Focus: health and healthcare

In cooperation withWorldRiskReport
2013
Together for people in need.

2 [ WorldRiskReport 2013

1. Assessing risk, reducing vulnerability .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

5Peter Mucke

2. Focus: Health and healthcare .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

11

2.1	Health and healthcare as risk factors .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

12

		Michael Marx

2.2	Combating disasters with clean water. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		

2.3	Why some people are particularly vulnerable .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		

27

Joost Butenop, Sonja Weinreich

2.4	The creeping disaster — global health in crisis .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		

20

Thomas Kistemann, Katrin Radtke

34

Kirsten Schubert, Thomas Gebauer

3. WorldRiskIndex 2013 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

45

Torsten Welle, Jörn Birkmann, Jakob Rhyner, Maximilian Witting, Jan Wolfertz

3.1	The concept .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

46

3.2	The terms. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

46

3.3 Updating and modification of the indicators .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

47

3.4 The WorldRiskIndex 2013 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

48

4. What’s missing: political determination and consistent implementation .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

57

Peter Mucke, Peter Schmitz

Annex . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

63

WorldRiskReport 2013 ] 3

4 [ WorldRiskReport 2013

1. Assessing risk,
reducing vulnerabilityPeter Mucke

Whether it be drought, cyclone, earthquake or floods, when an
extreme natural event hits a village or a town, the extent of harm topeople crucially depends on what the population’s health status has
been prior to the event — and on how well healthcare also works incrisis and disaster situations. In a nutshell, “health and healthcare”
are decisive factors in risk assessment. The WorldRiskReport 2013
focuses on this theme.

WorldRiskReport 2013 ] 5

I

t’s about more than the issue of how hard theforce of nature has hit the people. A country’s
risk of becoming the victim of a disaster is notdetermined solely by its exposure to natural
hazards, but to a crucial extent also by thesociety’s state of development. For a country
that has sufficient financial means at its disposal as well as functioning government andcivil society structures, that counters recurrent
natural disasters with an adaptive strategy andthat is willing to invest in adapting to changes
in framework conditions such as weather andclimate extremes will also be hit less hard by
extreme natural events. It is, as specialists say,less vulnerable. Adopting this fundamental
understanding of risk, the WorldRiskIndex
calculates the risk of disaster for 173 countries
worldwide by multiplying exposure to natural
hazards by precisely such vulnerability.
The Index is composed of indicators in thefour components of exposure to natural
hazards such as earthquakes, cyclones, floods,
droughts and sea level rise, ­susceptibility­depending on infrastructure, nutrition,

The term developing countries:
Finding the right word for the “poor countries” in Africa, Asiaand Latin America is not unproblematic. For one thing, different
terms are used by the various global organizations (the UN,
UN organizations, the World Bank) in this context. Second, any
expression one might use will be questionable. “Third World” isa term that the countries thus referred to will hardly appreciate.
“Developing countries” suggests that the countries in North
America or Europe are developed and the countries in the othercontinents are underdeveloped. Of course we do not subscribe
to such a simple view, but we have nevertheless opted forusing the term developing countries (not in inverted commas)in this report. In accordance with UN practice, it refers to all
countries in Africa, Asia (with the exception of Japan, South
Korea and Taiwan) and Latin America, including the emerging
countries.

6 [ WorldRiskReport 2013

housing conditions and economic framework
conditions, coping capacities determined bygovernance, preparedness and early warning,
healthcare, and social and material security,
and adaptive capacities relating to futurenatural events and climate change.
With its focal topic of “Health and Healthcare”, this year’s WorldRiskReport looks atimportant elements in the measurement ofvulnerability. For a society with high healthstandards and healthcare that is affordable for
all will be less vulnerable when it is hit by anextreme natural event. Just like every otherindex, the WorldRiskIndex can only consider
indicators for which comprehensible, quantifiable data are available on a global scale.
For example, this could be the proportion of
population undernourished, the number ofphysicians and the number of hospital beds
per 10,000 inhabitants. However, health isa multidimensional construct that impacts
on society in manifold ways, as described in
Chapter 2.1. And there is more to healthcare
than just the number of physicians and hospital beds. For example, while the importance oftraditional or neighborly support and remedial structures cannot be quantified as a rule,
it can hardly be overestimated. For primary
healthcare, which can save lives in many cases,
certainly does not always require a university
degree in medicine.
The WorldRiskReport 2013 deals with very
different aspects of the focal topic. The complicated links between health and healthcare on
the one hand and vulnerabilityon the other are looked at more closely inqualitative terms. For example, it becomesapparent that it is particularly the infectious
diseases, which, basically, are easy to prevent,that have a disastrous impact on a society’s
health, as Chapter 2.2 explains.
Whereas a child in Germany need not fear
diarrhea as a deadly threat, 13 percent of fatalities among children under five years of age inIndia are due to severe diarrhea. And even if
it does not result in death, the disease as suchis a serious impediment to the development ofboth the child and society as a whole. Worldwide, almost 650,000 children under the ageof five years died of diarrhea in 2011 — morethan of malaria and HIV/AIDS together. The
Map of the World on pages 40/41 illustrates
a crucial driver of the incidence of infectious
diseases: the proportion of a country’s people
who have no access to closed systems of feces
disposal. And these are an incredible 1.035
billion people worldwide, with three quartersof them concentrated in just five countries.
Chapter 2.3 takes a closer look at groups thatare especially vulnerable in crisis and disastersituations. For example, women living as refugees in the impoverished Northeast of India
who have become pregnant are particularly
vulnerable, as the fate of the young motherAnjali and her daughter Aisha shows.
Just like all other areas of life, health has
long ceased to be exempted from the generaltrend of economization. Chapter 2.4 showsthat large areas of healthcare have turned
into goods and services that are traded on
the market and are subject to profit-seeking. In developing countries in particular,
gaps in provision owing to a lack of financefor healthcare can be severe (World Map on
pages 42/43). One yardstick for the level ofhealthcare is the proportion of out-of-pocket
payments (OOPS), i.e. what people have to
pay for themselves beyond free-of-charge
government services or secure provision ofhealthcare via health insurance. Here, thepoorest of the poor fall by the wayside: thosepeople who have to live on less than the bareminimum of USD 1.25 a day. How are they
supposed to pay for the treatment and drugs
they need in Myanmar, for example, where
there is an 80.7-percent OOPS proportion?
In countries with a high OOPS proportion
and a low level of public healthcare, healthy
life expectancy is significantly reduced.
Whereas people in Germany (OOPS proportion: 12.4 percent) live 69 years on average
without any lasting disease or disablement,

Vulnerability — Societal sphere

Natural hazard sphere
Exposure

Susceptibility

CopingAdaptation

Exposure to natural
hazards

Likelihood of suffering
harm

Capacities to reduce
negative consequences

Capacities for long-term
strategies for societal
changeExposure

Vulnerability

WorldRiskIndex
Figure 1: The WorldRiskIndex and its components

WorldRiskReport 2013 ] 7

the level in Afghanistan (OOPS proportion:
84.4 percent) is just 47 years.
It is also against the background of such global injustice that the WorldRiskIndex
seeks answers to the following questions:++ How probable is an extreme natural event,and how likely is it to affect people?

++ How vulnerable do the natural hazards

make the people?
++ To what extent can societies cope withacute disasters?
++ Is a society taking preventive measures toaddress natural hazards to be expected in
the future?
In the WorldRiskIndex 2013, the exposure
values taken as a base are the same ones aslast year’s, since no updates were available.
This is why all changes in the disaster risk
relate to changes in vulnerability — and ultimately, it is vulnerability that human action
can address, that can be changed throughpolitical measures and at which the work of
the seven Alliance members Brot für die Welt,
CBM Christoffel-Blindenmission, Kindernothilfe, medico international, Misereor, terre
des hommes and Welthungerhilfe always
aims, too.

www.WorldRiskReport.org
The print version of the WorldRiskReport has avolume enabling it to be read quickly. The texts of
the Report are supplemented by maps, diagrams
and pictures to illustrate their content. More indepth information, scientific details of the methodology applied and tables are available atwww.WorldRiskReport.org. There, the 2011, 2012
and 2013 Reports can be downloaded, too.

8 [ WorldRiskReport 2013

Important developments in individual countries in the most recent past have also had
visible impacts on the WorldRiskIndex 2013.
For example, the civil wars in Syria and Libya,
the Japanese people’s loss of trust in theirgovernment owing to the mismanagement of
the Fukushima disaster or, also, the accelerated decline of Zimbabwe under the yoke of the
Mugabe dictatorship have resulted in significantly poorer risk values for these countries.
The concept of Alliance Development Works
is to view emergency aid and development
cooperation as an entity and link up the twomore closely in practice. Risk assessment, prevention, and coping and adaptive strategies
are components of this concept.
The claim formulated by the Alliance in theWorldRiskReport 2011 continues to apply:“Whether it be an earthquake or a tsunami, a
cyclone or floods, the risk of a natural event
turning into a disaster always depends only
partly on the force of the natural event itself.
The living conditions of the people in theregions affected and the options available torespond quickly and to provide assistance arejust as significant. Those who are prepared,
who know what to do in the event of an extreme natural event, have a greater chance ofsurvival. Countries that see natural hazards
coming, that are preparing for the consequences of climate change and are providing
the financial means required will be better
prepared for the future.
Alliance Development Works publishes theWorldRiskReport to look at these links at
global level and draw forward-looking conclusions regarding assistance measures, policies
and reporting.”

