference Habib, Basma and Yeretzian⁶ Minimum standards were set at inflection points in disease spread, with the understanding that when these standards were not met, mortality and morbidity (injury and illness) incidence increased significantly. In order to explore whether these inflection points are similar in urban areas, corresponding data from slums are urgently needed. Specific focus on the effects of density, rather than just gross population, is needed. These studies must also account for differences instandard health risk factors as well as geographic location, refugee or internally displaced versus long-term populations, and other factors with potential health impacts, such as poverty that vary widely but cannot be ignored in urban conclaves.

Limitations of Space

A fundamental challenge in cities is the severe limitation in space. Slums by their very nature attempt to utilize every available inch of land, including land unsuitable for shelter, while maintaining extreme density. There is generally little available land for establishing new settlements or sanitation facilities and mandating certain distances between dwellings is not feasible. The limitations include simple lack of available land as well as legal restrictions on using unsettled land. These restrictions are the same forces that guide the creation of slums by people with no alternative settlements. While Sphere prioritizes migrants settling with host communities and families, this is even more difficult in a dense urban area already at the limits of absorptive capacity.

Potential Alternative or Additional Standards

Some of the Sphere Standards may be less relevant in urban slums than rural camps, and in some cases new alternatives could be considered. For example, while walking distances to health facilities are probably shorter in urban settings, waiting times may be longer and safety may be a greater concern. Therefore, the round-trip time may be a more appropriate indicator for ease of access rather than walking time or distance alone. Standards are based on both access and availability of essential resources and consequently, it may be preferable to increase the size and capacity of pre-existing health clinics in slums rather than create more, better distributed clinics. In contrast, it is known that in some urban conclaves there is one latrine for every 150-200 people with a walking time of 10 minutes or more.⁷ These sanitation facilities lack privacy, especially for women and are currently a factor in endemic rapes,⁷ thus a certain level of facility distribution is necessary for safety. Additionally, urban environments present specific risks that requireadditional standards. For example, slum settlements are at high risk of fire and flooding so they may necessitate standards around fire prevention and flood zoning. Ultimately, the Sphere Standards must be predicated on both quantitative data and human rights and dignity. There may be dignity-ensuring alternatives in more established urban settings that are not available in rural areas.

Added Complexity in the Urban Context

Discussions of the UHAWG focused around the various complex dilemmas encountered by humanitarian agencies working in urban settings.Complexity is a universal characteristic of humanitarian engagement, even in the most remote rural settings. Historical context, political factions, ethnic and cultural diversity, and the dynamic nature of armed conflicts and ongoing disasters all add to the complexity that humanitarian agencies must navigate. Another layer of complexity in urban settings comes largely from pre-existing institutions including government, NGOs, military and police, informal authorities and civil society. Many of these complexities including lack of accountability and credentials were exposed in the humanitarian response to the 2010 earthquake in Haiti.^8–10

Engaging with Government

Humanitarian agencies routinely work withinthe existing local government but officially engage with national-level officials such as the ministry of health. In an urban setting, the local municipal government may be a more valuable partner than the national government. When a city is directly affected by a disaster, the municipal government is more directly involved in service provision and on-the-ground decisions. In cities receiving large displaced populations, the municipal government is primarily faced with the logistics of how to identify and protect that population. As in all situations, humanitarian agencies prefer to engage the government in their operations because the goal is usually to enable the local authorities to sustainably provide for the public health of their population and allow aid organizations to transition out.While circumstances differ, the local government should be the most accountable institution to the population.

A complicating feature of working in complex urban settings is that slums generally develop outside of a local government's control. Officials may ignore their responsibilities to the newly arriving population. They are often considered illegal settlements andnot entitled to basic resources or swept away when the government deems them unmanageable. Some city mayors preside over populations of 10-20 million, larger than some medium-sized countries. While in rural settings the local population is more familiar with their government representatives, in urban settings officials are more anonymous.Officials are also often unfamiliar with the health consequences of rapid urbanization and engaging with the health sector.¹

Humanitarian agenciesmust be familiar with governmental structuresand be politically savvy in understanding the attitude of the municipality toward the beneficiary population. They may need to advocate for the beneficiary population in order to get buy-in from the government. Any guiding standards that are utilized, be they Sphere standards or others, should be targeted not only to humanitarian agencies but also to the municipal governments.

