This blog is the fourth of the health in urban development blog series. View also:

Treat, contain, repeat: key links between water supply, sanitation and urban health
By Pascale Hofmann

Health in secondary urban centres: Insights from Karonga, Malawi
By Don Brown

Gaza: Cage Politics, Violence and Health
By Haim Yacobi

 

If you are interested in DPU’s new MSc in Health in Urban Development, more information can be found on our website.

 

Over the last few years there have been several initiatives to develop practical and policy-relevant ways to measure environmental risks faced by low-income groups. This has been in response to a severe lack of information about disaster and health risks available for policy makers to draw on in most low- and middle-income nations. There is a need for both detailed settlement-level data, particularly for informal settlements, as well as for aggregated data needed to inform city-level or national interventions[i]. In this blog, I discuss innovative methodologies that are being developed in cities of the Global South to generate much needed data for action.

Innovative methodologies for understanding health and disaster risks at the urban scale

Innovative methods developed for understanding and measuring these risks range from profiling and mapping informal settlements with community-led or co-production approaches, to detailed analysis of hospital, police and newspaper records. Other methods seek to build consensus based on perceptions and experiences of risk with communities and local governments. DesInventar is a collection of national, regional and city-level databases, which use newspaper reports, as well as police, hospital and accident records to create a detailed portrait of both large or intensive disasters and small-scale extensive disaster events. Other methodologies such as Slum/Shack Dwellers International (SDI) settlement profiling and Action at the Frontline use community-generated information about resident’s experiences of health and disaster risks in order to enter into dialogue with municipal governments about their needs. ReMapRisk uses community-generated risk information and offers a spatial analysis with maps to interrogate and visualise the information, there are maps for Lima (Peru), Karonga (Malawi) and Freetown (Sierra Leone).  Other approaches, such CityRAP, The City Resilience Index and 10 Essentials for Making Cities Resilient focus on the municipal government’s perspectives of risks and capacities for addressing risk at the city-level, and often in dialogue with communities.

 

Health and disaster risks faced by the urban poor

These studies have found that women, men and children living in informal settlements are disproportionally exposed to small and large-scale disaster risks such as flooding, landslides and fires, as well as everyday risks, such as water borne illnesses and poor air quality. For example, the AXA-funded research I have been involved in in Dar es Salaam in Tanzania, used Action at the Frontline methodology, with household surveys, focus groups and action planning Mtambani settlement in Ilala municipality and Bonde la Mpunga settlement in Kinondoni municipality[ii]. The communities identified crime, poor solid management, lack of storm-water drainage infrastructure, lack of wastewater and toilet infrastructure, lack of basic health services and hospitals, flooding, high living costs and drug abuse as the main issues in their settlements. Many of these are directly related to health problems, such as malaria, diarrheal disease and personal safety. While big disasters, such a major floods, earthquakes, tsunami and windstorms do affect the health and welfare of millions across the globe every year, it is actually the smaller events and everyday risks that impact the greatest number of people’s health and well-being.

 

These different methods of understanding risks have been employed in close partnerships between researchers, community organisations, municipal authorities and other research users in many cities across Asia, Africa and Latin America. While there are many innovative initiatives for understanding and measuring risks, the data still remains extremely patchy and limited in scope. Furthermore, and its uptake into municipal government operations and planning is not guaranteed.

 

Principles for the uptake of risk information in urban planning and policy making

Through the Urban Africa Risk Knowledge programme[iii], researchers have identified some principles related to the uptake of local-level risk information into planning and policy making: 1) It is important not just to provide the type of information that are assumed to be useful, but to work closely with partners in identifying data that will be useful for policy and practice[iv]. 2) The community-driven process can be more conducive to driving change in practice and policy in local government than expert-driven data. The use of local knowledge that comes through communities collaborating with local level decision-makers can capture the qualitative experiences of risks and measure the burdens arising from these risks, while enabling communities to engage with local governments/state about their needs[v]. 3) Small steps at collecting local data that are ‘good-enough’ can be valuable in the beginning.[vi] 4) Project-based risk measurement initiatives are rarely enough to make a difference in government practices and policies. What is required is long-term and sustained engagement with information that is regularly updated. 5) Improving official data collection, such as census, vital registration systems and healthcare records will be necessary to systematically address disaster and health risks in informal settlements[vii].

 

Many cities in low- and middle- income countries, and especially in sub-Saharan Africa, do not have functioning local governments, they lack a metropolitan structure or their resources are too meagre to take on new initiatives. While some progress has been made in developing methodologies that help us to better understand the everyday and small-scale disaster risks that underpin women’s, men’s and children’s health in informal settlement, there is still much more to do to scale up these initiatives and to enable local governments to take actions to address risks.

 

References

[i] Satterthwaite, D and Sverdlik, A (2018). Assessing health risks in informal settlements in sub-Saharan African cities. Urban Africa Risk Knowledge Briefing, No. 10. June 2018. Available from: https://www.urbanark.org/assessing-health-risks-informal-settlements-sub-saharan-african-cities

[ii] Osuteye, E. at al. (2018). Communicating risk from the frontline: projecting community voices into disaster risk management policies across scales. Urban Africa Risk Knowledge Briefing, No. 19. October 2018. Available from:

[iii] See www.urbanark.org

[iv] Dodman, D., Leck, H. and F. Taylor (2017). Applying multiple methods to understand and address urban risk. Urban Africa Risk Knowledge Briefing, No. 7. July 2017. Available from: https://www.urbanark.org/applying-multiple-methods-understand-and-address-urban-risk