Results at a glance

The global hotspots of disaster risk are in Oceania,
Southeast Asia, the southern Sahel and Central
America, as the WorldRiskIndex 2013 shows (seetable on the right). There, a high level of exposure
to natural hazards coincides with very vulnerable
societies. A very high level of exposure is asignificant risk driver, but a society’s high level ofdevelopment can substantially counteract this, as
the example of Greece shows. As far as exposure
is concerned, the country is ranked 24th among
the countries most at risk. But thanks to social,economic, ecological and institutional factors,
Greece has reduced its disaster risk enormously,
and in risk ranking worldwide, it comes up 71st.
While the impacts of the recent drastic cuts arealso going to have a negative effect on the healthsector over the coming years, Greece has so far
been able to maintain a relatively good positionin the WorldRiskIndex. The counterexample isEritrea. With a very low exposure position of 147,
the extreme level of vulnerability, at rank 3, hasresulted in the country being positioned 93rd in
the WorldRiskIndex, putting it in the same risk
class as Greece. In terms of vulnerability, Eritrea’s
situation is typical of that of many African countries.
Among the 15 countries with the highest level ofvulnerability, alongside Haiti and Afghanistan, there
are 13 African countries. Among the 15 countries
most at risk worldwide, there are eight island
nations. ­Owing to their proximity to the sea, they
are exposed to cyclones, floods and sea level rise toa particular extent.

WorldRiskIndex
Rank
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Country
Vanuatu
Tonga
Philippines
GuatemalaBangladesh
Solomons
Costa Rica
Cambodia
El Salvador
Timor-Leste
Papua-New Guinea
Brunei Darussalam
Mauritius
Nicaragua
Japan

Risk (%)

146.

Germany

3.24

159.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.

Singapore
Israel
NorwayEgypt
FinlandSwedenUnited Arab Emirates
Bahrain
Kiribati
Iceland
GrenadaSaudi Arabia
Barbados
Malta
Qatar

2.49
2.49
2.35
2.34
2.28
2.26
2.10
1.81
1.78
1.55
1.44
1.32
1.16
0.61
0.10

36.43
28.23
27.52
20.88
19.81
18.11
16.94
16.90
16.85
16.37
15.90
15.80
15.18
14.89
14.10

WorldRiskReport 2013 ] 9

10 [ WorldRiskReport 2013

2. Focus:
Health and healthcare

A society’s vulnerability towards natural hazards depends
considerably on its health and healthcare. But in times of the global
financial crisis, the health systems worldwide are being subjectedeven more strongly to economic principles. The poorest of the poor
are suffering most from the austerity and privatization measures.
Their already unacceptable vulnerability threatens to continue torise. And yet they are the ones who are, as a rule, most hard-hit byextreme natural events.

WorldRiskReport 2013 ] 11

2.1 Health and healthcare as risk factors
Michael Marx

Health is an essential aspect of risk assessment in the context of disasters. A society’s
poor state of health and insufficient healthcare
are crucial drivers of vulnerability and, hence,of risk factors. However, the causal link works
both ways. Not only do health and healthcare
determine the disaster risk, but disasters havea negative impact on a society’s state of healthand its healthcare system. Research on the impacts of disasters shows that mortality represents only a small part of the impact spectrum(UNDP 2004). For example, after earthquakes
or floods, injuries have the greatest impact.
Just like infectious diseases, chronic diseases,

suddenOnset delay

slow

low

Scope

high

high

Lethality

low

low

Predictability

high

s

d
te
la

s
ke

e

in

m
fa

12 [ WorldRiskReport 2013For example, earthquakes feature a high lethality, a short delay in outbreak (limited timefor early warning), a low level of predictability
and geographically localized impacts. In contrast, famine disasters that develop only slowly are at the opposite end of this scale (Guha-Sapir 1986, Guha-Sapir and Lechat 1986b).
The course of development that a disaster may
assume is a crucial factor in assessing suitable
preventive as well as curative measures in thehealth sector.
“The double burden of diseases“

e
t-r
gh
ou
Dr

ds
oo

Fl

e
on

cl
Cy

ua
hq

rt

Ea

Figure 2: “Disaster Characteristics Assessment Scale“(Guha-Sapir 1986; Guha-Sapir and Lechat 1986b)

mental health or disablement, they belong towhat are known as the morbidity indicators.
Morbidity refers to the frequency of a disease
related to a certain section of the population.
The ratio between morbidity and mortality inconnection with disasters is rated as 3.5 to 1
(CRED 2006). This means that for each deadperson, there are 3.5 sick or injured people.
With the Disaster Characteristics Assessment
Scale, crucial characteristics can be assigned
to different disasters: predictability, lethality,
extent and delay in outbreak.

Independently of the type of natural hazards,
developing countries are generally more
vulnerable than industrialized countries
owing to the usually poorer initial situationof the population. The acute, usually infectious diseases have long ceased to be the only
illnesses that people in developing countries
suffer from. For a number of years, “civilization diseases”, i.e. chronic, non-communicablediseases (NCD), have also been spreadingin the countries of the South. They include
cardiovascular conditions, diabetes, chroniclung diseases, cancer and depression (Mikschand Ledig 2012). These diseases occur more
frequently in older age, and since life expectancy is steadily growing in all countries theworld over, their proportion is continuouslyincreasing. According to the WHO, 63 percent
of fatalities worldwide were caused by thesechronic diseases in 2008, 80 percent of whichwere in emerging and developing countries.
NCD pose a considerable challenge forthe healthcare systems of the developing
countries, which have so far above all beenoriented on the treatment of acute episodesof disease. This widening range of diseases isturning into a double burden of diseases forthe already weak healthcare systems of thesecountries, which are struggling with what are
sometimes massive financing problems (alsosee Chapter 2.4).
In order to develop action strategies to reduce
the health hazard in these countries, we first of
all have to answer two basic questions:++ How do we define “health”?
++ What is a “health system”?
According to the WHO, health is a “state ofcomplete physical, mental and social wellbeing and not merely the absence of diseaseor infirmity”. This definition underscores
the important aspect that health has
not only a ­biomedical but also a psychosocial dimension. Already in the mid 19th
century, Rudolph Virchow recognized theinteracting effects of poverty, disease andunderdevelopment. Factors determining
health and causing disease occur above all in
the living and working conditions (including
income, education, social integration) andenvironmental conditions (including waterand energy supply and the availability oftransport). Food plays a very important role aswell. The influence of social status on health isundisputed. As a rule, poorer people are more
ill and have less access to medical facilities. To
varying degrees, this applies to industrialized
and developing countries alike.

In other words, health is a complex goodthat is influenced by manifold variables. One
important variable is the functionality of thehealth system (Phalkey et al. 2010). In its
2000 World Health Report, the WHO defines
a health system as the totality of organizations, actors and initiatives whose aim it is
to maintain and promote health and appropriately treat diseases and disabilities that
occur. This definition covers activities outside
the health services such as health promotion
and traditional healers and midwives as wellas traffic safety measures (WHO 2000). To
address these various components, the WHO
developed a framework concept in 2007 that
illustrates the basic roles of a health systemwith the aid of six building blocks (WHO2007). These building blocks are:++ Leadership and governance++ Healthcare++ Human resources++ Financing++ Drugs and medical technology++ Information systems.
These components mutually influence one
another, and their manifold interplay is anindispensible precondition for a functioning
health system.
Critics have pointed to an insufficient representation of the interaction between thesebuilding blocks and with other sectors outside
health. A more recent WHO analysis (Savigny
and Adam 2009) acknowledges the danger
that individually supported components cansegment and thus block a holistic development of the system.
More than mere provision
According to this more recent definition, a
health system reaches far beyond a super­

WorldRiskReport 2013 ] 13

ficially perceived system providing healthservices. Rather, it is a complex social system in which the various actors — the target­population including the patients, service
providers, government officials, fundingorganizations, representatives of other sectors — are in permanent interaction and thus
in a state of constant internal development(World Bank 2007). Thus it represents not a­mechanical but a complex, adaptive, i.e. open
system.
This system as a whole is, in turn, embedded
in a complex field of influence comprising
genetic and social factors, the environmentand other sectors such as labor, education andagriculture/nutrition.
So how can measures to reduce healthhazards in the countries of the South bedesigned — both independently of disastersituations and during or after a disaster?
Basically, there are two aspects to bear inmind here: at the level of the individual andat the level of the system. Health promotion
and prevention address the former. Healthpromotion refers to a preventive strategy
aimed at recognizing and strengthening
health potentials and factors protecting healthand enabling people to treat their own healthin an independent and responsible manner(WHO 1986).
The Ottawa Charta adopted in 1986 (Siebertand Hartmann 2010) encourages a reorientation from a view focusing on disease to healthpromotion and the issue of how health develops. It refers to three central action strategies:++ actively campaigning for health by influ-

encing political, economic, social, culturaland environmental and behavioral factors++ promoting skills and enabling people totake self-determined action++ active and lasting cooperation between all
actors.

