WHO-EM/CBI/065/E

A preliminary framework to safeguard

Health security in cities of the

Eastern Mediterranean Region
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Document WHO-EM/CBI/065/E/01.10
 CONTENTS

1.INTRODUCTION...................................................................................................................1

PRACTICAL HEALTH SECURITY THEMES IN CITIES OF THE REGION.......................1

Shelter and safety of buildings and housing......................................................................1

Safety and accessibility of hospitals and health facilities..................................................2

Prevention of chronic and acute environmental health hazards........................................3

Slum areas..........................................................................................................................4

Emergency preparedness, assessment and response..........................................................5

Road traffic accidents, injuries, violence and crime..........................................................6

1. INTRODUCTION

Health security in cities encompasses a wide range of concerns. The primary concern is the
physical safety of city dwellers: ensuring safe housing (shelter, structural safety, preventive
measures against prevent fire and electrical accidents), preventing road traffic crashes,
preventing violence and maintaining law and order. Physical safety further requires timely access
to emergency services and health facilities and safeguards against environmental hazards,
epidemics and pandemics, as well as natural and man-made disasters such as earthquakes, floods
and conflict.

In the WHO Eastern Mediterranean Region, health security concerns are particularly
relevant in cities and large towns in middle-income and low-income countries. In the high-
income countries of the Gulf Cooperation Council (GCC), urban planning and management is
very good and most cities have safe buildings, services and facilities and master plans for long-
term urban development. In contrast, cities in middle-income and low-income countries face
enormous health security challenges. Urban planning, management and safety standards are
below average in some of these countries, and downright deficient in others. Cities of low-
income and middle-income countries are highly vulnerable to emergency situations. They have
sizeable slums and low-income areas and many shortcomings in health and other related
services.

Chronic urban problems related to environment, nutrition, poverty, health services and
health related factors are addressed in the WHO healthy city programme. However, there is an
urgent need to address acute health threats and conditions within the “health security in cities”
concept. The occasion of World Health Day 2010 provides a good opportunity to launch the
concept, particularly through the healthy city programme.

Given the wide scope and involvement of many agencies, institutions departments, civil
society and other stakeholders, the best approach would be to select a group of priority health
security themes that can be advanced by a healthy city programme and as a part of World Health
Day’s promotional and awareness raising efforts. The health security theme(s) selected by each
city should be simple, practical and feasible for advancement by WHO.

PRACTICAL HEALTH SECURITY THEMES IN CITIES OF THE REGION

Shelter and safety of buildings and housing

The healthy cities programme may promote “safe shelter” as a human right and a health
prerequisite. A homeless person or a person who lives in a makeshift shelter with plastic sheets
as walls and dry leaves as a roof has no protection to safeguard his/her health.

In some areas where the price of urban land has sky rocketed and housing shortages are
severe, extra floors are sometimes added to buildings, which can result in building collapse.
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Many countries are also earthquake-prone and in almost all cities, especially in low-income
areas, buildings are extremely vulnerable to seismic tremors and earthquakes. The earthquakes in
the Islamic Republic of Iran (2003) and Pakistan (2005) showed that for cities in many parts of
the Region, calamity can be just around the corner.

Healthy city programme interventions

• Promoting the long-term goal of eliminating homelessness and unsafe shelters on the city
political and development agenda.
• Conducting a strong promotion and advocacy campaign for structural safety of buildings,
reinforcement of building codes and promotion of seismic protection for new multistory
buildings.

Safety and accessibility of hospitals and health facilities

In many cities, private hospitals are often allowed to function in 2–3 apartments of a
building located in a narrow alley or highly congested street, making timely emergency access to
them at times impossible. Such hospitals also expose neighbours to unwanted health risks.

Many of the large public hospitals in cities of the Region are old and in need of repair.
They lack space for parking and for people who bring patients to hospital. The waiting areas for
outpatient clinics, laboratories and examination rooms can expose people to communicable
diseases. In these hospitals, poor structural and building conditions are barriers to maintaining
good hygiene standards. Post-operative recovery rooms sometimes lack air-conditioning,
resulting in heightened health risks during summer heat.

The structural safety of health facilities in the event of natural disasters is unknown in most
cities and in most countries, especially for new public and private hospitals. A formidable
challenge facing all cities is to make their hospitals and health facilities safe.

