YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING · Natural hazards present many risks to young people, particularly those living in poverty in less developed countries. Disasters can

OCTOBER 2013

YOUNG PEOPLE’S HEALTH IN

TIMES OF FLOODING

A research report on the opportunities and constraints for building resilience for healthcare provision in Bogra, Bangladesh

by Hannah Jobse

edited by Lizz Harrison

Learning for impact Disaster Risk Reduction

Y CARE INTERNATIONAL 2

Contents

Foreword 3

Acknowledgements 4

About 5

List of acronyms 5

Executive summary 6

1 Introduction 8

Expected outcomes 9

2 An overview: health, disaster resilience and emergency preparedness 10

Flooding, health and poverty 10

Disaster resilience 11

A needs-centered perspective 11

3 Methodology 12

4 Bangladesh 13

4.1 Bogra District and Sariakandi Upazila 13

5 Results 15

5.1 Learning to live with uncertainty 16

5.2 Nurturing diversity 16

5.3 Creating opportunities for self-organisation 17

5.4 Combining different kinds of knowledge for learning 18

5.5 Young men and women 19

6 Conclusions, recommendations and further research 21

Conclusions and recommendations 21

Areas of further research 23

7 References 24

Annex 1 – Resilience Theory 26


Foreword

More than 1 million people have been killed and one billion affected

by disasters since 2000. Floods, cyclones, tsunamis, earthquakes

and other natural hazards have cost the world more than US$1

trillion in destruction since then. Last year alone, natural disasters

affected over 150 million people worldwide.

Natural hazards present many risks to young people, particularly

those living in poverty in less developed countries. Disasters can

affect young people’s education, livelihoods and health, and also setback gains made

through development activities. Disaster risk reduction (DRR) is one of Y Care

International’s key focus areas and all of our projects and programmes consider

disaster risks throughout the project cycle to support young people and their

communities to become more resilient to disasters, and to ensure sustainable

development.

We believe that for DRR activities to be effective and sustainable, they must include

the leadership, participation and engagement of the young people in the communities

in which we work. Young people are assets in development and therefore supporting

them to identify and address disaster risks that face them and their needs in

emergencies is essential.

In a world where disaster risks are becoming increasingly unpredictable as a result of

the changing climate, supporting young people to lead and engage in disaster

resilience building efforts in their communities is key to reducing vulnerability. This

research study is the second such one to come out of our valuable partnership with

King’s College London. We are very grateful to Hannah Jobse for her research report

based on her discussions with people living in communities in Sariakandi in

Bangladesh. We are also very proud to be working with Bangladesh YMCA who are

currently carrying out a DRR pilot project in Bogra, Chittagong and Gopalgonj in

Bangladesh and we thank them for their commitment to this and their support to

Hannah.

Finally, Y Care International aims to integrate as many of the recommendations

outlined in this report as feasible into our DRR projects and activities to ensure that

young people are leading the effort to help their communities to become less

vulnerable to disasters, and thus better places to live.

Dylan Mathews

Director, International Programmes

Y Care International


Acknowledgements

Acknowledgements from Y Care International

Y Care International would like to thank the people involved in this research and

acknowledge the young people around the world who are engaged in disaster risk

reduction (DRR) work.

Thanks to King’s College London and particularly Professor Mark Pelling for the

valuable partnership and support which made this research possible. We hope that this

link continues to enable Y Care International to learn, improve and deliver on our

mission. Through this partnership, we hope to continue to work alongside Masters

students at King’s College London to carry out more research on young people,

disasters and DRR.

Thank you to the National Council of YMCAs in Bangladesh and particularly Bogra

YMCA for their time, dedication and hard work in supporting young people and for

supporting Hannah in this research study.

Finally, Y Care International would like to say a big thank you to Hannah Jobse for her

support, enthusiasm and research work. This valuable piece of research will feed into

our project development and help us to ensure young people are leading on and

participating in DRR in Bangladesh and across the world. Thank you Hannah.

Acknowledgements from Hannah Jobse

I would like to express my sincere gratitude towards the following organisations for

hosting and supporting this research project throughout its various stages: King’s

College London, Y Care International, the National Council of YMCAs in Bangladesh,

Bogra YMCA, World Vision Bogra and World Vision Sariakandi. In particular I would

like to thank: Mark Pelling and Lizz Harrison, for guiding the collaboration; and Nipun

Sangma, Robert Robin Marandi, Apu Da and the other staff at Bogra YMCA, for

making this research project possible.

A special thank you goes to Alex, Supta, Asher, Nazrul Bai, Jakir Bai and Dalim Bai for

supporting me in the field over a four-week period not only as research assistants but

as friends, too. I would also like to thank my family and friends for supporting this

project in various ways.

My full academic research report is available on request from Y Care International.

Photography

Images © Hannah Jobse (including front page) and © Y Care International as

referenced.

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | ABOUT/ACRONYMS


About

About Y Care International

Y Care International is the YMCA’s international relief and

development agency. We work in partnership with YMCAs and

other local partners across the developing world to respond to the needs of the most

disadvantaged young people.