14 [ WorldRiskReport 2013

The Ottawa Charter and its political approach
have since proven their worth in practice,as is borne out by numerous laws relating
to health issues, such as environmental andindustrial safety laws, road traffic acts or food­regulations.
Prevention is aimed at avoiding or slowing
down the development of risk factors and thegenesis of diseases. One distinguishes measures focusing on people (behavioral prevention) and measures addressing the conditions
in which people are living and working (conditional prevention). Behavior-related measures
are to enable individuals to improve theirpersonal health prospects through self-determined action (e.g. refraining from smoking,promoting physical exercise and good nutrition), whereas condition-related ­measures aim
at social, ecological and ­economic framework
conditions (e.g. workplace safety, emissions
reduction).
Prevention is worthwhile
Health promotion and prevention are an effective first step towards challenging the spreadof chronic diseases that create the disastrous“double burden of diseases” for developing
countries. And they are an important step instrengthening capacity to cope with disasters
or prepare for them in the sense of adapting.
Also, the long-term positive economic effectsof health promotion are undisputed. Greater
fitness of those concerned results in their being able to take more strain and develop greater productivity in professional and private life
as well as a lower level of absence from work
owing to sickness (Aldana 2001). This figuresout both from a business management and anational economy angle.
Since the first UN Summit on the topic of NCD
in September 2011, in which 132 countries
participated, the NCD have been high on theinternational political agenda. An intensive international and partly controversial discussion

on strategies and implementation has been
started. What are the roles that the family, thecommunity and the government have to assume? Should the government urge people tochange their behavior? Should it allow “risky
behavior”, or should such behavior even bepunishable?
There is agreement on the issue that both
treatment and prevention and health promotion have to cover the social causes of diseases and can only be effective and lastingly
successful if they are based on transsectoral
approaches.
This is the interface with the second aspectthat needs addressing in the context of measures to reduce the health risk in the countriesof the South: the health system. Here, a distinction has to be made between supportingand strengthening the system. Support comprises measures aimed at one or more acuteproblems of the system and usually leading
to short-term success — e.g. construction
measures, the distribution of mosquito nets
or salary increases for a certain period. It also
includes measures relating to certain selective
disease programs. Success depends on theextent and duration of investment, although it
can generally also be achieved within a shortperiod.
Strengthening the system as a long-termtask
In contrast, measures seeking to strengthen
the health system cause more comprehensive and lasting changes in the system as awhole — e.g. in the organizational structure,efficient management or personnel skills
development. Usually, success can only bereached in the long term. Nowadays, thestrengthening of health systems is attributed
a key role in achieving the health targets (e.g.
of the Millennium Development Goals) and in
preparing for possible disasters.

Various principles and demands regarding
improvements in the functioning of the healthsystem are regarded as indispensible to reaching such goals:++ Improving accessibility for the population

as a whole: geographical, cultural, social,financial accessibility++ Reaching out to the respective target
groups for preventive and health promotion measures++ Equity in service provision: Equal accessto services addressing the same needs for
all citizens++ High quality of service provision: considering proof-oriented methods, quality
management and the efficient employmentof resources..
These principles and demands have to be applied to all building blocks of the system:
kkLeadership and governance (also referred
to by the WHO as stewardship) first of all refers to the responsible role that governments
assume in the health sector and how they relate to the actors in the sector. This comprises
steering the entire health system –public andprivate — in the interest of the public.
kkProvision of healthcare: Healthcare
services should be easily accessible andaffordable for all and provide high-quality,
effective services addressing respective needs.
This applies both to individual measures andthose related to the population as a whole,and in the area of prevention as well as in thatof curative and rehabilitative medicine. As arule, the health services are organized at threelevels of the health system: health centers at
the primary level, district hospitals as referral
facilities at the secondary level and major hospitals and specialized facilities at the national,
tertiary level. Here, the services of both thegovernment and the private and not-for-profit
operators are included. Alternative models
of provision offering the population easierWorldRiskReport 2013 ] 15

access can be tested and integrated — for example community based health workers andtraditional midwives as well as information
campaigns (social marketing).
kkHuman resources: Health workers
form the central contact point between the
population and the health system. A sufficientnumber of qualified health personnel are
crucial to the quality of the health services.
At an average 42 percent, personnel costs
account for the largest proportion of theconsequences of the health personnel crisis
are manifold and mutually conditioned:
training of an insufficient number ofhealth workers, inadequate pay levels
and few other performance incentives,difficult living and working conditions andenticement and exodus of health workers
to other, better-paid sectors or abroad,especially to Europe, North America andAustralia. For example, 37 percent of
the physicians trained in South Africa
are working in OECD countries (Mundt,

Zimbabwe
UgandaSouth Africa
Ghana
Cameroon

Desire to work in a betterorganized health system

Desire to continue training,
upgradingDesire for more support inprofessional environment

Desire for appropriate or
higher pay

0%

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

Fig. 3: Reasons for exodus of medical personnel from five African countries (Stilwell et al. 2004)

worldwide health budget. On a world scale,there is a lack of more than four million
health specialists, 1.5 billion in Africa alone.
Within individual countries, too, there isoften an extremely unequal distributionof medical personnel — 60 percent of all
nurses and 75 percent of all physicians workin towns (WHO 2006). The causes and16 [ WorldRiskReport 20132011). The exodus of health personnel
frequently results in the closure of healthfacilities, above all in rural areas. Often,
inadequately trained personnel have tobe taken on. Corruption also plays a role,for example when unofficial payments aredemanded for services in order to top up
salaries.

100 %kkFinancing: Only a small number of Africancountries have attained the target set by theAfrican Union in the 2001 Abuja Declarationof spending 15 percent of the government
budget on health. The WHO estimates that at
most, eight of the 49 income poor countries
are going to raise sufficient revenue to achieve
the targets stipulated in the Millennium
Development Goals (MDG) by 2015. Thus theneed for support continues to be high (WHO2010). The WHO devoted the World HealthReport 2010 to the financing of health systems(WHO 2010). In the context of global healthfinancing, efforts are being made to mobilize
additional funding to achieve the MDG with
innovative financing methods, such as theInternational Financing Facility (IFF) or theuse of debt swaps. The IFF is a fund that was
launched in 2006 to raise additional financeon the capital market for immunization(GAVI). So far, a total of 6.3 billion US dollars
has been reached. This fund is supported byAustralia, South Africa, Brazil and seven European countries, but not by Germany. The
World Bank acts as a fund administrator. In adept swap, a debtor country is relieved of adebt by a creditor country provided that thesum involved is spent in the debtor country
e.g. on combating poverty, on schools or on
the health system. A functioning system ofmutual health financing is aimed at ensuringthat people have access to health services they
happen to need while being safeguarded
against ruinous expenses and resulting
impoverishment. Thus there is a close link
between health financing aspects and social
security. A nationwide achievement of thisgoal is also referred to as universal coverage.
Revenue is raised via prepayment systems(public tax revenue, health insurance contributions, external financing contributions) ordirect payment such as service fees (out of
pocket payments). Most countries have a
mixture of prepayment and fee systems.
Appropriate regulations have to be applied for
sections of the population that are particularly
disadvantaged, such as the poor, disabled

people or orphans, in order to enable theiraccess to health services — e.g. community
certificates or vouchers. Pooling of revenue
allows for a balancing of risks between theusers as long as fees are calculated on a
uniform basis rather than relating to risk.
Thus contributors with a low disease risk
subsidize people with a high disease risk, andemergencies resulting in ruinous expenses inthe event of illness are avoided. However, both
tax-financed and health insurance prepayment systems require a sophisticated institutional framework that most of the developing
countries cannot provide at the moment.
kkDrugs and medical technology:
Access to affordable vital drugs, vaccines andtechnologies whose quality and effectivenessis assured represents a vital building block of
the health system and is also stipulated in theMillennium Development Goals. Althoughnearly all countries in the poorest regions ofAsia and Africa have introduced the Essential
Medicines List as the basis of logistics andprocurement, up to 50 percent of the population still have only restricted access to these
medicines. The AIDS pandemic, an aging population and the increase in chronic diseases
are a further burden. Each year, millions ofpeople die as a result of diseases that could betreated or prevented with the aid of safe andaffordable essential medicines and vaccines.
Twenty to 60 percent of expenditure in thehealth sector is spent on medicine and medical products alone and exerts a heavy burden
on the government budgets. At the sametime, ten to 25 percent of public procurement
expenditure worldwide is lost through corruption (WHO 2009).
kkInformation systems: Every health systemneeds an information system that provides reliable data on a) the factors influencing healthb) the efficiency of the health system andc) the population’s state of health. Possible
threats to the public through acute epidemics
or other health hazards require special atten-

WorldRiskReport 2013 ] 17

tion. Without this information, it is impossible to analyze a situation, set priorities, planmeasures. that match needs and are efficient,monitor their implementation and evaluate
impacts.
Today, modern information systems bear two
essential characteristics. They are no longer
paper-based but computer-aided, and they are
no longer limited to national or sub-national
dimensions but are conceived at a global or regional level in a transnational sense (Reichertz
2006). Here, data quality as well as data security are of paramount importance.
In a nutshell, multi-sectoral or trans-sectoral cooperation in strengthening the healthsystem can generally develop in all areas ofsociety but above all affects the areas of laborand social affairs, education, environment andagriculture/food. Experience has shown that
it is in these sectors that the chief causes ofrestricted health can be found.
Health as a human right
Precisely because weak health systems often
even exacerbate the fatal impacts of disasters, it is crucial for health to be addressedin the United Nations Human Rights Charter of 1948. Article 25 states: “Everyone has
the right to a standard of living adequate forthe health and well-being of himself and his
family, including food, clothing, housing andmedical care and necessary social services”.
The UN Social Pact of 1976, which obliges thegovernment to create the conditions “which
would assure to all medical services andmedical attention in the event of sickness”(Article 12), puts these aspects into more
concrete terms. Thus the right to health opens
up a claim to access to the existing infrastructure of public healthcare. Healthcare services
must above all be accessible and affordable
for those concerned. Currently, this demand isbeing emphasized considerably by the propagation of universal coverage.

18 [ WorldRiskReport 2013

Traditional health “impact” analyses often
overlook the fact that a community’s resilience is a function of the socio-demographic,socioeconomic, sociopolitical, socio-culturaland socio-structural variables (Phalkey et al.
2010). In spite of the close mutual relations
between social, health and economic effects,
the focus continues to be largely on isolated
impact assessments.
What counts today is to overcome the theoretical limits and simplifying dichotomiesof health and healthcare in order to understand the risks of disasters and their impacts
on human life and the social and economic
sectors. We are convinced that only a holistic
understanding of health and disease within
the functional domain of a health system canenable an effective limitation and preventionof harm, both in normal circumstances and inconnection with disasters.