Healthy city programme interventions

• Promotion and support for the assessment of: structural and functional safety of hospitals
and major health facilities; ease of access for ambulances and emergency services;
facilities for movement and transportation of patients; adequacy of elevators and outpatient
waiting areas; and enforcement of hospital building and functional codes and standards.
• Promotion and strong advocacy for inclusion of strict codes and standards for location and
facilities of hospitals in urban planning and urban development.
• Assist for development of private hospital licensing and the required codes and standards
and criteria.
• Promoting and providing technical support for strengthening and improving the structural
safety of all major hospitals to resist earthquake.

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• Strong advocacy and technical assistance in resource mobilization to ensure water supply
adequacy and safety and proper waste management and disposal for all hospitals.

Prevention of chronic and acute environmental health hazards

Many cities in the Region suffer from acute and chronic air pollution. There are no strict
protocols or guidelines for housing and population density in urban planning and management.
New housing schemes rarely address the need for adequate road capacity. Instead of planning for
it, money and time are later wasted in building flyovers, bridges and other unplanned “quick
fixes”.

Furthermore, there are no regulations for adequacy of parking facilities. Streets in many
cities are public car parks, resulting in health-threatening congestion in city centres and many
parts of the city. There are no standards to connect the number of projected cars with road
capacity and parking facilities, and transportation and traffic management do not use strategic
planning for congestion prevention. There are severe shortcomings in urban planning and
management, with a huge negative impact on health and well-being.

As cities have grown, many large industrial complexes such as cement plants, metal
foundries, power generation plants and petrochemical plants are now encroaching on urban
areas, or are already in the middle of congested housing. A major chemical disaster could occur
at any time. The standards of monitoring, inspection and enforcement of chemical safety in toxic
chemical producing plants and factories are inadequate in many areas or are not followed with
the necessary rigour.

The problem of solid waste management still is a serious public health hazard. A critical
deficiency in solid waste management is the lack of ironclad regulations to separate medical and
toxic hazardous waste from domestic waste. In a large number of cities, these wastes are mixed
and dumped in disposal sites. This poses considerable threat to public health, especially in
countries with asignificant number of solid waste scavengers that earn their living by recovering
recyclable material in solid waste dumps. Similarly, untreated wastewater is still being used to
irrigate vegetables grown in urban peripheries in a substantial number of cities. This is a very
serious urban health security issue.

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Healthy city programme interventions

• Organizing educational meetingson air pollution and urban planning and management.
• Promoting/assisting multicity research studies on city transportation and air pollution
(population density and length of roads, compared to number of cars, rules and regulations
for vehicle licensing, car age, type of fuel, moratorium on allowing new cars entering
roads, etc.).
• Encouraging/assisting in multicity studies and evidence generation on air pollution impact
on respiratory, cardiovascular diseases and other health matters, including resulting
morbidity and mortality.
• Encouraging/participating in health impact assessment of solid waste management,
especially among high-risk groups such as garbage collectors, scavengers, etc.
• Encouraging/assisting in multicity studies on impact of untreated wastewater on the health
of urban periphery farmers.
• Promoting and advocating in identification of heavy polluter and toxic chemical industries
in cities and their removal to suitable areas out of the city.

Slum areas

Slum areas can threaten the health of the entire city. Critical deficiencies in infrastructure,
sanitation and environmental conditions, as well as poor nutrition and poverty often make slum
areas breeding grounds for diseases and other health hazards, as well as crime, illicit drug use
and other social ills. The health, environmental, economic and social conditions of slum areas are
a major health security challenge in cities.

Healthy city programme interventions

• Encouraging/assisting in national reviews of available material on health in slum areas in

each country.
• Promoting, assisting and mobilizing assessment studies on health and its determinants
(environmental, economic and social factors) in slum areas of the city, with participation of
city universities and research institutions.
• Promoting and assisting in creation of an intersectoral “health and slum areas forum”,
network and observatory.
• Promoting and assisting in establishing community based projects to raise the health status
of slum dwellers.
• Identification of critical health security risks in slums with respect to epidemics and
pandemics and setting special action to minimize risks.

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Emergency preparedness, assessment and response

Emergencies in relation to the city include natural and man-made disasters (earthquake,
flood, landslide, cyclone, fire and conflicts), epidemics and pandemics, and environmental
emergencies (chemical and physical).