The needs of disadvantaged young people in developing countries are often neglected,

making the transition into adulthood difficult. We help young people develop

alternatives to a future of poverty and empower them to contribute to the development

of their communities.

www.ycareinternational.org

About Bangladesh YMCA

Established in 1965, the Bangladesh YMCA movement seeks to unite

young people to work towards building an eco-sensitive and just

society, based on equal opportunity for all. The movement, comprised

of 12 local YMCAs, is youth-led with strong youth involvement in

governance and the planning and delivery of all activities. Their main

programmes include non-formal education for disadvantaged children, vocational

training for young people, healthcare, and youth empowerment and leadership

development. The YMCAs work with all people irrespective of their religion or caste,

with a view to uplifting their socio-economic condition.

www.bangladeshymca.org

About King’s College London

King's College London is one of the world's leading research

and teaching universities based in the heart of London. It is

also one of England’s oldest, founded in 1829. King's is

dedicated to the advancement of knowledge, learning and

understanding in the service of society.

www.kcl.ac.uk

List of acronyms

DRR Disaster risk reduction

KCL King’s College London

NCYB National Council of YMCAs of Bangladesh

NGO Non-Governmental Organisation

YMCA Young Men’s Christian Association

http://www.ycareinternational.org/

http://www.kcl.ac.uk/

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | EXECUTIVE SUMMARY


Executive summary

Disasters can significantly worsen levels of poverty by negatively impacting the lives,

health and livelihoods of the most vulnerable people. People living in developing

countries are particularly vulnerable to the impacts of natural hazards such as floods,

earthquakes and cyclones. Building disaster resilience is essential for ensuring

sustainable development and the protection of development gains made so far at all

levels of society. Reducing the burden of illness is also critical for sustainable

development and is intrinsically linked to reducing the risk of disasters given that ill-

health is often experienced in times of emergency such as flooding.

Bangladesh is one of the most disaster prone countries in the world, in particular to

flooding. In the past, flooding has had enormous affects in Bangladesh including on

people’s health; diarrhoeal disease transmission, along with respiratory and skin

diseases are particular concerns during times of flooding. However, little is known

about how communities deal with healthcare in emergencies and how they respond to

health emergencies.

This research attempts to respond to this gap. The purpose of this research is to

understand the opportunities and barriers for building resilience for emergency

healthcare provision and accessing healthcare in times of emergency. The healthcare

needs of young people are central to this study. Y Care International hopes that the

findings and recommendations from the research will help to inform project design and

Community members who live on the banks of the Jamuna River © Hannah Jobse

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | EXECUTIVE SUMMARY


ensure community-based DRR projects and activities also address the healthcare

needs of young people and their communities.

Key recommendations

• For community disaster resilience:

Community level participatory Hazard, Vulnerability and Capacity Assessments

could be part of this process.

Fostering a sense of responsibility among community members to support each

other in times of crisis will also help this.

Ensuring young people are engaged in these actions is important; young people

have the energy and power to drive change in their communities. Including

young women in particular is key.

• Early warning systems should be improved at community level.

• Healthcare providers should be supported to develop, or adapt existing,

contingency plans to enable them to address the needs of local communities

particularly during emergencies. More autonomy of local government and

organisations in healthcare provision might also help.

• Increasing the understanding of the importance of the humanitarian principles for

all actors in humanitarian response (not just NGOs) will ensure those most in

need are supported in emergency response activities.

• Support the development of affordable health insurance schemes; which could

be in the form of savings and credit groups.

• Improved information sharing and knowledge management on healthcare

options.

• Continue to participate in post-2015 development agenda dialogues and

advocate for the inclusion of disaster risk reduction (DRR) goals and targets in

both the follow on from the Millennium Development Goals and the Hyogo

Framework for Action.

The report starts with an introduction to the research project (Chapter 1) and then goes

on to give an overview of health, disaster resilience and emergency preparedness

(Chapter 2). Chapter 3 then explains the methodology of the research, followed by a

justification for, and description of, the research locations; Chandanbaisha and

Kutubpur (Chapter 4). Analysis and discussion of the results and findings of the

research are outlined in Chapter 5. Finally, Chapter 6 concludes and provides ideas for

further research and recommendations for projects and programmes.

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | INTRODUCTION


1 Introduction

In light of the projected increase in the frequency and intensity of hydro-meteorological

hazards as a result of a changing climate, there is increased commitment from a range

of stakeholders that the risk of disasters must be reduced. Disasters negatively affect

lives and livelihoods and can significantly worsen poverty; people living in developing

countries are particularly vulnerable. Therefore, building disaster resilience is essential

in development programmes for development to be sustainable. Disaster resilience

focuses on more than poverty reduction and livelihood strengthening, but emphasises

that individuals, institutions and communities should work together to be better

prepared to withstand and rapidly recover from shocks such as floods, earthquakes

A lady washing in the Jamuna River © Hannah Jobse



and cyclones1. Disaster risk reduction (DRR) is therefore an essential element of

disaster resilience.

Bangladesh is one of the most disaster prone countries in the world, in particular to

flooding. In the past, flooding has had enormous affects in Bangladesh including on

people’s health. Although the majority of flood-related deaths are caused by flash

flooding, ill-health and disease are usually produced over the course of a flood event

as flood waters are combined with poor drainage and sanitation systems, open waste

dumps, and animal waste. The result is a high number of diseases transmitted via the

oral-faecal route as well as respiratory and skin diseases. However, little is known

about how communities collectively deal with healthcare in emergencies and how they

respond to health emergencies. This research attempts to respond to this gap; this

information could help to support communities to better prepare for health emergencies

and build disaster resilience.