The 1892 cholera outbreak in Hamburg

Eels from the tap“Gentlemen, I can hardly believe that I am in Europe.” Robert Koch is shocked as he inspects the “Gängeviertel” in the
Port of Hamburg in the summer of 1892. The Hanseatic City
has requested the assistance of the Director of the Instituteof Hygiene in Berlin following an outbreak of cholera in
the poor district with its narrow alleys, damp basement
flats and shared toilets that are not linked to the sewage
system.
In 1892, the month of August is unusually hot, and the water levels of the Elbe and Fleete rivers are correspondingly
low — ideal conditions for germs to multiply. And there isan abundance of them. For when the tide comes in, thedirty water of the docks builds up towards the water intake
point two miles up the Elbe. There, the water for the “Gängeviertel” is taken from the river without being cleaned. At
the other end of the leaky pipes, it is not only murky waterthat comes out of the taps. Worms and elvers are by nomeans a rare occurrence.
While there has long been awareness of a risk to health,the Hamburg Senate and the City Parliament have been
unable to agree on the construction of a filtering plant inneighboring Altona for decades. They prefer to invest in
prestigious projects in order to enhance the city’s image asa “gateway to the world”. The 5,000 emigrants from Russia
who also want to go through this gateway on their journey to America are suspected to have brought the cholera
pathogen to Hamburg. The sewage from the shacks along
the America Quay that the emigrants use for the night in
the Port of Hamburg flow untreated into the Elbe — andtherefore back to the intake point for the drinking water
mains.
When cases of cholera start to occur in the docks area, theauthorities first of all play down the gravity of the situation. Out of consideration for the economy, the fatalities
are kept secret, and no measures are taken. Clean bills of
health are still being issued for emigrant ships even after
the outbreak of the disease, so that the cholera pathogen
can find its way to New York, where, however, there is no
outbreak of the disease thanks to the determined action of
the authorities. In Hamburg however, the disaster can takeits course unhindered. From
mid August 1892 on, there is a
rapid increase in the numberof people infected with thedisease. Regardless of this, theauthorities seek to cover up thefacts. The press also keep a low
profile or publish misleadingly
reassuring news. The people inthe docks area continue to drink
the contaminated water.
Only when the extent of the epidemic can no longer be
kept secret is action taken at last. The medical authority
informs the public with leaflets and posters about the link
between water quality and disease, and tank carts deliverclean water, while public hot food stalls provide people
with meals free of bacteria. Schools are closed. Trade activities and traffic grind to a standstill. The wealthy citizens
have long left the city. Dockers are busy day and night disinfecting roads and houses with different chemicals suchas chlorinated lime, carbolic, lysol and creolin, bringing thesick away and digging graves.
The sad toll of the epidemic is 16,596 people who havecontracted cholera, 8,605 of whom die. The human disasteris accompanied by economic harm totaling more than 400
million Deutschmarks. Subsequently, the “Gängeviertel” areradically redeveloped, and new zoning laws are enacted.
The dirty shacks for emigrants in the docks area are pulled
down and replaced by new accommodation. In April 1893,
Bernhard Nocht takes the newly created office of port physician. Nocht, who studied under Robert Koch, is to monitor
compliance with hygienic precautionary measures and,should the need arise, sound an early warning. Today, theBernhard Nocht Institute is one of the worldwide leading
institutions in the field of tropical medicine.
On the 1st May 1893, the filtering plant of the Hamburg
Waterworks is completed, and in 1896, Hamburg is Germany’s first town to erect a waste incineration plant. It waswith this development that the Hanseatic City had reachedmodern times in Europe, not only to Robert Koch.

WorldRiskReport 2013 ] 19

2.2 Combating disasters with clean water
Thomas Kistemann, Katrin RadtkeT

he mechanism is obvious. Whenevercyclones, floods or earthquakes coincidewith insufficient water supply, ailing sanitary
infrastructure and a lack of hygiene standards,
there is always the danger of water sources
becoming polluted and pathogens entering
drinking water. Inadequate hygiene education and knowhow about simple measures
to reduce the risk of infection worsens thesituation. Diseases involving diarrhea, hepatitis A and E infections and leptospirosis areexamples of the health consequences. This is
no different in wars and conflicts.

sanitary infrastructure and hygiene (WASH)
and the resulting absence of WASH-related
health risks are regarded as commonplace.
However, this does not apply to a considerable
proportion of the world’s population. It can bereckoned with that this situation will tend to
get worse over the next few decades owing to
global climate change. These prospects alreadyprompted the United Nations to refer to aworld water crisis ten years ago (UN 2003).
In December 2010, the UN General Assembly
then decided to declare 2013 World Water
Year.

The availability of clean drinking water is a
crucial factor when it comes to health or disease — and therefore, frequently, also determines whether an event is going to turn into a
disaster at all.

What is lacking

In Syria, for example, access to drinking water,
sanitary infrastructure and hygiene articles
has worsened so much after two years of war
that a significant increase in diseases has been
established (WHO 2013, see showcase on
page 25). Following an outbreak of cholera,
Haiti was also forced to announce a sanitarystate of emergency just a few months after
the earthquake in 2010, which claimed up to
250,000 lives. Around 270,000 people became
infected, while more than 5,000 died of thedisease, which had been caused by polluted
drinking water.
The significance of water, sanitary infra­
structure and hygiene for health
The availability and quality of water andsanitary infrastructure, and the facilitationof personal hygiene, to which it is extremely
closely linked, are of central importanceregarding an individual’s health, but also interms of the health, prosperity and economic
development of whole societies. In the more
affluent parts of the world, clean water,

20 [ WorldRiskReport 2013

WASH deficiencies comprise the following
health-endangering factors: the quantitativelack of available freshwater, the lack of waterthat is qualitatively suitable for the different
needs of human beings (drinking, bathing,washing, cleaning, irrigating, cooling, etc.),
the lack of sanitary infrastructure, resulting inpathogens and harmful chemicals short-circuiting via the fecal and oral propagation paths
and causing health hazards, and a lack ofhygiene.

++ Quantitative WASH deficiencies: Water

for human use is becoming scarce. World
population is growing by approx. 80
million people annually, and the annual
demand for water of approx. 3,800 trillion
liters (Oki and Kanae 2006) for agricultural(74 percent) and industrial production (18percent) as well as for covering domestic
water requirements (eight percent) is evenrising at a disproportionately high rate, byan annual approx. 64 trillion liters (UNand Unesco 2009). Around one third of theworld’s population are affected by water
shortage (Kummu et al. 2010): more than
768 million people are without adequate
drinking water supply, and around 2.5
billion people lack adequate sanitary infra-

Case study: Pakistan

structure (Unicef and WHO 2013). Bothfrom a global perspective and comparing
the urban and the rural situation, there
are enormous discrepancies, as Illustration 4 on page 26 and the annual “BlueFootprint” show: USA: 2.48 million liters
per capita; China, Kenya, Congo, Ethiopia:
600,000 to 800,000 liters; world average: 1.24 million liters (UN und UNESCO 2009). Presently, around half of the
population of the less developed countries
are living in quantitative water shortage
conditions. For a quarter of the populationin Sub-Saharan Africa, the water required
daily is procured involving a time effort ofmore than 30 minutes. Seventy-two percent of this work is performed by womenand girls.

++ Qualitative WASH deficiencies: Only halfof the children in less developed countries
have access to “better” drinking water,and even fewer have access to sanitary
infrastructure. The situation continues
to be particularly critical in Africa, wherearound 37 percent of the population
had no access to “better” drinking waterand just 16 percent had a water tap intheir household in 2008. Here too, thedifference between urban and rural
population has to be additionally stressed.
The term “better” drinking water relates
to the origin of the water and not to its
being safe in terms of hygiene when it
is used (Unicef and WHO 2013). Thus
drinking water is regarded as “better” if
it comes from a central domestic water
connection, a public standpipe, a protected
well or a protected spring or is collected
via rainwater harvesting. However,independently of this, drinking water
may be of insufficient quality hygienicallyat the time of use, for example throughtransportation or storage in unclean
vessels.

Strengthening resilience
after the floods
Again and again, devastating floods occur in the mountainous
regions of the northern province of Khyber Pakhtunkhwa. Since
the great floods in the summer of 2010, which, according to
official statements by Pakistan’s government, directly affected
more than 20 million people throughout the country, there havebeen several outbreaks of severe precipitation in Khyber Pakhtunkhwa. The last floods so far were caused by the monsoon in2013, although their impact was less devastating than in 2010.
Since July 2012, together with its local partner organization, theEnvironmental Protection Society (EPS), Welthungerhilfe has
been running a project to promote the population’s resilience inthe field of WASH (water, sanitation and hygiene) with which corresponding infrastructure is to berestored and improved. The aim isalso to have reduced the population’s susceptibility to reneweddisasters after conclusion of the project in 2014. All project
activities contribute to long-term development in the region.
Around 21,700 people affected by the floods in ten Union
Councils in the Districts of Shangla and Kohistan are benefitingfrom the project. Committees have been formed in the villages
that are supporting the planning and construction of 19 drinking water supply plants and will later on ensure a sustainable
operating and maintenance system.
continued on page 23 k

WorldRiskReport 2013 ] 21

++ Chemical or organic pollution: The mostimportant sources of pollution worldwide
are industrial wastewater and agriculture.
The most important contaminators regarding health include organic compounds andheavy metals from industry, acid substances from mining and the atmosphere andnutrients and pesticides from agriculture(UN 2003). Human and animal feces may
contain pathogens that can be taken up
via water and food if they are not properly
disposed of and can thus cause diseases(Herbst and Kistemann 2007).

