Understanding Issues

Who Suffers? Identifying the Vulnerable Groups

Extracted from: DANIDA Workshop Papers: Improving the Urban Environment and Reducing Poverty; December 5, 2000; Copenhagen, Denmark.

It is not only that low-income groups generally face higher levels of risk but also that they have less possibility of getting rapid and appropriate medical treatment if they are injured or fall ill as a result of some environmental hazard. They can least afford treatment and medication or income loss while recovering from sickness or injury, and often have jobs that do not provide for health insurance or sick leave. Low-income households rarely have assets that can rapidly be converted to cash to cover food expenses when an income-earner is off work or to pay for treatment to hasten recovery. Low-income groups are generally at much higher risk of suffering from psycho-social health problems because they live and work with much higher levels of environmental stress factors – for instance, greater noise levels, higher levels of overcrowding, less security and fewer services. They also have to cope with the stresses caused by much higher levels of ill-health and injury and of infant and child death within their households which are, themselves, partly the result of environmental factors.

Vulnerability and susceptibility

There is considerable variation among ‘low-income groups' in the range and severity of environmental hazards. The presence of an environmental hazard (for instance, a pathogen, pollutant or physical hazard) does not necessarily mean that it will harm someone, and the characteristics of the individual, household or social group exposed to the hazard also play a role in its effect.

Certain people or households are more at risk from environmental hazards because they are:

  • Less able to avoid them (e.g. living in a settlement lacking provision for protected water, sanitation and drainage).
  • More affected by them (e.g. infants are at much greater risk of death from diarrhoea and acute respiratory infections than older groups).
  • Less able to cope with the illness, injury or premature death they cause (e.g. persons who cannot afford treatment from a doctor or medicine).

Such individuals or households are generally termed vulnerable. But to ensure a more precise understanding (from which more appropriate responses can be developed), it is worth distinguishing between susceptibility (where the increased risk is related to endogenous factors such as a person's nutritional status, the state of their immune system or their genetic makeup) and vulnerability (where it is external social, economic or cultural conditions that increase the risk – for instance, through an increased likelihood of exposure to environmental hazards or less capacity to cope with or adapt to an illness or injury).

Characteristics that influence susceptibility to environmental hazards include:

  • For many biological pathogens: weak body defences (mostly a function of age and nutritional status, some a function of acquired immunity as in the protection given against certain diseases by vaccines). High-risk groups include those suffering under-nutrition and those with immune systems compromised by HIV. Pregnant women and their foetuses and infants are high-risk groups, especially in contexts where there are high risks of infectious and parasitic diseases and under-nutrition.
  • For physical hazards: limited mobility, strength and balance (as is evident in young children and many older people and in people with physical disabilities). In poor quality and overcrowded housing, the incidence of serious accidents is particularly high.
  • For exposure to chemicals: age and health status at the time of exposure. There are also certain groups such as asthmatics and elderly people with chronic respiratory diseases who are particularly susceptible to certain air pollutants.

Vulnerability to environmental hazards is much influenced by household income and assets, gender, the quality of housing and basic services, and environmental health risks within the workplace. So, among the most vulnerable groups are:

  • Individuals/households living in poor quality homes and neighbourhoods that lack adequate provision for water, sanitation, drainage and garbage removal and as such also lack safe indoor and outdoor living and play environments. For people living in shacks made of inflammable materials such as wood and cardboard, the risk of accidental fire is much increased, particularly when households also use open fires or portable stoves for cooking and/or heating and have no electricity so that kerosene lights or candles are used for lighting. This vulnerability can extend to a large share of the urban population in many cities.
  • The persons doing the ‘dangerous' tasks within households, which increases the duration and/or severity of exposure to environmental hazards. An analysis of vulnerability has to be gender and age aware, since many dangerous tasks are allocated to women and children. For instance, it is generally women who have to manage the disposal of human excreta where provision for sanitation is inadequate. Where there are high levels of indoor air pollution, it is generally women and young children who spend longest indoors because they have been allocated most household tasks.
  • Income-earners with particularly hazardous work – for instance, working in factories with high levels of exposure to dangerous chemicals or hazardous machinery. Those who make a living from picking and sorting wastes also face many hazards, especially those working at large waste dumps (where residential wastes are often mixed with industrial and commercial wastes, including some toxic wastes).
  • Groups facing discrimination in obtaining adequate incomes, housing and basic services; in many societies, particular ethnic groups or castes face discrimination in all these.