The aim of this study is to examine a community’s ability to cope with health issues

during times of emergency; specifically flooding. the two communities chosen are in

Sariakandi, Bogra in Bangladesh. The research study also aims to examine the

limitations and opportunities for resilience building of communities by providing a

retrospective analysis of the relief efforts to manage and reduce ill-health following a

major flood in October 2012 in Sariakandi. Since early 2013, Y Care International has

been supporting Bangladesh YMCA to implement a DRR project in Bogra, Chittagong

and Gopalgonj through local YMCAs in these locations. Sarikandi is the working area

of the local YMCA of Bogra.

Expected outcomes

Reducing the burden of illness is critical for sustainable development and is intrinsically

linked to reducing the risk of disasters given that ill-health is often experienced in times

of emergency such as flooding. The purpose of this research is to understand the

opportunities and barriers for building resilience for emergency healthcare provision

and accessing healthcare in times of emergency.

Y Care International is committed to helping young people to change their lives for the

better and incorporating DRR into their development programmes wherever they are

located in hazard prone areas is just one part of this. Y Care International hopes that

the findings and recommendations from the research will help to inform project design

and ensure community-based DRR projects and activities also address the healthcare

needs of young people and their communities.

1 DFID (2011)



2 An overview: health, disaster resilience and

emergency preparedness

Flooding, health and poverty

Floods have enormous impacts on public health, causing mortality, physical injury,

short-term acute disease, long-lasting impairment, chronic disease, and mental ill

health. Increased risk of disease after flooding is reported primarily in developing

countries, where the interaction of flood water with poor sanitation and drainage

systems, open waste dumps, and animal waste may result in diarrhoea, dysentery,

cholera and typhoid; all transmitted via the oral-faecal route. Other types of illness,

including skin infections, respiratory diseases and malaria are also associated with

flooding.

Ill-health can have an enormous impact on a household’s income earning opportunities

and is therefore an important issue to address. However, it remains undervalued in

professional literature, practice and policy2. Examining how communities can

collectively cope with illness in times of emergency is essential; relief efforts are often

insufficient, delayed or completely absent3. In addition, preparedness is increasingly

seen as an appropriate approach to the projected negative health outcomes of climate

change4. However, little is known about how communities collectively respond to health

emergencies and how information can help them to better prepare for health

emergencies and build disaster resilience5.

2 Chambers (2007)

3 Plough et al. (2013)

4 Keim (2008)

5 Few (2003)

Members of a micro-finance group in Sariakandi © Y Care International

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | AN OVERVIEW: HEALTH, DISASTER RELIENCE AND EMERGENCY PREPAREDNESS


Disaster resilience

Since the adoption of the Hyogo Framework for Action 2005-2015, emphasis has been

placed on how communities can collectively absorb the impact of shock, ‘bounce back’, and

mitigate disaster risks and adapt to climate change with limited external assistance6.

The four components outlined below are essential for building resilience to disasters and are

used to analyse the opportunities and constraints that individuals, communities and

institutions face when responding to healthcare in emergencies within the study area. These

four components were adopted from Berkes’ Resilience Theory7 (see Annex 1 for a more

detailed description of this theory).

1 Learning to live with uncertainty: preparing for uncertain events to make sure that

communities are not surprised by disaster and left unprepared.

2 Nurturing diversity: individuals, institutions and communities need to have a diverse

range of options to draw upon in times of disaster.

3 Creating opportunities for self-organisation: communities need to be prepared to self-

organise so that they are not dependent upon external assistance and can act as soon

as possible after disaster strikes.

4 Combining different kinds of knowledge for learning: resilience building programmes

need to combine different kinds of knowledge for learning, emphasising the

importance of incorporating the voices of those who face the negative outcomes of

disaster. This includes incorporating the voices of young people.

A needs-centered perspective

It is essential to incorporate the experiences, priorities and needs of those whose lives

and livelihoods are to be improved into the development process. This is also

emphasised by the increasing work on resilience building; resilience is a product that

grows from people rather than something that is imposed upon them8. The

incorporation of self-identified needs of flood-affected people is particularly relevant for

the purpose of this study. In addition, Y Care International is committed to improving

the lives and livelihood opportunities of young people and recognise the value of young

people playing a part in society and participating in decision and policy-making at all

levels of society. Young people are a central element of this study.

6 Manyena (2006)

7 Berkes (2007)

8 Paton and Johnston (2006)



3 Methodology

To allow for in-depth analysis research methods consisted of semi-structured

interviews held with 15 households. At least one young person and another two of

their family members were interviewed in each household. In total 42 interviews were

conducted, of which nearly half were with people 35 years old or under and 60% were

female. In addition, 11 in-depth interviews were held with institutional representatives

from community clinics, NGOs, and government representatives.

Households were chosen as the main unit of analysis due to the presumption that the

situation of young people can only be understood by examining the full context of the

households in which they live, as decision-making on response mechanisms is

primarily determined at the household level9.