Engaging with Civil Society and Local NGOs

In addition to complex and cumbersome government bureaucracies, humanitarian agencies in urban settings also face a myriad of non-governmental organizations (NGOs) and civil society actors. The number of NGOs, large and small, serving urban populations and specifically urban slums is growing at a rapid pace.¹¹ Many organizations are based in and run by local populations. Especially in acute-on-chronic disasters, partnership must be a guiding principle of humanitarian engagement.Reference Farmer¹² Many slum populations are organized beyond what is obvious at first glance. They often know key characteristics and information about their community and environment that are crucial for reaching populations in need. For example, in order to reach a scattered refugee population, humanitarian agencies must partner with a wide range of local leaders who can guide them through complex social networks and cultural norms. Partnerships allow agencies to identify the most vulnerable populations and coordinate their efforts so that major needs are not missed and there is generation of buy-in for their work.

In urban settings many indigenous NGOs and social service organizations already serve the population. When confronted with a humanitarian crisis their work will encompass, if not wholly, transition to relief work even when it is not part of their mission or skill set. Humanitarian agencies should include active communication and mobilization of these local organizations as part of their initial assessments and operations. Urban centers are more likely to have an abundance of local talent, urban planners, and those that know how to operate in that context.

Local organizations will stay in the cities long-term, and building strong links from the initial assessment is key to planning sustainable exit strategies and transitions to sustainable livelihood development. In settings of cyclical disasters, such as locations prone to frequent flooding, the goal should include long term capacity building so that the local health system can eventually handle crises.

Many urban slumshave multiple healthcare facilities including public and private clinics as well as traditional healers and dispensaries that act as clinics. The challenge for the urban poor is often less about the availability of these services than it is about their quality andaccessibility. Barriers include prohibitively high fees, lack of information about times of service, prior negative experiences with clinics, and substandard treatments. Nonetheless, when humanitarian agencies seek to offer health services in urban settings they must be aware that these multiple providers and systems must be assessed and appropriately incorporated into the relief effort if possible.

The Haitian Experience

The 2010 Haiti earthquake highlighted the challenges in meeting Sphere standards in urban post-disaster settings. The response in Haiti was extraordinarily fast compared to prior disasters and within 4 months of the earthquake 1.5 million people had full emergency response services. Yet as they moved from relief to recovery people moved into areas that were already substandard, forming slums in flood plains and on landslide-prone hillsides. When attempting to create better shelter options, humanitarian agencies were faced with the limitations of urban space. Currently, private contractors are building multi-story homes to compensate for the population density and experimenting with financing schemes for renters rather than assuming beneficiaries will be homeowners. NGOs also became involved in providing municipal services such as water distribution and sanitation and they now face the challenge of transitioning these services back to municipal control where beneficiaries pay for utilities that were free during the disaster phases.

Overall, humanitarian agencies were unable to meet humanitarian standards in Port-au-Prince. One study of the Parc Jean Marie Vincent IDP camp in Port-au-Prince showed that while minimum standards for healthcare and water access were met, those for food, shelter, sanitation, and security were not.Reference Cullen and Ivers¹³ Given that Port-au-Prince is a relatively small city which had a population of only 2.5 million, these issues willbe magnified when a disaster strikes a larger city.

Challenges in the Urban Setting

The UHAWG also discussed several challenges specific to working in urban slums. These include health burdens that are associated with urban living, land ownership and land-use regulations, and the inability to differentiate displaced from local populations.

Urban Health Burdens

Much attention is paid to the potential for infectious disease outbreaks in the setting of humanitarian crises. Correspondingly, many humanitarian operations are primarily aimed at preventing and treating such disease outbreaks. Extreme population density with poor water and sanitation added to healthcare infrastructure in urban slums greatly increase the risk of disease transmission. As discussed, it is not yet clear if there are different inflection points for disease outbreaks in urban settings, but they should remain a major concern of humanitarian agencies working in urban settings.