In flood events, too, the impaired qualityof water has a negative impact on people’s
health. This is caused by the flooding of sanitary and drinking water infrastructure and by
burst pipe.
Health consequences
The WASH deficiencies impact on healthin many ways. In its most extreme form,
a quantitative shortage of water will leadto dying of thirst, while more frequently, ascarcity of water will have an indirect impact
on human health. The remaining amount ofwater is usually only available with a poorer
quality, so that personal and domestic hygiene
is restricted. Alone a quantitative reduction
will already result in insufficient washingmethods and frequencies, which can leadto so-called water-washed diseases suchas trachoma, relapsing fever and typhoid.
A lack of hygiene owing to an insufficientamount of water for hand-washing can also
contribute to becoming infected with common
pneumonia pathogens. In addition, there are
the indirect consequences of water shortage
such as poorer food security, conflicts between
different users and restrictions regarding
many livelihood activities (such as operating asmall-scale industry).
Water-associated diseases occur worldwide
either endemically (at a permanently raised

22 [ WorldRiskReport 2013

level regionally) or epidemically. They are broken down into four groups (RIVM 2000):++ Water-borne diseases are caused by anintake of microbiologically or chemicallycontaminated water. Classic examples thatcan be traced back to fecal pollution of
the water and that usually feature a small
infection dose include cholera, typhoid,dysentery, hepatitis A and E and amoeba
dysentery.

++ Diseases caused by a lack of water occur because of insufficient personal and domestic
hygiene owing to this water scarcity. The
pathogens are transmitted from individual
to individual or via contaminated surfaces.
The range of diseases comprises eye, skinand diarrhea diseases, respiratory tract
diseases and pneumonia as well as diseases
transmitted by lice and ticks.

++ Water-based diseases such as dranculiasis
and schistosomiasis are caused by aquaticorganisms, above all worms, that spend
their life cycle in different habitats andmove from aquatic mollusks, above allsnails, to another definitive host.

++ Vector-borne diseases are transmitted by

insects living or breeding in water. Malaria,
dengue fever, sleeping disease and filariasis
belong to this group.

It is estimated that around half of the people
living in less developed countries depend on
chemically polluted water resources, whichraises the incidence of the corresponding
diseases. In PR China, more than 85 percent of
all sickness cases relating to chemical contamination are caused by wastewater emissions.
Increased cancer rates result from a lack ofwastewater treatment (Wu et al. 1999).
More recent estimates relate around nine
percent of the global disease burden to waterand hygiene, and even 20 percent in the group

Case study: Pakistanof small children (up to four years). Each year,
three million people, most of them children(1.8 million), die of diseases caused by a lack ofsafe drinking water, insufficient sanitary infrastructure and poor hygiene. If all effects — suchas infection via the intake of water, a lack ofwater, insufficient personal, domestic or agricultural hygiene, vectors breeding in water andcontaminated aerosols — are combined, thenan estimated 80 percent of diseases worldwide
can be attributed to inadequate water supply,and half of all hospital beds throughout theworld are occupied by patients suffering from
diseases related to water problems.
Diarrheal diseases cause 1.4 million deaths ayear among children, 88 percent of which areassociated with WASH (PrüssÜstün 2008).
Small children (up to four years) are at particular risk: 700,000 died in 2011. Last decade,diarrhea killed more children than the numberof humans who lost their lives in all the armed
conflicts since the Second World War. It is
typical for children in developing countries tohave four to five diarrhea episodes a year. They
weaken the children affected both physicallyand mentally and stunt their development,
often marring them for the rest of their lives.
Diarrheal diseases also raise mortality owing
to other diseases by weakening immune resistance. A major proportion of children in lessdeveloped countries suffer from parasiticalintestinal infections which in turn are conditioned in particular by WASH deficiencies.
Parasites use up nutrients, aggravate malnutrition, and slow down the physical and mental
development of children, also resulting ininterrupted school attendance (UN and UNESCO 2009). Numerous studies have confirmed
both that the range of water-related diseases is
growing and the incidence of many water-related infections is increasing. Changes in human behavior (such as mobility and frequent
absence from home), new technologies with ahigh level of water consumption or the threatof contamination (for example air conditioning, new industrial and agricultural ­processes)

k continued from page 21
In addition to drinking water supply, 300 latrines, five sealed
footpaths with side drainage ditches and ten solid waste
collection points with foundations are being built, serving
respectively as models for further construction ventures. Education campaigns and training for multipliers as well as the
distribution of 1,200 hygiene kits complement the construction
measures.
The project operator, EPS, is ensuring that the villages willagain have electricity supplies — from renewable sources.
To this end, 18 micro hydropower plants are being planned
together with the village inhabitants and are to be built incollaboration with local companies. In order to make the villages more accessible again, five pedestrian bridges are being
restored. EPS is checking all technical measures for longevity,
improved functionality and efficiency. Care is taken that a disaster-proof mode of construction is applied, especially with aview to earthquakes and floods. Here, too, a model characterfor other construction ventures is sought.
In order to ensure sustainability, the population is trained inmaintenance and repairs. This is supplemented by supervision and support of improvements in the hygiene situation
as well as by training and mobilization campaigns on disaster preparedness. In 2010, landslides, rock fall and flooding
caused massive damage to water supply systems. Pipes
and reservoirs, distribution equipment and walling of wells
were destroyed, also because they had already been showing deficiencies owing to wear and tear and inappropriate
maintenance previously. The few available sanitary facilities
sustained severe damage by the floods as well. Only a quarterup to a maximum of one third of all households had accessto simple latrines. And only few of the existing, locally built
latrines fulfill the basic requirements for adequate sanitary facilities. These requirements include interrupting the transmission chain of pathogens that represent health hazards. Being
prepared for renewed severe flooding will demand more thanmerely restoring the situation before the floods. The projectmeasures are to significantly improve the WASH situation, andthus make an important contribution to strengthening the
population’s resilience.

Katrin Radtke

WorldRiskReport 2013 ] 23

as well as developments in medicine (forexample the development of resistance to antibiotics and insecticides), deforestation andhydraulic engineering projects are among thecauses (WHO, WMO und UNEP 2003).
Changes in drain-off conditions owing to
the climate and the hydraulic engineering
projects, which are also aimed at preventing
seasonal or regional water scarcity, can resultin a lower flow velocity, stagnation and evenly
regulated water levels. This encourages theoccurrence of water-based diseases such as
schistosomiasis and vector-borne infections
like malaria and dengue fever because therespective intermediate host (e.g. snails) or
vector (e.g. mosquitoes) will then find morefavorable living conditions (RIVM 2000).
Strengthening resilience
A wide range of approaches are available toprevent diseases developing through polluted
water in the wake of a disaster. Over the last
few years, the concept of resilience has increasingly gained importance. It indicates thatdisasters can only be overcome in the longrun by strengthening the ability of societies
or sections of the population to recover fromdifficulties. Resilience is a holistic concept because it can be promoted in a wide range of areas. Promoting resilience in the WASH sector
is one of the key starting points for improving
the overall resilience of societies. However,in order to implement such promotion, thecorresponding political frameworks have to becreated at national level first. Access to water
resources is governed by national legislation
on water, which is either linked to land tenure
or exists as an independent right of usufruct.
In areas with a scarcity of water, such rights
are often the cause of conflict. Many governments neglect the establishment of thenecessary legal and political frameworks, do
not have appropriately qualified personnel,
or there is simply a lack of sufficient engagement and interest. Causes of shortcomings

24 [ WorldRiskReport 2013

can also be identified in the context of international donor policies. In 2010, for example,
the WHO reported that almost two thirds ofOfficial Development Assistance (ODA) for
the WASH sector was concentrated in urban
areas. Moreover, just 42 percent of ODA for
the WASH sector flows into the least developed countries (WHO 2010).
There are various options to enhance resilience in the areas of water, sanitary infrastructure and hygiene:++ Water supply sources can be diversified,i.e. dependence on a single water source isreduced by tapping other water sources. In
dry periods in particular, depending on asingle source of water can result in overuse
and lead to pollution. The most importantalternative water sources include collecting
rain and surface water (for example in rockbasins or by building small earth walls)
and the treatment of sanitary water.

++ Since groundwater systems are usuallyaffected by droughts much later than traditional supply systems such as springs or
surface water systems, improved access togroundwater is a key variable in reducing
the disaster risk posed by a drought.

++ Technical adaptation will help additionally.
Simple measures can make water supply
systems such as water reservoirs, springs,
community standpipes and water mains
systems more disaster-resistant. In orderto prevent untreated wastewater from
penetrating springs and water tap systems,
for example, these have to be positioned
higher than latrines.

The latrines themselves have to be built at aslightly raised level in order to prevent waterfrom pouring into them in the event of flooding. At the same time, they can be protectedagainst water penetrating from underneath bybuilding concrete pits.