In addition, two focus group discussions were held and two transect walks executed.

One of the focus group discussions was held with one of Bogra YMCA’s youth groups.

This allowed for a good opportunity to uncover the stories and experiences of young

people10. This research investigates the opportunities and constraints of resilience

building for emergency healthcare provision and accessing healthcare in times of

emergency. Three research questions were formulated:

1 What response mechanisms were employed at household, community and

institutional levels to manage and reduce health ill-health during the October

2012 floods in Sariakandi? What barriers and opportunities were encountered?

2 What were the needs and priorities of those affected by flooding? To what extent did

the response mechanisms employed meet the needs of those affected?

3 Specifically, what was the role of young people in emergency response? What

difficulties do young people face in terms of health emergencies?

9 Cutter et al. (2008)

10 Y Care International define young people as those aged between 15 and 24, however due to

lengthy research ethics procedures for under 18 year olds, this study includes those above 18 only.

Rice paddy fields in Sariakandi, a staple crop for families here © Y Care International



4 Bangladesh

Bangladesh is one of the most disaster-prone countries in the world and at risk from a

number of hazards including earthquakes, cyclones, flooding, landslides, and droughts.

The country is particularly vulnerable to flooding as it is situated at the confluence of

three of the largest rivers in the world; the Ganges, Brahmaputra and the Meghna.

One-quarter of the country experiences annual flooding11. While such seasonal

flooding provides good conditions for agriculture and fishing – upon which many people

depend on for their livelihoods – extreme floods can have devastating effects. The

frequency of flooding in Bangladesh, as well as the projected climatic changes in the

country12 means that building resilience to disasters by strengthening communities’

capacity to cope with flooding with limited external assistance is essential.

4.1 Bogra District and Sariakandi Upazila

Bogra, one of Bangladesh’s 64 districts, is situated in the North of the country and has

a tropical climate with heavy rainfall in the Monsoon season, lasting from late June to

October. Bogra is one of the most flood-prone districts of Bangladesh; the Jamuna

River, the largest tributary of the Ganges, runs through the district. Research by the

Bangladesh Water Development Board estimates that climate change will play a major

part in river fluctuations over the next years13.

Sariakandi Upazila is one of Bogra’s 12 sub-districts with more than 270,000

inhabitants and is located next to the Jamuna River. Within Bangladesh, the Jamuna

River has an average width of nearly 12km. River erosion is one of the main problems

11

Haque and Zaman (1993) 12

Ministry of Environment and Forest ( MoEF) (2009) 13

Bangladesh Water Development Board (BWDB) (2013)

Jamuna River at Chandanbaisha, Sariakandi © Hannah Jobse

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | BANGLADESH


in Sariakandi Upazila. The total level of river erosion along the Jamuna was 2,408

hectares in 2012; based on the average population density, this contains living space

for around 24,000 people. For 2013, a total of 93 hectares is predicted to erode in

Sariakandi alone14.

Chandanbaisha and Kutubpur Union Parishads

Prior to the research period, a scoping study by the National Council of YMCAs of

Bangladesh (NCYB) had identified the high prevalence of flood-related illness in

Chandanbaisha Union Parishad and Kutubpur Union Parishad (wards). In addition, the

area had experienced a recent flood in October 2012, which caused a large number of

health issues. At the end of September 2012 a part of the Jamuna embankment broke; it is

estimated that more than 20,000 households in Sariakandi were affected by the floods.

Eight days later the water levels of the Jamuna River had risen to over 17 metres, which is

above the safety level. Water levels were estimated to flood houses up to 7 metres and

were reported to last for four weeks.

The two wards of Chandanbaisha and Kutubpur were heavily affected by the flooding in

2012; it is estimated that 100% and 80% of the population were affected respectively15.

The population is over 25,700 in Chandanbaisha and more than 10,500 in Kutubpur12.

With consultation with the host organisations: the NCYB in Dhaka and Bogra YMCA, these

two wards were selected for the study (1 and 2 respectively in Figure 1).

Figure 1: Map of Bogra showing location of Chandanbaisha and Kutubpur

Source: © Wikimapia and author’s contributions

14

Rahman and Saha (2008) 15

World Vision (2012)

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | CONCLUSIONS, RECOMMENDATIONS AND FURTHER RESEARCH


5 Results

All respondents reported acute health issues following the flooding in 2012 including

fever, diarrhoea, cholera, typhoid, respiratory issues, scabies, headaches, and

stomach pains. Many respondents, in particular the elderly, reported chronic health

issues induced or worsened by the floods. Health issues had a significant negative

impact on people’s reported mental and physical ability to cope.

Transect walks and interviews with NGO and community clinic representatives in the

area showed there were only two special emergency camps in Kutubpur, set up by the

government during the floods in 2012 despite over 34,000 people estimated to have

been affected. The government-owned community clinics in the area were all flooded

but relocated to higher ground and continued to operate during the flood. These

institutions are an important channel for the provision of medication for acute

symptoms such as oral rehydration salts, paracetamol and other, particularly because

they do not charge for services or medicine. In most of the community clinics

interviewed, the majority of the clinic staff were not medically qualified; doctors were

only scheduled to attend one day a week, but reportedly often did not attend.