Other health burdens have higher prevalence in urban centers includingmotor vehicle injuries, obesity and related non-communicable diseasesand illness secondary to environmental hazards. Increases in the number and density of motor vehicles and collisions are a growing health burden in urban centers.¹ An urban lifestyle is also associated with an increase in the prevalence of obesity, hypertension, coronary artery disease, stroke, and other non-communicable diseases. Similarly, respiratory illness and other diseases exacerbated by pollution and environmental hazards are more common in urban settings.Reference Zhang, Mauzerall, Zhu, Liang, Ezzati and Remais¹⁴ Poor communities are at risk as they settle on land otherwise considered unfavorable, such as that used by the rest of the city for waste disposal, adjacent to nuclear power plants, and downwind from industrial smog.

Violence, crime, and banditry by predatory gangs are on the rise where guns and weapons of war are becoming more prevalent in civilian hands. The nature of unregulated and un-policed slums allows the proliferation of the arms trade, crime, and violent gangs. Refugee populations may also face harassment from corrupt law enforcement officials in many cities where the police may become a barrier to humanitarian operations. These security concerns not only directly relate to rates of trauma, but also affect people's access to a variety of human rights and resources such as basic services, livelihoods, markets, and social support. The most vulnerable groups of women, children and the displaced, bear the brunt of the lack of security.

Land Ownership and Use

Both the local poor and displaced populations tend to move to wherever they can find cheap unregulated land, and this is where slums tend to form, both after disasters and in non-emergency times. After the 2010 Haiti earthquake essentially all open spaces in Port-au-Prince were settled in an uncoordinated fashion.Reference Cullen and Ivers¹³ An obvious worry of the humanitarian community is that these locations are prone to natural and man-made disasters. Slums tend to form on land that is not zoned for housing as in flood plains and landslide-prone areas. In some cases, slums that grow on undeveloped land that retain a high market value due to their locations risk being forcibly removed as development moves in.

Given the illegal nature of many slum settlements, humanitarian organizations face the task of working with city leaders to gain both permission and partnership to build facilities in these areas such as latrines, sewage systems, water taps, and housing. This infrastructure development is best done in concert with the pre-existing infrastructure and long-term strategic public health planning. For example, rather than building pit latrines, a sewage system that connects to the rest of the city's sewage is preferable. Also, displaced populations that settle in slums often establish and maintain their tenure on a piece of land through occupancy. Therefore, it may not be advisable to prioritize their return to their prior settlements since even temporary displacement puts them at risk of losing tenure.

The government view of a population's migration and settlement affectsthat population's ability to utilize resources, gain employment, and secure land tenure. Countries vary in their recognition of the United Nations Refugee Convention. In the example of Iraqirefugees in Jordan, the refugees avoid government clinics because they do not want their names on government documents. When refugees migrate to urban settingsit is unclear what institutions hold primary responsibility for their well-being. In refugee camps, humanitarian NGOs traditionally hold that role under the auspices of United Nations High Commissioner for Refugees. In rapidly urbanized conclaves, there is a question of how much responsibility should be put on the local government. The UHAWG believed that city governments must share responsibility with humanitarian agencies from the outset.

Inability to Differentiate Refugees from Locals

A further challenge is the inability to differentiate the internally displaced or refugees from the local indigenous population. In a camp setting, it is more straightforward to register occupants and keep a census to distinguish between the target beneficiaries and the local population. In an urban slum this is almost impossible because the entire population already faces dire challenges to their health and livelihoods and because the refugees often have an advantage in blending in.

As in all settings, it is important to provide services for refugees without engendering resentment and conflict between them and the local people. Distinguishing aid for migrants versus the host population can be destabilizing and stigmatizing for the displaced population. The UHAWGthought that the best way to address this dilemma would be to avoid providing services exclusively to refugees. In this way refugees are seen as bringing a benefit to the area rather than using overburdened local resources. In urban settings, humanitarian interventions should be developed with an eye toward reaching the standards for the entire population in a sustainable way and integrated into a longer-term urban planning process.

Advantages of Urban Settings

While the challenges of urban settings can be daunting, there are also a number of advantages and opportunities that come with working in cities. These include pre-existing supply chains, economies of scale, infrastructure and availability of technology, and a monetized economy. As a counter to political challenges, there arise opportunities for advocacy for slum populations. Urban environments also present opportunities to effectively implement urban planning and disaster preparedness to mitigate the effects of future crises.