WHO Health Report Syrian Arab Republic

Syria: from political conflict tohealth crisis
The pictures from Syria that have been reaching us frequently and on a regular basis are often shocking. The
struggle between President Assad and the opposition isliterally bleeding the country to death. The impacts on theprovision of healthcare for the population are also dramatic, as the Health Report by World Health Organization(WHO) of the 5th June 2013 shows. The Report reveals
how a political conflict has brought about a humanitariancrisis — both in Syria itself and in the neighboring countries
absorbing Syrian refugees. A total of 6.8 million people arein need of humanitarian aid, 400,000 have been injured,and 80,000 have lost their lives. The WHO reports that caring for the injured and those in need is only possible to avery limited degree: “The health system is severely disrupted, compromising the provision of primary and secondary
health care, the referral of injured patients, treatment ofchronic diseases, maternal and child health services, vaccination and nutrition programmes as well as communicabledisease control.”
There have been massive impacts on the infrastructureof medical facilities. According to the WHO, 37 percent of
the hospitals are unserviceable, and 20 percent are damaged. In those facilities that are still functional, the lack of
medical expertise, particularly regarding injuries and anesthetics, and the absence of specialist laboratory personnel
complicate professional care. This applies in particular to
those regions that are strongly affected by violence. But
even if a hospital does maintain its services, it will usually
be difficult for the population to get to it in the first place.
Roadblocks and persistent clashes are obstructing access to
medical and humanitarian aid.
The grave shortage of medicines represents a further massive problem, for there has been a 90-percent collapse inlocal production, and supplies are mostly difficult to organ-ize. In particular, there is a lack of essential medicine suchas anesthetics, analgesics and infusions as well as medicine to treat chronic diseases. The WHO puts financial aid
required to provide the entire country with the medicine
needed for one year at 900 million US dollars, out of which
467 million US dollars is required alone for the provision oflife-saving medicine.
The Report also points to an increased risk for mothers
and their children. Owing to access to healthcare being
obstructed, delivery bears considerable risks. In addition,
as a result of the civil war, the inoculation rate regarding allimportant vaccines dropped strongly, from 81.5 percent (onaverage between 2008 and 2011) to 70 percent in 2012.
The WHO is concerned about the danger caused by infectious diseases in Syria and the refugee camps in the neighboring countries. There is a significantly greater risk owing
to overcrowding, poor water supply, a lack of sanitary andwaste management and interruptions in inoculation andtransmission monitoring. In order to recognize epidemics at
an early stage and take timely action, the WHO is currently
extending its disease early warning system in cooperation
with its partners.
Data: WHO Health Report Syrian Arab Republic, 05.06.2013

WorldRiskReport 2013 ] 25

In all measures aimed at improving waterand sanitary provision, it is always important
to involve the population in planning andimplementation and invest in hygiene education measures. Many projects in the WASH
sector fail because of their being focused on
purely technical elements, and without the
involvement of the population, there will be nosustainable solutions that are supported by thepeople themselves (Welthungerhilfe 2013).
Realizing the human right to water
In the context of the Millennium Development
Goals (MDGs), the international community
set itself the task in 2000 to halve the proportion of people without access to better drinking water by 2015. It is a considerable accomplishment that this goal has already beenachieved, and this shows that changes are

possible. However, there is no reason to be complacent. More than 768 million people are still
without access to clean water, and around 2.5
billion, well over a third of humanity, do not havesufficient sanitation (Unicef and WHO 2013).
In July 2010, after many years of discussion
and debate, the UN General Assembly adopted
a resolution on the human right to water. Twomonths later, the UN Commission on Human
Rights passed a resolution according to which
the human right to water and sanitary infrastructure was to be part of the human right to decent
living conditions. While this does not imply any
enforceable obligation, on such a basis, civil societies can exert political pressure on their respective governments and assert these rights.
What must be regarded as highly problematicin this context is the growing trend towards aWorld
Latin America
and the Caribbean
North Africa
Sub-SaharanAfricaurban water supply

Western Asia
Central Asia

rural water supply

Southeast Asia
Southern Asia

urban
wastewater disposal

Eastern Asia
Oceaniarural
Industrialized
wastewater disposal
countries
0%

20%

40%

60%

80%

100%

Fig.4: percentage of population with access to “better” drinking water and “better” sanitary infrastructure in 2011 (source: WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2013)26 [ WorldRiskReport 2013

privatization of water (of both the sources
and the supply systems). At present, aroundan eighth of the world population are provided with water by private companies (Pinsent
Masons LLP 2012). These may be local firms
or corporations that operate on a global scale.
The largest global players are from Europe.
Regarding its impact on rates, efficiency, quality and health, privatization of water supply isa highly controversial subject in debates. Thisapplies in particular to less developed countries, where the World Bank was among those
who urged a privatization of water supplies for
major metropolises.
Examples such as that of Bolivia show thatthe privatization e.g. of urban and rural watersupply, the introduction of franchising mechanisms and the establishment of water markets

have failed to secure access to and the affordability of water in particular for the poor. The
ecological conservation of water is also frequently neglected.
In order to minimize the disaster risk in the
WASH sector, governments are going to haveto insist on the realization of the human rightto water. They must see to it that the improvement of water supply, sanitary infrastructure and hygiene is also high on the agendaof the debate on the follow-up agreement to
the MDGs and the development of so-called
Sustainability Goals (SDGs) after 2015. Given
climate change and a rising number of disasters (EM Dat 2013), it has to be ensured thatdisaster preparedness and the strengthening ofresilience are integrated as goals in the sense ofdevelopment that is viable in the long run.

2.3 Why some people are particularly vulnerable
Joost Butenop, Sonja WeinreichA

village for displaced persons near Paradip
Garth, in the Federal State of Orissa. People living here, in the Northeast of India, lost
just about everything in the great floods in thelate summer of 2012: from their houses offering them shelter to all their possessions. Like
Raavi and Anjali, who are living in a makeshift
straw hut with their three children when Anjali again becomes pregnant. Many people intheir community belong to the most vulnerable groups, who comprise large families, single
parents, elderly and disabled people or thosebelonging to the lowest caste, the Dalit.

ing the birth of Aisha, Anjali, the mother, starts
bleeding. The traditional midwife who assistedwith the home delivery is hastily called from theneighboring village. The old woman finds Anjali
lying on her mat at home, hardly responsive.
She urgently advises to take her to hospital as
quickly as possible. But the trip to the small
district hospital in the little town of Cuttack
takes over an hour. Raavi, the father, persuades
a lorry driver to give his baby, his wife and himself a lift in the lorry’s load area — he pays his
week’s wage of ten US dollars for this makeshiftambulance service.

Most people living here are at risk of being
particularly hard hit by disasters and natural
hazards. This vulnerability becomes apparent
not only when extreme natural events occur,
but also in everyday life — for example after
little Aisha was born. For in the night follow-

Maternal and children’s healthEvery day, an estimated 800 women worldwide
die of preventable complications related
to pregnancy and delivery. While maternalmortality declined by 47 percent between

WorldRiskReport 2013 ] 27

1990 and 2010, it still amounted to morethan a quarter of a million cases (273,000)
in 2011 (UN MDG 2013). The risk of dyingof complications during pregnancy is fourtimes higher for women in Africa than it ise.g. in Asia and more than 150 times higher
than in industrialized countries (SWI 2011).
For every dead pregnant woman or mother,
there are an additional 20 cases of women
suffering a chronic disease or permanent
disability related to pregnancy or delivery(UNFPA 2012).
Four key risks are identified as causes:
1. 	Health seeking behavior: The numberof risky home deliveries continues to behigh, and very often, women wait toolong before they seek medical assistancebecause they cannot afford the costs oftreatment and transport this involves.
2. 	There is a lack of qualified midwives.
In Africa and Asia, less than half of alldeliveries are accompanied by physicians
or trained midwives. As a result,complications in pregnancy such as
bleeding, obstructed labor and infections
are not treated fast and professionally.
Necessary surgery, such as a Caesarian
section, cannot be carried out, or if it is,
it often comes too late. Together withextremely unsafe, risky abortions carriedout by medical laypersons, these factors
are responsible for 80 percent of allmaternal deaths.
3. 	The consequences of “poverty-relateddiseases”, e.g. malaria and HIV/AIDS.
Pregnant women are more at risk to asevere course of malaria, which, especiallyin the tropics, is widespread among those
who live in poor conditions.
4. 	Disadvantages, neglect and discrimination of women and girls because of
their social status and gender roles bear

28 [ WorldRiskReport 2013

considerable health risks — e.g. becauseof poorer access to medical services andsexual violence, women and girls are more
vulnerable.
Children’s health is closely linked to this.
Worldwide, 3 million newborn babies dieeach year because of premature birth, a lowbirth weight and infections such as sepsis. In
addition, there are 2.6 million stillbirths. Considerable progress has been made in reducing
mortality among infants and young children,
not least because of the Millennium Development Goals. Mortality among under-5-yearolds has dropped by 41 percent over the last
20 years (UN MDG 2013).
However, in total, almost seven million children died in 2011 before reaching their fifthbirthday (CME 2012 and UN 2013). Morethan 70 percent of these deaths could havebeen prevented by simple means. The mostimportant ones include measures applied athome such as exclusive breast-feeding during
the first six months of life, oral rehydration
with a sugar and salt solution and bed nets.
Maternal and children’s health are important
indicators of a country’s level of healthcare
services and health. If a health system cannot
even support the wellbeing of pregnant women and newborn children, this is a reliable signof the system’s weakness. This weakness also
affects the other vulnerable groups — in thecommunities as well as in society as a whole.
Single parent and destitute
When the lorry arrives at the hospital, Anjali’s breathing is hardly perceptible. The only
physician at the hospital is not around. Raavi
is told that the physician is being paid hismonthly salary in the provincial capital today.
In the casualty unit, the nurse prescribes v.
fluids. Raavi is handed a prescription and sent
to the chemist’s to buy the solution for theinfusion and the infusion set, since the hospi-

Case study: Haiti
tal does not have these things in store. Anjali
is admitted to the women’s ward, washed andtreated. There is no intensive care unit here.
Early in the afternoon, the doctor returns andexamines Anjali, who has lost consciousness inthe meantime. For months, the small laboratory where blood tests can be performed has
run out of suitable reagents, and the laboratory
assistant has not been present for a number ofweeks because, under these conditions, there
is no work for her to do. Therefore, an obviously urgently needed blood transfusion can
no longer be performed. In the evening, Anjali
develops a high temperature. Further infusions
do not help. With the large distance involved,
referral to another hospital is out of the question. The nurse applies an antibiotic, but it is
too late. In the same night, Anjali, weakened
by the considerable loss of blood, dies of blood
poisoning. Devastated, Raavi returns to his village with little Aisha — as a single parent withfour children.
Vulnerable people, vulnerable groups
In a developing country with high birthrates,
children under the age of 5 years account foran average of 12 to 20 percent of the total
population, while 2to 4 percent are infants
below the age of one year. Correspondingly, 2
to 4 percent of the population are pregnant or
nursing mothers. This number also depends
on the respective birthrate and is based on alactation period of one year. This means that,
if an earthquake affects 100,000 people, inplanning aid measures, one has to bear inmind that 2,000 to 4,000 pregnant or nursing
women and well over 10,000 children need
to be considered. Furthermore, approx. 1,000
deliveries have to be reckoned with over the
next three months, out of which 2to 4 percent
will require a Caesarian section (Schmitz 2013).
People with disabilities who depend on special
support or special aids account for 3 to 10
percent of the total population. They include,