Interviewees suggested that the community clinic’s response to the increased

healthcare needs as a result of the flooding was insufficient; interviewees reported long

queues and shortages of medicine; for example:

"I went to the community clinic but I didn’t get anything, it was too crowded”

One of the surveyed household members.

Young men fishing in Bangladesh © Y Care International

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | RESULTS


5.1 Learning to live with uncertainty

Individuals and institutions in Chandanbaisha and Kutubpur struggle to deal with

uncertainty. Floods here usually occur during the monsoon season from July to

September. However, the 2012 October flood occurred later than the usual flood

pattern due to the sudden fracture of the embankment in Sariakandi, and was therefore

unanticipated. The unexpected timing and extent of the flood presented a significant

challenge for some of the community clinics interviewed and impeded the relief efforts.

Interviewees and representatives from two community clinics and a health facility,

reported they usually prepared for the flood season by increasing their supply levels,

thus reducing transport and supply issues during the actual period of flooding.

However, because the fracture of the embankment was unanticipated, the clinics did

not have additional reserves prior to the October floods, leading to severe supply

shortages in the area. For example:

“We didn’t turn anyone down, we had to give our clients less medication”.

A representative from a community clinic.

In addition, individuals noted that although they usually prepare for the flood season by

putting their cookery equipment and their fuel in a higher place, the unexpected timing

of the flood meant that they had not carried out this preparedness activity.

5.2 Nurturing diversity

Coping strategies

Diversity means there are mechanisms to fall back on if primary strategies fail. The

main problem for the medication supply chain was timing, and access to the

communities. As noted above, the flood was not expected. Moreover, heavy currents

and winds created dangerous conditions, preventing access to the communities.

Despite these conditions, response among institutions varied, depending on the

contingency plans already in place. An interview with a health facility representative

revealed that hierarchal command structures in its organisation and a lack of supply led

to difficulties in obtaining necessary resources. For example:

“We asked for more boats, but they said they couldn’t supply it…and there is only one

point of reference. If that person says no, there is no other option”.

A representative of a health facility.

In comparison, a privately owned community health clinic funded by a Swiss NGO,

which provided free medication during the first four weeks of the flood period,

demonstrated that emergency relief can be efficient, provided governance structures in

place work efficiently and more supplies are available; staff were able to secure

additional supplies by contacting their head offices.

Legislation

Bangladesh has a complex legislative system that operates, administers and approves

foreign funding including emergency relief from external donors, run by the NGO Affairs

Bureau. This represents a barrier to timely response by local NGOs. The donation of



emergency relief by any foreign institution is only approved if the local government

officially declares a state of emergency according to interviews with local NGOs. The

floods in 2012 had a significant impact on the lives, livelihoods and health of

community members in Sariakandi with impacts on crops, homes, schools, and

community clinics. However, as there were no fatalities, a state of emergency was

never declared, restricting the degree to which NGOs were able to provide appropriate

emergency supplies.

5.3 Creating opportunities for self-organisation

Self-organisation is primarily about communities developing the strength to collectively

reduce risk and enhance disaster preparedness. Collaboration between community

members is essential to achieve this but was seen to be largely absent during the

October 2012 floods. Few respondents received help from neighbours; the majority

noted that villagers did not help each other during the flood. For example:

“No one helps each other during the flood; everyone is vulnerable”.


In addition to this lack of collaboration, some boat owners took advantage of the flood

situation. Many respondents reported they were unable to reach their preferred

healthcare provider because those who owned boats charged user fees. For example:

“My brother broke his leg. We couldn’t take him to the hospital for two days because

the boatman would not take us”.


However, those who charged for the use of their boats during the flood were often

fishermen coping with the negative effects of being unable to fish as a result of the

flood conditions.

As a goal of self-organisation, communities are no longer dependent upon external

assistance. This is not yet the case for Chandanbaisha and Kutubpur and

unfortunately, the study revealed that emergency relief was not always distributed

according to the humanitarian principles. A number of respondents said that some

people received more medication as a result of their relationships with the community

clinic staff.

Another issue in distributing medication comes from community clinic representatives’

stories of community members requesting medication which they did not need. Two

community clinic representatives said that this was the case and this clearly presents a

barrier to efficiency and effectiveness of healthcare provision in relief efforts.

Interviews with flood-affected households highlighted that there was a need for basic

medication to prevent illness as well as to treat it, showing there are different ideas

about the purpose of medication between healthcare providers and flood affected.

One-hundred percent of respondents believed that healthcare during floods and non-

crisis periods should be the responsibility of the local government and its

representatives. Linked to this, many respondents believed that they themselves could

not do anything to reduce the risks or impacts of disasters. These views may present a

significant barrier to self-organisation and disaster risk reduction.



5.4 Combining different kinds of knowledge for learning

Health as a priority

Considering the self-perceived needs and experience of those affected by flooding is

essential for analysing the effectiveness of emergency management strategies in

meeting the needs of individuals and households in Chandanbaisha and Kutubpur.

