World Resources 1996-97
(A joint publication by The World Resource Institute, The United
 Nations Environment Programme, The United Nations Development
 Programme, and the World Bank)
(Data edited by Dr. Róbinson Rojas)

2. Urban Environment and Human Health

Box 2.5 Community Perceptions of Urban Health Risks

Understanding how a community perceives health risks such as polluted water, inadequate drainage, or lack of garbage collection is essential to designing effective programs to address those problems. Individuals perceive risks to their health through a lens derived from their cultural, economic, societal, and educational backgrounds and respond accordingly. For example, a squatter in a slum in Calcutta, India, might happily boil water collected at a public tap rather than move to a house with piped water that was located far from job opportunities; a middle-class family in Los Angeles would probably make a very different choice.

Until recently, these differences in how people view and respond to risks were not part of formal health risk analysis, which has traditionally relied on statistical correlations between exposure to risks and the incidence of various illnesses. Now, health planners are beginning to realize that using such objective measures of risk to design public health projects without accounting for how the affected community itself views the health risk being addressed is a recipe for failure.

CASE STUDY: INDORE'S DRAINAGE IMPROVEMENT PROJECT

The importance of incorporating community perceptions into project planning can be seen in the case of a public project designed to relieve flooding in the slums of Indore, India. The majority of Indore's 183 slums are located on the banks of canals and rivers that crisscross the city and on land located in the city's flood plain. Monsoon waters frequently flood these communities, submerging city streets and destroying homes.

Residents of the slums are well aware of the health risks associated with this flooding. Although they might not know the epidemiological details of pollution and contagion, they are all too familiar with the symptoms that they suffer. The names given to different floodwaters illustrate their perception of health risks. Each type of water has its own name. Dirty water that is contaminated with feces is known as Ganda pani and is seen as the worst kind of water, containing "small unseen insects" (kitanuh) responsible for causing stomach problems and other illnesses. Even wading through such water is recognized to be unhealthful. On the other hand, Maila pani (dirty water without excreta) is unpleasant to walk through, but not dangerous. Pineh ka pani is water that is clean enough to be used for drinking.

For these poor communities, however, the advantages of their location--close to the city center, with easy access to jobs, low land costs, and strong community ties--far outweigh the health risks associated with flooding and contact with dirty water. In addition, although city planners view the flooding only as a recurring problem, local residents associate flooding with heavy rain and good crop yields, leading to a positive perception of flooding.

In designing a project to improve health conditions in 157 of Indore's squatter settlements, city planners identified flooding as a major health risk and constructed closed drainage channels in an effort to reduce flooding and upgrade sanitary conditions. Despite these improvements, many community members now perceive flooding problems to be worse than before.

One important source of their dissatisfaction is that the new drainage system has reduced the ability of the community to apply its own risk reduction strategies, thus increasing economic losses from the flooding. Because the drains are closed, residents can no longer predict the severity of the approaching flood. With the previous open drains, community members would adjust their level of flood response depending on rainfall intensity and the volume of water that they could see in the open drains.

In light floods, structural adaptations including high internal shelving, raised storage platforms for valuables, and electricity connections at head height were enough to minimize damage. Food supplies, electronics, and mattresses were moved to ceiling-level platforms for safety.

When community members anticipated severe floods, all valuable possessions were moved to higher ground. Children, the elderly, and livestock were evacuated first, while clothes and utensils were generally moved last. Unable to implement these coping strategies with the new drainage system, residents fear they may now lose many of the valuables on which they depend for their livelihood.

Residents also believe that the closed system does not drain as effectively as their previous open system. Unlike the open sewers, which were wider, the closed sewers are easily blocked by plastic bags and other trash. Water backups flood the area, in some cases affecting houses that were previously outside the flood-prone area. In addition, because residents can no longer see the water flowing, they do not have confidence that it is draining adequately. Finally, the open drains had the added benefit of washing away rubbish and excreta, which now remain on the streets.

INCORPORATING COMMUNITY PERCEPTIONS INTO HEALTH SOLUTIONS

Can risks to health from environmental hazards be reduced in a way that integrates community perceptions and priorities? Some recent efforts to address the health problems surrounding solid waste collections argue that this approach can succeed.

Although the "formal" urban planner considers municipal garbage a health and environmental hazard, many of the poor who earn their livings as scavengers look upon urban waste as an economic resource from which marketable products can be derived. In cities throughout the developing world, scavengers collect waste such as plastic, paper, glass, tin cans, and bones, contributing greatly to garbage collection and recycling efforts in the city.

Of course, scavenging is hazardous employment. It is poverty driven, undertaken by the most vulnerable people--often women and children. In the process of sorting through trash, scavengers expose themselves to serious health hazards such as injuries from broken glass and cans and are disproportionately exposed to disease-carrying pests that breed in garbage.

Nonetheless, implementing a modern garbage collection and recycling system in many cities in the developing world is infeasible and would take jobs from those who need them most. Thus, city officials are starting to realize that this "informal" approach to waste has its benefits. Rather than trying to eliminate scavenging, governments are working with nongovernmental organizations and community groups in an effort to reduce the health risks to scavengers and to make scavenging more profitable. For example, in Cairo, Egypt, wastepickers have built special areas where they can sort waste, rather than bring the waste into their homes, as they did previously. In Manila, Philippines, wastepickers are given masks, gloves, and boots to help protect them from injuries.

Two lessons emerge from these examples. First, for many urban dwellers in developing countries, health is a luxury they cannot afford because their immediate economic survival is at stake. Aware of their limited options, they design innovative ways to try to optimize their conditions. The slum dwellers in Indore, for instance, have developed intricate strategies that attempt to minimize the economic damage done by flooding. These can be very effective in reducing vulnerability to natural and man-made risks.

Second, it is clear that a better understanding of the cultural perceptions of community members can help in the design of local programs that both reduce risks to health and respect the choices of the people living in these cities. The challenge now lies in developing a reliable means of ascertaining community views on local health risks and incorporating them into the planning of environmental health interventions.

--Anton Baare and Rajesh Patnaik

Anton Baare is a social anthropologist with Nordic Consulting Group in Taastrup, Denmark, and Rajesh Patnaik is a research fellow in social anthropology in the Anthropology Department of Andhra University in Visakhapatnam, India.

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