[v] Osuteye, E. at al. (2018). Communicating risk from the frontline: projecting community voices into disaster risk management policies across scales. Urban Africa Risk Knowledge Briefing, No. 19. October 2018. Available from: https://www.urbanark.org/communicating-risk-frontline-projecting-community-voices-disaster-risk-management-policies-across

[vi] Spaliviero, M. at al. (2019). Urban Resilience building in fast-growing African Cities. Urban Africa Risk Knowledge Briefing, No. 20, January 2019. Available from: https://www.urbanark.org/urban-resilience-building-fast-growing-african-cities

[vii][vii] Adelekan, I.O. and D. Satterthwaite (2019). Filling the data gaps on everyday and disaster risks in cities: The case of Ibadan. Urban Africa Risk Knowledge Briefing, No 22. January 2019. Available from: https://www.urbanark.org/filling-data-gaps-every-day-and-disaster-risks-cities-case-ibadan

This blog is the first of the health in urban development blog series. View also:
Gaza: Cage Politics, Violence and Health

If you are interested in DPU’s new MSc in Health in Urban Development, more information can be found on our website.

They may be small, but don’t let their size mislead you. Secondary centres form a significant—though underappreciated—part of the global urban landscape. Drawing on my doctoral research in Karonga, a small town in Malawi, I explain why achieving a healthy urban future will depend increasingly on how urban growth occurs outside the largest cities.

 

It is widely proclaimed that we now live in an urban age, with more than half of the world’s population living in ‘cities’. While impressive, this statistic does not tell the whole story. It is widely assumed that most of the world’s urban population live in the largest cities and that they are the fastest growing. But there are relatively few mega cities (with more than 10 million residents) and they account for less than 10% of the world’s urban population. Many are also not growing especially fast.

Far more urban dwellers live in small and intermediate centres (with less than 1 million inhabitants), many in Asia and Africa. These ‘secondary’ centres constitute the bottom and middle of the urban hierarchy, where a large and typically growing share of the world’s future urban growth is expected to occur. But this is also where the capacity to plan and manage urban growth, provide services, and reduce environmental risks is so often lacking.

If the growth of secondary centres in Malawi and other sub-Saharan African countries is to contribute to a healthy urban future, research and action is required on several fronts:

The dynamics of in situ urbanisation

Most accounts of Africa’s urban transition have focused on the causes and patterns of urbanisation and peri-urbanisation. Much less attention has been paid to in situ urbanisation—the placed-based transition from a rural area into an urban one. These dynamics are of growing importance in sub-Saharan Africa given its low urbanisation level and moderate urbanisation rate, meaning that many small settlements have yet to emerge.

Karonga exemplifies the process of in situ urbanisation: it grew from a small trading post in the colonial era into a sub-regional service centre under the current national planning framework. The town’s population increased nearly four-fold from around 11,000 in 1966 (the first census year) to over 40,000 in 2008 (the last census year). Karonga is now the second largest centre in the Northern Region following Mzuzu.

Despite its size and growth, Karonga has no local government and so lacks the capacity to effectively plan and manage its growth. Numerous environmental hazards have subsequently emerged, ranging from poor sanitation, to seasonal floods, to large-scale disasters, posing major health risks.

The need for disaggregated urban data

Most demographic and health data is aggregated to provide averages for urban populations, obscuring widespread health disparities within and between urban populations. Basic health data is especially limited in sub-Saharan Africa in the absence of vital registration systems, disease surveillance sites and electronic health records, even though the region bears the brunt of the world’s deadliest epidemics, including HIV/AIDS, malaria and tuberculosis.

Where available, local information sources can be used to generate disaggregated data at the urban scale. Among the most valuable sources are hospital records, which provide information on the causes of disease in populations. To generate this information for Karonga, nearly 3,000 inpatient records from Karonga District Hospital (located in the town) were collected over a 12-month period (August 2016 to July 2017) to produces estimates of the prevalence of environmental disease.

While the sample is not completely representative of the town’s population, the findings reveal alarming patterns:

• 63% of all recorded diseases were environmental (i.e. related to factors in the physical environment);
• 64% of environmental diseases were infectious and parasitic; and
• cholera outbreaks during the rainy season are recurrent in areas with the poorest sanitation.

These observations support the longstanding suspicion that smaller settlements with limited capacities can be among the most hazardous places to live, highlighting the need for urban environments far more capable of preventing disease.

The dynamics of rural governance regime change

As in situ urbanisation unfolds, villages will grow into towns, towns will be reclassified as urban (raising the urbanisation level), and modern institutions will attempt to intervene in rural governance regimes that may be resistant to change. This process is creating new governance challenges for planning authorities attempting to intervene in towns once they have already emerged.

These challenges are heightened in Karonga in the absence of a local government, meaning the balance of power has not shifted from traditional to modern institutions in much the same way the planning system has not resulted in formal urban development. Instead, customary and modern institutions have intertwined in hybridised governance arrangements in which the authority and legitimacy of the state is contested.

Understanding the place-based dynamics of rural governance regime change in emerging towns such as Karonga is at the forefront of planning research on in situ urbanisation. Case studies of this kind have significant potential to reveal the possibilities and obstacles for planning healthy towns at the bottom of the urban hierarchy. This is where many of the future challenges facing public health will be increasingly concentrated, but where little scholarly or practical attention has been paid to this and other important urban development issues.

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Donald Brown is an urban planner and researcher interested in the nexus between urban development planning, public health and (disaster) risk reduction in sub-Saharan Africa and other urbanising regions. His doctoral research focused on environmental health in smaller African urban centres as increasingly important to overall urban population health.