Remarkably, despite the food security issues, all households reported increased

spending on medication during the floods. Many respondents stated that medication is

important to ‘feel better’; they feel comforted after having taken medication even if it is

not necessarily to treat or prevent illness. One respondent linked this to their ability to

continue working. Many respondents believed medication served not only to treat

illnesses but also to prevent it. Those households who did not receive sufficient

medication from community clinics all opted for private village doctors or local medicine

shops. Free government hospitals in other towns were also favoured, however these

were associated with increased transport costs, and patients were required to cover the

costs of their medication. The lack of sufficient healthcare provisions in the flooding

period therefore placed enormous strain upon household budgets.

The results also emphasise the perceived importance of healthcare for most

respondents and the priority they place on their health despite limited resources and

income. For example:

“Health is the most important thing there is; when I am dead what’s the use in food and

property?”


Access to healthcare for acute and chronic illness

Although respondents identified a need for more non-prescription medication,

specialised medical support was also lacking for those with more serious health

conditions during the floods. One burden on households during the flood was their

difficulties in obtaining medical support for acute health issues and in obtaining

medication for chronic illnesses. Many respondents reported that their health needs

A rural community close to the river in Bangladesh © Y Care International



were not satisfactorily met as they were not able to see doctors, obtain high quality

targeted medication, and adequate transport to the larger towns where the free

government hospitals are based. This meant that, even with higher supply levels at

community clinics, the needs of the most vulnerable were not fully addressed.

The findings of the study show that access to effective and appropriate healthcare is a

structural problem in the rural areas of Sariakandi not just in times of flooding or other

emergencies. At least three community clinics have been destroyed by river erosion in

the past few years, which has eroded community capacity to cope with the effects of

flooding.

Good practice case studies

One community clinic in the study area presented a good example of how greater

attention to local needs can be a good basis for effectively addressing the healthcare

needs of communities in times of flood. In addition to the distribution of basic

medication such as oral rehydration salts and paracetamol, this community clinic also

responded to the more pressing need of some community members with more severe

and chronic health issues by arranging doctor’s appointments outside of the flood-

affected area. During the flood, buses were scheduled to take those in need to

government hospitals in the surrounding areas at no cost. This bus scheme was

already in place but was scaled up during the floods.

Another good example is that of a Kutubpur based NGO, which runs a small health

insurance scheme. Participants in this scheme pay a one-off fee of 100 Taka (less than

£1) and are then eligible to regular home visits by qualified doctors. During the floods,

this NGO hired boats and doctors checked up on their registered patients, prioritising

the most vulnerable.

Sources: Interviews with community clinic and NGO representatives (2013)

5.5 Young men and women

Challenges for young women

Interviews with young people face demonstrated that they face difficulties in accessing

healthcare during floods. Both young men and women reported being too scared to go

to the emergency camps to get basic medicine. In general, young women face bigger

challenges than young men in accessing healthcare. Cultural norms constrain the

extent to which young women in particular can access medical support (and other

emergency relief support). Many young female respondents reported that they cannot

visit emergency camps during floods or go to the doctor by themselves. This is a real

challenge for young women who do not have a family member able to accompany

them or access appropriate support on their behalf.

Long-term disadvantage of ill health within families

Data from the interviews shows a clear difference between men and women in their

self-identified priorities during times of flooding. The majority of men think that their

health is more important than their belongings and nutrition during times of flood; in

direct contrast to the responses of women who think belongings and nutrition are more



important than their health. One women’s focus group discussion revealed that women

perceive their own health in relation to their position in the household. All women in the

focus group discussions agreed that they prioritised the health of the main income

earner and their husbands over their own health. For example:

“If I die, my husband can get married again. If my husband dies the whole family is in

trouble.”

A female participant of a focus group discussion.

A distinct difference in healthcare seeking behaviour was revealed during household

interviews between men and women. Often only the male head of the household

received medical support. Such decision-making can have long-term repercussions for

the other members of the household, and certainly reduce the household’s ability to

cope with future shocks and disasters. Two of the households included in the study

reported transfers of household responsibilities from older female members of the

household as a result of neglected health issues, to younger female members. In

these cases, this burden prevented these young women from studying; impacting their

future opportunities for improving their own lives. Such gender identities are deeply

rooted in societal and cultural structures but they are important to consider in times of

emergencies as well as longer term health interventions.



6 Conclusions, recommendations and further

research

This research analyses the opportunities and constraints of resilience building for

emergency healthcare provision in communities in Sariakandi, Bangladesh. Through the

study it is clear that communities in Sariakandi face challenges in addressing their

healthcare needs during periods of flooding. It has also shown that many of these

challenges are also experienced throughout the year at times of no disruption.

The barriers and opportunities of emergency healthcare provision are summarised below

with some recommendations based on the findings of this piece of research. Some of the

recommendations are large in scope, however, there are a number of short-term actions

that can be carried out.

Conclusions and recommendations

First, the study has shown that communities in Sariakandi are not prepared for flooding or

other natural hazard events. This is particularly true for events outside historical trends;

and flooding in the area is becoming more unpredictable with the changing climate

affecting weather patterns16. This highlights a need to increase the awareness and

understanding of community members of disaster and climate change risks, and

potential impacts and actions to reduce these17. This is essential for building the

resilience of communities18. It also suggests a need for improved early warning systems in

the area so that community members are forewarned of likely flooding and can take

actions to prepare. Lastly, there is also a need to support healthcare providers to

16

Bangladesh Water Development Board (2012) 17

Y Care International are currently implementing activities with the NCYB and local YMCAs in

Bogra, Chittagong and Gopalgonj which aims to build the capacity of young people in these locations

to reduce the risk of future disasters. 18

van Aalst et al. (2008)

Young boys enjoying a swim in the Jamuna River © Hannah Jobse



develop, or adapt existing, contingency plans to enable them to address the needs of

local communities particularly during emergencies.