A window to life
One of the important elements of emergency assistance andrehabilitation is psycho-social support and trauma care. In Haiti,
terre des hommes has been supporting the project partners“Unité de recherche etd’action médico legal”(URAMEL) and also,
since 2013, “Fondation
IDEO” (FOI). In thewake of the earthquake in January 2010,
URAMEL worked with children from the camps in the capital
Port-au-Prince. Some of the children attracted attention through,on the one hand, extremely timid, withdrawn behavior and on
the other by being aggressive and restless, often in combination
with hardly being able to concentrate. When working with thesechildren, their parents and teachers, it frequently became apparent that their psychological stress was very complex. The source
was not only the disaster itself but also previous experiences,and in particular, those involving violence.
Traumatic experiences that have not been sufficiently dealt withwill lastingly disrupt people’s lives. They have an impact on theircapacity to act and communicate. Sometimes, experiencing acontinued on page 31 k

WorldRiskReport 2013 ] 29

for example, those whose sight or ability towalk are impaired, persons who cannot escapefrom a hazard, and persons with a hearing
deficiency or who are deaf and are not reachedby acoustic warning signals and information.
Older people account for 15 to 20 percent(depending on the definition, e.g. from the60th year of their life on). The proportion ofolder people with disabilities , also those that
may be caused by chronic diseases, will behigh. Further groups that are at particular riskor particularly vulnerable in crises or disasters
include:++ people affected by poverty++ single-parent households++ migrants++ orphans and children who have been

separated from their families++ people without access to social services++ members of marginalized groups++ membership of a low caste.
It is very difficult to correctly establish thevalues of the respective proportion of vulnerable groups in a population. One example isthat, while around 15 percent of the world’s
population are living with a disability according to the United Nations, in many developing
countries not all people with disabilities areregistered. This may be because they have notbeen identified, because their disabilities are
kept secret and they are hidden by theirfamilies (UN 2007).
However, increased vulnerability can also be adirect consequence of crises/disasters,
particularly through:++ loss of possessions++ loss of employment and sources of income++ destruction of houses, of shelter++ serious diseases or injuries/disabilities++ loss of or serious illness among family
members through the disaster (injured
people, people gone missing and deaths)

30 [ WorldRiskReport 2013

Targeted analysis
It is absolutely crucial to learn from the affected
themselves what they can do to cope with disaster risks and problems and what capacities they
have to do so. Planning disaster preparedness
and humanitarian aid always has to set out froman optimally accurate establishment of the needsof vulnerable people or vulnerable groups. It has
to be identified which capacities are lacking e.g.
through:++ limited access to resources of the community(e.g. homeless or marginalized people)++ restricted options for individuals to express

their special needs or assert their own rights(for example people with disabilities)++ severe health impairment (creating, forexample, dependence on medical or technicalassistance or medicines)++ lack of mobility to be able to adequately
respond to hazards (e.g. older people orpeople with difficulty walking)++ isolation or lack of support networks (such as
homeless people, older people/orphans)++ cultural or language isolation from thecommunity (for example refugees, indigenous
groups, migrants).
All these characteristics develop their devastating
force under one certain condition: poverty.
In the course of humanitarian aid and reconstruction and rehabilitation, the aim is always toreach the most vulnerable people and sections of
the population in particular. Often, however, it
is not obvious and therefore difficult to establish
the most vulnerable in a needs assessment. Again
and again, for example, people with disabilities
are “overlooked” because their special needs
are also negated by their own families owing todiscrimination and stigmatization. This has an
impact not only during an extreme natural event
but in particular also during the subsequent aid
measures. Against this background, it is all themore important to actively integrate people withdisabilities — and other vulnerable persons– into

Case study: Haiti
disaster risk reduction programs. They can be
an important resource when it comes to planning measures for disabled people (also see
project example on page 33). For example, deaf
people who understand sign language can communicate with deaf people who don’t, obtain
information from them or pass it on to them.
Older people with chronic diseases are particularly vulnerable. Because of their experienceof life, older people can often provide special
knowhow that is vital for survival in disaster situations or of importance in disaster prevention.
The basic principle of integration and participation of the affected in prevention and projectplanning applies to all vulnerable groups. They
know the worries and needs of people best andcan decide which problems need to be solved
most urgently.
Effective aid
Just like disaster preparedness, emergency aid
aims at saving lives, mitigating suffering andenabling the victims to get back to a decent life.
The measures required to achieve this internationally agreed goal are clearly defined. There
are recognized standards and guidelines regarding the minimum requirements for appropriate
shelter, food supply, water supply and sanitary
installations, protection against violent attacks
and primary healthcare. The latter also comprises vaccinations (particularly against measles), supply of drugs and pregnancy examinations and midwifery as well as psychosocial andlegal support in the wake of violence (SPHERE2011).
These standards and the indicators relate to the
UN Millennium Goals, which up to 2015 will
be an important international guideline for thetargets that need to be achieved to make emergency aid efficient and reduce vulnerability.
For example, the most important measures toreduce maternal and child mortality are sufficiently well-known and can be implemented
with a relatively low effort:

k continued from page 29

disaster can evoke suppressed traumatic events. If traumaticstress is not appropriately dealt with, reactive frustration andhelplessness can evoke long-term effects, including depression, alcohol and drug abuse, and aggressions.
Often, children can already be supported with playful activities: care and a space allowing them to express their feelings,
simple breathing exercises for stabilization or a guided imagining of a safe place. In addition to such stabilization, somechildren require further psychological assistance.
Methods used by the 20 psychologists working for URAMEL
and FOI include EMDR (Eye Movement Desensitization and Reprocessing). The key element in EMDR therapy is guided eye
movements. The patient follows the fingers of the therapist
with his or her eyes as the therapist’s hand moves alternately
to the right and the left. These movements are comparable
to the eye movements in the REM sleep phase, in which theevents of the day are processed. Thus EMDR supports processing and self-healing. Its aim is to address traumatic experiences that have been stored without being processed. The aim is
to process these experiences and reintegrate them.
Experiences in Haiti show that, on average, four to five sessions will already help the patient to overcome post-traumaticstress that has developed as a response to a single event. So
far, the two project partners have reached a total of around
12,500 people. About a third of them required additional
individual therapy support. If severe or long-lasting traumatization, caused for example by experiencing recurring violence,
has to be addressed, the psychologists work with the patientsduring an average of ten to twenty individual or group sessions.
Not every child that has undergone terrible experiences
needs professional psychological treatment. And not all of
the children who have had therapy are resilient against facing
extreme events in their lives that may traumatize them again.
Therefore, psycho-social activities must not only be reactive
but also have to aim at strengthening children and theircommunities so that they can actively and self-determinedly
shape their own lives.

Wolf-Christian Ramm

WorldRiskReport 2013 ] 31

++ Promoting prenatal healthcare and availa-

bility of essential midwifery health services
including emergency surgery++ ensuring that newborn babies are breastfed for six months++ treating diarrheal diseases with rehydration solutions (especially in the developing
countries, which is only ensured in 35
percent of cases)++ further improvements in vaccination
coverage and the range of vaccines against
potentially deadly diseases such as measles or frequent pathogens of pneumonia
among children++ availability of antibiotics to treat pneumonia (so far they are available in only 30
percent of cases)++ improvements in the hygiene situation.
More than a third of all people worldwide
have to live without basic sanitation. Thisis a considerable hygiene risk and is amajor factor in the spread of infectious
diseases (WHO and UNICEF 2013).
Ideally, acute emergency aid is linked toforward-looking reconstruction and disasterprevention. The aim is to reduce vulnerability
and enhance the resilience of those affected — especially with a view to recurrent natural events such as the floods.

32 [ WorldRiskReport 2013

Rice alone is not enoughAfter returning from the district hospital andhis wife’s funeral, Raavi is struggling for thesurvival of his four children, above all newborn
Aisha. In spite of the difficult circumstances,
she makes it through the difficult phase after
being born. Weighing just 2,800 grams, sheloses half a kilogram without her mother’snourishing milk, which would also strengthen
her body’s defenses. Just like her brothers
and sisters, she is fed with rice. Nourishingmilk substitute is rarely available since thefamily cannot afford it. Again and again, Aisha
has diarrhea, since the milk powder is mixed
with contaminated water. The family has too
little firewood to sterilize the water by boiling. Shortly before her first birthday, Aisha
is weighing just five kilograms, half of what achild her age ought to weigh. Her hair is thin
and reddish-blond, which is a visible sign ofchronic malnutrition.
This makes her particularly susceptible todiseases such as diarrhea, influenza, measles
and pneumonia. Just like Aisha, many children also lack vaccination. She belongs to the
20 percent of children worldwide who are notvaccinated against measles. Especially after
disasters like the floods in Orissa, a lack of vaccination can prove deadly — not only in poor
regions such as the northeast of India.