The Urban Advantage

As centers of trade and commerce, cities have pre-established markets and supply chains, which can be valuable tools for humanitarian agencies. While they must be careful not to disrupt the local markets in ways that can adversely affect the local population, agenciesshould focus on augmenting the existing marketplace and supporting the local economy. Interventions are also more amenable to being scaled up for a larger population than interventions made in temporary camps.

The high prevalence of cell phones and telecommunications infrastructure can be used in urban settings for data collection, crowd sourcing, mapping unknown slums, information dissemination, and multiple other purposes. The field of crisis mapping has the opportunity to utilize these advantages in urban settings and magnify their impact. In Haiti, maps were constructed and modified as needed in a matter of hours and days at a pace far beyond any prior disaster due to these technologies. Modified methodologies that may be considered for data collection in population-dense areas include sampling through social networks, and monitoring increases in mobile phone traffic and sales of consumer goods. Opportunities also exist to refine information systems to process and organize data that can be used by cities in the long term.

Finally, the monetized economies in cities, both formal and informal, allow for a range of interventions and resource provision. Since almost all goods are acquired and available through purchase in cities, using cash transfers, cell phone credits, or vouchers that may allow people to access the same goods that aid organizations usually provide in-kind through existing supply chains. This process makes logistics easier for aid organizations and supports the local economy.

Advocacy Opportunities

While a large municipal government and other established political groups may createundue complexity, they also present opportunities for humanitarian agencies to advocate for the well-being of displaced populations and the urban poor. This can be accomplished in part by promoting appropriate standards for service provision and viable public health infrastructure to municipal governments.

The humanitarian community must approach this in a way that accounts for the interests of the municipal government. Government officials may not immediately recognize that providing for slum dwellers or migrants is in their best interest. Rather than taking the naming and shaming approach, humanitarians must not only reveal potential problems and risks, but why it is in the government's interest to address them. Slum populations are linked to the larger urban population and the formal health sectors in these cities manage the consequences of illness and injury, chronic and acute, from these areas.Reference Riley, Ko, Unger and Reis¹⁵ The public health systemsdeveloped to serve the non-slum population face the costs of undiagnosed and untreated chronic diseases as well as the consequences of disease spillovers from outbreaks.Reference Riley, Ko, Unger and Reis¹⁵ Showing the financial advantage of providing basic services and planning for these populations has always been a strong tool for advocacy. A perfect opportunity for this is the immediate post-crisis period. Additionally, humanitarian organizationsmust target policy-makers at critical non-crisis moments that allow for advocacy, such as when cities host major international events.

This advocacy and education should also extend to the non-governmental organizations and the slum occupants themselves. The communities can use data gathered by humanitarian agenciesto aid in service provision and development. In doing so, there is an opportunity to change normative frameworks of advocating for human rights for slum populations. As slum occupants become more engaged in self-advocacy, they also become more active in their political representation.

Disaster Preparedness

A major opportunity presented by urban settings is the chance to create, fund, and implement coordinated disaster prevention and preparedness plans. The UHAWG's meeting time emphasized the need to develop indicators for urban disaster preparedness.

Conclusion and Future Directions

The inaugural meeting of the UHAWG was an active collaboration of humanitarian experts with interests in humanitarian work in urban settings. Initial discussions focused on laying out the context, challenges, and opportunities that humanitarian agencies face and laying the groundwork for future initiatives.

Next Steps for the UHAWG

As a part of the humanitarian community, the Harvard Humanitarian Initiative (HHI) and the UHAWG will undertake several tasks to continue their work. This includes:

1. 1. Collaborating with groups that are developing standards and policy recommendations for urban settings.

2. 2. Developing case studies that evaluate slums in various regions in comparison to Sphere Standards.

3. 3. Investigatingthe impact of density and other aspects of rapid urbanization on health and well-being, as well as interventions aimed at improving conditions.

4. 4. Collaborating with agencies that are developing practical technical standards and documents for humanitarians working in urban settings on a variety of activities from water to livelihoods and shelter.

5. 5. Convening and soliciting feedback from scholars, policy makers, and organizations in cities around the world that are already adapting to these circumstances with creative solutions.

6. 6. Developing tools for the humanitarian community, policy-makers and communities to understand and mitigate the risks of future humanitarian crisis in urban environments.