Secondly, nurturing diversity, a component of resilience, lies largely in the effective

collaboration of different actors at different scales, yet poor governance often forms a

significant barrier19. In Sariakandi, political institutions are crucial in resource management

structures, but hierarchical governance may pose barriers to providing an alternative if

primary strategies fail. Lobbying for more autonomy of local government and

organisations and creating structures that allow them to act independently of government

mechanisms may help.

Creating opportunities for self-organisation at the community level is important for

resilience. At community level, there are a number of opportunities for self-organisation

and collaboration between community members. Fostering a sense of responsibility

among community members to support each other in times of crisis and addressing

attitudes that there is nothing that can be done to reduce the risk of disasters will

help to build community resilience. Also, increasing the understanding of the importance of

the humanitarian principles for all actors in humanitarian response (not just NGOs) will

ensure those most in need are supported. Community level participatory Hazard,

Vulnerability and Capacity Assessments could be used as a way of identifying those

who are most vulnerable, and could also be used to begin discussions on the capacities

of the community and the value of working together.

In addition, the provision of schemes and mechanisms to support those with chronic and

severe health issues in particular in times of disruption such as flooding will increase

resilience of these households. One way to do this would be to support the development

of affordable health insurance schemes; which could be in the form of savings and

credit groups.

An important finding of this study was the divergence of ideas of healthcare providers and

community members on the use of medication. Many community members said that they

took medication to prevent illness and sometimes just because they felt better when they

had; this is most likely the result of a lack of understanding about healthcare, treatment and

medication. Better information sharing and knowledge management on healthcare

options may well be one strategy to address these differences; and respecting people’s

adaptive preferences for facing hardship is important too20.

Additionally, it is important to ensure young people are engaged in actions that build

theirs and their communities’ resilience to disasters. Additional efforts need to be

made to include the involvement of young women in particular in these actions. This is

particularly important considering the bigger challenges they face in accessing their

healthcare needs in times of flooding. Increasing the recognition of the value of young

women’s roles in the community will be important in ensuring this happens and changing

attitudes that women’s access to healthcare is as important as men’s.

Finally, continuing to support and advocate for strategic investment in disaster risk

reduction (DRR) at the national and local government level will be important in supporting

19

Folke (2006) 20

Sen (1999)



development and disaster resilience in Bangladesh and other disaster-prone countries.

The inclusion of DRR actions and goals in the international goals which will follow on from

the Millennium Development Goals and the DRR-specific Hyogo Framework for Action will

support this process. Therefore the final recommendation is to continue to be involved

in the post-2015 development agenda dialogues.

Areas of further research

The findings of this study suggest a number of directions for future research:

1 Further studies need to focus on the divergence of ideas of healthcare providers

and community members on the use of medication. A better understanding of the

ways in which community members define their own healthcare needs would be

informative.

4 What Further research on strategies for improving access to healthcare for remote

rural communities at risk of disasters such as flooding could also be conducted. A

particular focus on the unique barriers for young women is essential.

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING | REFERENCES

7 References

Bangladesh Water Development Board (BWDB) (2013) Prediction of River Bank

Erosion along the Jamuna, the Ganges and the Padma Rivers in 2013. Centre for

Environment and Geographic Information services, Bangladesh.

Berkes, F. (2007) ‘Understanding uncertainty and reducing vulnerability: lessons from

resilience thinking’. Natural Hazards, 41, pp.283-295.

Chambers, R. (2007) ‘Vulnerability, Coping and Policy’ (Editorial Introduction). IDS

Bulletin, 37(4). pp.33-40

Cutter, S.L., Barnes, L., Berry, M., Burton, C., Evans, E., Tate, E., Webb, J. (2008) ‘A

place-based model for understanding community resilience to natural disaster’. Global

Environmental Change, 18, pp.598-606.

Department for International Development (DFID) (2011) Defining Disaster Resilience:

What does it mean for DFID? [online]. Available at: https://www.gov.uk/government

Few, R. (2003) ‘Flooding, vulnerability and coping strategies: local responses to a

global threat’. Progress in Development Studies, 3, pp.43-58.

Folke, C. (2006) ‘Resilience: The emergence of a perspective for social-ecological

systems analyses’. Global Environmental Change, 16, pp.253-267.

Haque, C.E., Zaman, M.Q. (1993) ‘Human responses to riverine hazards in

Bangladesh; A proposal for sustainable floodplain development’. World Development,

21(1), pp.93-107.

Keim, M.E. (2008) ‘Building Human Resilience The Role of Public Health Preparedness

and Response As an Adaptation to Climate Change’. Am J Prev Med, 35(5), pp.508–

516.

Manyena, S.B (2006) ‘The concept of resilience revisited’. Disasters, 30(4), pp.433-

450.