Women are more vulnerable than men to many environmental hazards because of gender relations (i.e. as a result of the particular social and economic roles that women have, determined by social, economic and political structures). In many societies, women face discrimination within labour markets and with regard to obtaining housing, land, basic services and credit. Women are also especially susceptible to many environmental hazards when pregnant, since the reproductive system is particularly sensitive to adverse environmental conditions.

Vulnerability to disasters

The death toll from disasters of a comparable type and scale vary greatly from place to place. In a wealthy, well-managed city, it is rare for many people to die from a hurricane, flood or earthquake but large death tolls are much more common in lower-income, poorly managed cities. These differences are greatly influenced by how much action had been taken beforehand to reduce people's vulnerability to the disaster.

In most cities, it is low-income groups that are heavily concentrated in the sites most at risk from disasters - flood plains, steep slopes, sites around heavy industry and sites most at risk from earthquakes. Indeed, hazardous sites suit low-income groups well because the fact that they are hazardous makes other groups avoid building there, thus keeping down their value and often making them the only sites which poorer groups can occupy which are close to income-earning opportunities. Low-income groups inevitably have less money to spend on building or renting a house designed to avoid or limit damage in the event of a disaster and it is also generally the low-income neighbourhoods that have the least provision for protective infrastructure. Low-income groups also have the least resources on which to call when some disaster damages or destroys their housing.

Reducing vulnerability

A person’s or household’s vulnerability is also much influenced by the extent to which they can cope with the consequences of the illness, injury or premature death caused by environmental hazards. For instance:

  • Can they get treatment and can they afford it and any medication they need?
  • Can they get emergency services when needed?
  • Can they get a loan to help them manage a sudden drop in income?
  • Do they have assets they can call on (monetary and non-monetary)?

Thus, among the factors that reduce vulnerability and risks for susceptible groups are:

  • The extent of public, private and community provision for disease/injury prevention-oriented health care (including provision for immunisation and the quality of services for ante-natal, childbirth and post-natal care) including emergency response to accidental injuries or acute diseases.
  • Good quality homes and neighborhoods which reduce exposure to biological pathogens, chemicals and physical hazards, and reduce vulnerability to 'natural' disasters.
  • Good standards of occupational health and safety, and control of air pollution.
  • Good standards of traffic management.
  • Good provision for children's needs at different ages (e.g. good quality day care, pre-school, school, children's play at different ages).
  • Good standards of nutrition.

There are also many different ways in which vulnerability to disasters can be reduced. For instance, for the inhabitants of a settlement at risk from flooding, vulnerability may be reduced by:

  • Reducing the risk of flooding – which may be achieved 'upstream' through better watershed management.
  • Offering them a safer site and help in moving there (although care is needed to offer appropriate alternatives, since hazardous sites often serve the needs of low-income households well in all other aspects so it may be difficult to find a less hazardous site that will serve their needs).
  • Helping make their homes and neighbourhoods better able to cope with floods – for instance, structural modifications to buildings and improved storm and surface drains (but tenants often face particular problems because landlords are reluctant to invest or allow tenants to alter their homes).
  • Developing an effective early warning system to warn when floods are likely (so that people can take protective measures or move away temporarily).
  • Ensuring emergency services are ready to respond rapidly in the event of a flood; and
  • Having in place the supports the inhabitants need to cope with their losses after the flood.

There is often considerable overlap in the means to reduce people's vulnerability to disasters and to reduce their vulnerability to ‘everyday' hazards. As external agencies have learnt to work in more participatory ways with ‘vulnerable' groups, the analyses of hazards and vulnerabilities have also come to include analyses of local capacities to identify and act.

Strengthening asset bases

The key role that assets play in helping low-income individuals or households avoid deprivation is now more widely recognised. However, the discussion of the role of assets in this has generally concentrated on those that are important for generating or maintaining income or for helping low-income people cope with economic stresses or shocks. Too little attention has been paid to the role of good quality housing, infrastructure and services in reducing low-income groups' vulnerability by reducing exposure to environmental health hazards, and to the role of health care services and emergency services in reducing their health impact. In this sense, it is the quality of housing and basic services that is the asset – regardless of whether the house is owned, rented or borrowed. Discussions on housing as an asset tend to concentrate on its capital value or its potential income-earning possibilities (through providing space for income-earning activities or for renting out space) rather than on its potential role in helping its inhabitants avoid environmental hazards.