Emergency preparedness, assessment and response are usually undertaken at the national
level. The functional structure is still very much highly centralized (with exception of one or two
countries). Considerable work has been done in risk and hazard analysis in relation to emergency
in the Region. Emergency preparedness policies, strategies and organizational approaches have
been prepared in 11 countries of the Region, with focal points identified at the local level. These
are a good basis on which to build emergency preparedness capabilities in cities. These activities
could be further strengthened by developing a health vulnerability profile in each city. The
vulnerability profile includes assessing the capabilities of the public and private health sectors in
the city, covering hospitals, clinics, available expertise of the staff to handle emergency medical
needs, data and information collection, disease surveillance systems and media and public
information channels. The vulnerability profile also covers capabilities for environmental health
monitoring and management and logistic support such as ambulance and fire services,
emergency power supply and heavy machinery such as loaders, bulldozers, etc.

Healthy city programme interventions

Natural disasters

• Developing a format and a protocol for health vulnerability profile preparation, including
health facilities, environmental health conditions, health and environment staff, related
emergency health management, information collection, exchange and reporting,
surveillance, media and public information mechanisms.
• Assessing ambulance, fire department and civil defense capabilities to cope with
emergency conditions as part of the above protocol.
• Examining the existing and required linkages between different sectors at the city level and
national disaster management set-ups.
• Developing prototype demonstration projects in 3–4 cities in emergency-prone countries.

Epidemics and pandemics

• Developing a format and a protocol for epidemic and pandemic monitoring, control and
management (in line with the national and international strategies and regulations),
including existing and required capabilities for surveillance and public communication and
media reporting.
• Promotion of the establishment of intersectoral committees for epidemic control and
management, especially in schools, crowded public places and high risk contributing
factors, etc.

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• Promoting the education of city health staff and health facility workers to cope with
epidemics and pandemics.

Environmental emergencies

• Promoting and facilitating the preparation of a chemical safety profile at the city level,
especially identifying the industries and plants producing or using large quantities of toxic
chemicals, such as fertilizer, pesticides, petrochemicals, etc.
• Assessing the safety status and routine safety monitoring of such plants.
• Advocating the relocation of such plants away from densely populated areas, especially in
the case of older plants.
• Based on the chemical safety profile, strengthening the capabilities of hospitals and health
facilities to cope with potential chemical accidents, including access to a chemical
information bank and poison control centre.
• If not existing, establishing poison control facilities in a focal poison control hospital with
access to poison and antidote information to advise hospitals and clinics to deal with
affected patients.
• As part of chemical safety profile or separately, assessing the collection, transportation,
treatment and disposal of chemical and medical waste at the city level, especially the
handling of medical and industrial radionuclide waste.

Road traffic accidents, injuries, violence and crime

Countries of the Region have among the highest rates of road traffic crashes in the world,
especially countries of the GCC. An elaborate WHO collaborative programme is ongoing with
countries in the Region. It will be necessary to connect road traffic crashes as a health security
concern at the city level to the national programme. The healthy city programme is an excellent
venue to bring together all concerned sectors at the city level.

Injuries in cities of the Region have many causes, including unsafe roads and pedestrian
walkways. The rate of falls and injuries is particularly high among children and the elderly.
Residents of slum areas are also more exposed to accidental injuries. In some countries of the
Region, violence against women is common. Similarly, many cities have “street children” who
are used in the drug trade and in petty theft, and are often abused. Commercial sex workers, who
often enter the trade because of poverty, are often subject to abuse. The safety and well-being of
all these vulnerable groups is an important urban health security concern.

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Healthy city programme interventions

• Promoting the application of national road traffic crash prevention activities at city level.
• Promoting the safety of sidewalks and public places in cities and developing projects to
improve their safety.
• In close collaboration with civil society, religious organizations, women and children’s
groups, creating neighborhood watch groups to protect the safety of children.
• In collaboration with legal and religious authorities, establishing women’s volunteer groups
to help in preventing violence against women.
• As part of social mobilization for prevention of and control of HIV/AIDS, promoting the
safety of commercial sex workers.
• Promoting/facilitating the preparation of chemical safety profiles at the city level,
especially identifying the industries producing or using large quantities of toxic chemicals
such as fertilizer, pesticides, petrochemicals, etc.
• Assessing the safety status and routine safety monitoring of such plants.
• Advocating for the relocation of such plants away from densely populated areas, especially
older plants and factories.