Ministry of Environment and Forest (MOEF) (2009) Bangladesh Climate Change

Strategy and Action Plan. Dhaka, Bangladesh: Government of the People’s Republic of

Bangladesh.

Paton, D., Johnston, D. (2006) Disaster Resilience: An integrated approach. Illinois,

USA: Charles C Thomas Publisher Ltd.

Plough, A., Fielding, J.E., Chandra, A., Williams, M., Eisenman, D., Wells, K.B., Law,

G.Y., Fogleman, S., Magaña, A. (2013) ‘Building Community Disaster Resilience:

Perspectives From a Large Urban County Department of Public Health’. American

Journal of Public Health, 103 (7), pp.1190-1197

Rahman, R., Saha, S.K (2008) ‘Remote sensing, spatial multi criteria evaluation

(SMCE) and analytical hierarchy process (AHP) in optimal cropping pattern planning

for a flood prone area’. Journal of Spatial Science, 53 (2), pp.161-177.

Sen, A. K. (1999) Development as freedom. Oxford UK: Oxford University Press.



van Aalst, M.K., Cannon, T., Burton, I. (2008) ‘Community level adaptation to climate

change: the potential role of participatory community risk assessment’. Global

Environmental Change, 18, pp.165–179.

World Vision (WV) (2012) Sariakandi Flood Response Concept Note (unpublished).

Bogra, Bangladesh: World Vision.

Other reports available in this series:

Youth Volunteerism and Disaster Risk Reduction: A

research report on the motivations for young people

volunteering in urban slums of Freetown, Sierra Leone.

Written by Ayden Cumming and edited by Y Care International in 2012.

The Role of Social Capital in Disaster Resilience: A

research report on the influence of social capital on

disaster resilience in the Ayerwaddy Delta, Myanmar.

Written by Y Care International based on Kenneth Green’s research in

2014.

Available online from: www.ycareinternational.org/publications

http://www.ycareinternational.org/publications



Annex 1 – Resilience Theory

Table 1: Berkes’ four components of resilience

1. Learning to live with uncertainty ‘‘Learning to live with uncertainty requires

building a memory of past events, abandoning the notion of stability, expecting the

unexpected, and increasing the capability to learn from crisis. ‘‘Expecting the

unexpected’’ is an oxymoron, but it means having the tools and the codes of conduct to

fall back on when an unexpected event happens.’’ (Berkes, 2007; pp.288-289)

2. Nurturing diversity ‘‘The main idea behind diversity is that it provides the seeds for

new opportunities in the renewal cycle. It increases the options for coping with shocks

and stresses, making the system less vulnerable. Diversification is the universal

strategy aimed at reducing risks (by spreading them out, as in an investment portfolio),

and increasing options in the face of hazards.’’ (Berkes, 2007; pp.289)

3. Creating opportunities for self-organisation ‘‘The resilience of a system is closely

related to its capacity for self-organization because nature’s cycles involve renewal and

reorganization. From the point of view of reducing vulnerability to hazards, several

aspects of self-organization merit discussion: (a) strengthening community-based

management, (b) building cross-scale management capabilities, (c) strengthening

institutional memory, and (d) nurturing learning organizations and adaptive co-

management.’’ (Berkes, 2007; pp.290)

4. Combining different kinds of knowledge for learning ‘‘Bringing different kinds of

knowledge together and focusing on the complementarity of these knowledge systems

helps increase the capacity to learn…The creation of platforms for cross-scale

dialogue, allowing each partner to bring their expertize to the table, is a particularly

effective strategy for bridging scales to stimulate learning and innovation.’’ (Berkes,

2007; pp. 290)

Source: Berkes, F. (2007) ‘Understanding uncertainty and reducing vulnerability: lessons from

resilience thinking’. Natural Hazards, 41, pp283-295.


Y Care International is a registered charity and a company limited by guarantee, registered in England and Wales. Charity no: 1109789. Company no: 3997006. Registered office: Kemp House, 152-160 City Road, London EC1V 2NP

Y Care International supports youth-focused programmes of action and

advocacy that meet the needs of disadvantaged and vulnerable young people

across the world. One of Y Care International’s areas of focus is disaster risk

reduction (DRR). It is essential to increase our understanding of how disasters

impact on young people and what their capacities are to deal with them and

reduce theirs and their community’s resilience to them. The importance of

disaster resilience is key to sustainable development and Y Care International

believes young people must lead on, and participate in, disaster risk reduction

activities.

This report summarises the findings from Hannah Jobse’s research in rural

communities in Bogra, Bangladesh in 2013. The report attempts to understand

and analyse the opportunities and constraints that young people and their

communities face in accessing healthcare in times of flooding. The

recommendations will be considered in project design to increase the impact of

Y Care International’s projects.

© Y Care International 2013

Y Care International

Kemp House

152-160 City Road

London EC1V 2NP

United Kingdom

Tel +44 (0)20 7549 3150

Fax +44 (0)20 7549 3151

[email protected]

www.ycareinternational.org

Documents

YOUNG PEOPLE’S HEALTH IN TIMES OF FLOODING · Natural hazards present many risks to young people, particularly those living in poverty in less developed countries. Disasters can