Case study: India

Preventing disabilities throughfirst aid
At the age of 18 years, Paulus Masih had an accident inwhich his left foot was seriously injured. “If I had known
then about first aid what I do today, I wouldn’t be disabled
now,” Masih says today. He is one of 3,500 disaster relief
workers in Northwest India. He was trained by the Emmanuel Hospital Association (EHA), which has been a project
partner of the Christian Blind Mission in New Delhi formany years. In eight of the 28 Indian Federal States, with a
total population of 128 million people, the first responders
are now integrated in a network of regional crisis centers.
One special focal area of activities is calling on and involving people with disabilities. For they are often the first ones
to be hit by a disaster and the last to get help.
Nearly every year, disasters such as floods, earthquakes orstorms leave a trail of devastation thatseverely harms the people themselves,
their livelihoods and infrastructure. In order to be able to act quickly in the eventof disaster and not leave disabled people
behind, preparations have to be made foran emergency. These include developing
a disaster network and the compilationof contingency plans, in cooperation withboth disabled people and other vulnerable groups. And then there are very concrete measures thathave to be considered. For example, wherever ramps havebeen added to entrances to hospitals and to pharmacies,
handrails have been fitted to toilets or connecting corridors
without steps have been built in hospitals, people with disabilities can make use of public aid services in the event ofa crisis. In addition, there is the protection of important apparatus against damage by firmly securing it (earthquakes
tremors) and by installing it on a high plinth (floodwater).
In this manner, a disaster preparedness program has beendeveloped that also demonstrates how inclusion can beachieved at low cost and with only little additional effort.
The people affected take part in the preparatory and train-

ing measures themselves
and attend the disasterprevention committees. A
model hospital project isbeing implemented thisyear. The preparedness
program is also being
presented at regional and national conferences in order toencourage other organizations and government bodies toimplement the respective projects and to draw up individual disaster control plans for individual health facilities.
The 3,500-member disaster team, in which disabled andnon-disabled people are involved, some of them in anhonorary capacity and some of them on a professional
basis, serves as a contact point for theentire region. Not only physicians andnurses but also teachers, policemen,taxi-drivers and many other volunteers
from the communities have undergone
training in first aid, resuscitation measures and the basics of disaster relief.
And thanks to this training, they are now
also able to asses the special needs ofdisabled people. Paulus Masih is both avictim of disaster and an aid worker. He belongs to the 127
key persons who act as independent instructors for further
volunteers in their respective region.
It is also their task to remind local organizations andgovernment representatives of their responsibility towards
people with disabilities, to raise an early alarm and also tohave both disaster preparedness plans and first aid plans
available in sign language and braille. Masih is certain
that, “thanks to the large number of disaster relief workers, an injury like the one I sustained will no longer cause
any lasting disability in the future”.

Ulrike Veismann

WorldRiskReport 2013 ] 33

2.4 The creeping disaster — global health in crisis
Kirsten Schubert, Thomas GebauerT

he news reaching us from Greece is shattering: “Growing numbers of suicides dueto the greatest economic crisis since 1929”,“Chronically ill lacking access to medicine”,“Doubling in the number of HIV infections”.
They remind us of the link between socioeconomic factors and people’s health. Austerity
policies in times of crisis have been proven to
cost human lives. Disasters such as wars, famine or floods are going to have a far more tragic impact among a world population shaken
by financial crisis — if the right to good publichealthcare for all is not given priority.
“The global economic downturn has profoundimportance for the health and well-being of
populations and is likely to worsen healthinequity. The people who are already most
exposed to vulnerability and disadvantage feelthe effects of the global economic downturn
more strongly, similar to the effects of natural
disasters”, health scientist Sir Michael Marmot
noted in his interim report for the World
Health Organization (WHO) in 2011 (Marmot2011).With the end of the financial crisis inlate 2007, the world economic crisis set in, andgiven its extent, it is easily comparable to theGreat Depression of the 1930s. Already in its
first years, a hundred million people wereplunged into poverty by rising energy and foodcosts (WHO 2009).
Evaluating experience from previous economic
crises, the WHO called on the Member States
to seek to ensure that „the economic crisis is
not turning into a social and health crisis”(ibid.). Its warning went unheeded.
Poor preconditions for health
While the economic crisis started in theindustrialized countries, it is going to have its
most dramatic impacts in developing countries(Ortiz and Cummins 2013). The decline inoverseas direct investment and return remit-

34 [ WorldRiskReport 2013tances from relatives abroad or the drop indevelopment aid adds to the consequences ofcrisis within previously already fragile healthand social welfare systems. Thus the partnerorganization of medico international “Centro
Ecuménico Antonio Valdivieso” (CEAV) in
Nicaragua reports that a major proportion of
the money that it used to receive from Spanish organizations is no longer available. In
many countries, development aid money for
health accounts for a considerable proportionof health expenditure — often up to 50 percent. In times of crisis, this dependence canquickly lead to disaster.
Spending on health worldwide reflects extreme inequality which cannot be explainedby a lack of resources, since enough is available for everyone — only that it is extremely
unequally distributed. Eighty-four percent of
the world’s population live in the developing
and emerging countries of the South. However, they account for just 29 percent of the
global Gross Domestic Product (GDP). Theybear 92 percent of the world’s health burden
but have just 16 percent of global expenditureon health at their disposal (Moon and Omole2013). The per capita health expenditure
ratio is revealing, too. In Germany, it is 3,573
US dollars a year, and in Uganda just 10 US
dollars, i.e. 350 times less (WHO 2013). One
consequence of this imbalance is that in Germany, people live up to an age of 81 years on
average, while life expectancy in Uganda is at
56 years.
No saving on health
Economic crises, such as the Great Depression, the debt crisis of the developing countries or the Asian crisis towards the end of the20th century, but also sudden transformation
processes, such as the one that Russia saw after the disintegration of the Soviet Union, areproven to have cost many people’s lives. Sui-

Case study: South Sudan

cide statistics, child mortality and the incidenceof chronic diseases shot upwards — although
they did not do so to the same degree everywhere. In their survey published in May 2013,
the two health scientists Stuckler and Basudemonstrate that the extent of harm to healthowing to “economic disaster” is a consequenceof the political measures taken by governments.
The core issue is whether they opt for an austerity and budget consolidation policy or whether
they promote social and health programs. From
the Great Depression up to the euro crisis, it
can be scientifically proven again and againthat “the true threat to public health is not therecession as such but the austerity programs”(Stuckler and Basu 2013).
Thus the impressive developments that had
taken place in some African countries in the
1950s and 1960s, such as the halving of childmortality or the extension of public health andeducation systems, were ruined all at once in
1980, when the debt crisis set in. A massive
increase in the price of oil, rising interest rates
and the decline in exports owing to protectionism among the industrialized countries
coincided with cuts in public budgets. Similar
developments could be observed in Latin America in the 1980s and 1990s. The major financial
actors, the International Monetary Fund (IMF)
and the World Bank, developed structuraladjustment programs, which were the precondition for debt relief or external investment in
the crisis-shaken countries. In addition to tradeliberalization and the elimination of subsidies,
this also included cuts in the health budget.
The dubious assumption that these
conditionalities would result in economic
growth failed to materialize. Rather, themeasures forced the countries to carry out
a neoliberal reform of their economic andsocial systems and secured access for theindustrialized countries to natural resources.
There were times when countries such as

The crisis still goes on after the war
South Sudan continues to be in a state of crisis despite the endof the war. For more than 20 years, civil war raged in the region
until a peace treaty was signed by the conflict parties. In 2011,
after a referendum, South Sudan declared its independence
from the Republic of Sudan and is now the youngest state in theinternational community. But regardless of independence, peaceand an economic upswing have not yet come to the country.
Eighty-six percent of the population are living below the poverty line. People’s everyday life is characterized by the flaring up
of internal conflicts and continuing
disputes with the Republic of Sudan.
In addition, there are border disputes with paramilitary groups from
Uganda.
The civil war and the lasting crisis have destroyed social and economic infrastructure, and public healthcare hardly exists. Eighty
percent of the few existing health services are operated by civilsociety organizations and the Churches. Otherwise, the poor inparticular would lack any access to these services. Brot für die
Welt is supporting the Action Africa Help International (AAHI)
organization, which provides comprehensive primary healthcare.
continued on page 37 k

WorldRiskReport 2013 ] 35

Zimbabwe or Nicaragua were spending
between a quarter and half of their revenue
on debt repayment — often several times
the amount of their health and educationbudgets.
In the current crisis in Europe, the IMF,
together with the European Commission andthe European Central Bank, is formulating
the conditions for debt relief. They arevery similar to the structural adjustment
programs of the 1980s and 1990s. The
Structural Adjustment Participatory
Review Initiative (SAPRI) launched by theWorld Bank in 1997, which documented
the disastrous developments at the timeand led to a reorientation less than twenty
years ago, appears to have been forgotten
since. However, the impacts of the Greek
health budget being cut by almost half
were predictable — ranging from a lackof medicines and dressing material
through an exodus of health specialists
and a rising number of HIV infections toincreased influenza mortality (Bonovas andNikolopoulos 2012). The question mustbe permitted whether this was consciously
accepted as a possible consequence of themeasures.
In many developing countries, too, the IMF
continues to be active in providing support
for governments. Presently, the following
IMF structural adjustment programs are on
the agenda (Ortiz and Cummins 2013):++ eliminating or reduction of subsidies,including fuel, agriculture and food products (in 100 countries)++ wage bill cuts/caps, including the salaries
of education, health and other public
sector workers (in 98 countries)++ rationalization and further targeting ofsafety (in 80 countries)++ pension reform (in 86 countries)++ healthcare reform (in 37 countries)++ labor flexibilization (in 32 countries).

36 [ WorldRiskReport 2013

Structural adjustment through privatization
The reforms called for in the health sector
include, in particular, cuts in government
services and medical personnel and usually go hand in hand with increases in out of
pocket payments for healthcare facilities or
the purchase of medicines. In the field of thesocial security system, the IMF often recommends restricting the public security nets andwelfare to the poorest sections of the population — as is the case in 25 industrialized countries and in 55 developing countries, suchas Nicaragua, Sudan, Zambia, Mali or Haiti(Ortiz und Cummins 2013). Usually, this isdifficult to implement both administratively
and politically, and given the large numberof vulnerable groups in the population, also
above the poverty line, it is not recommendable. Rather, comprehensive public healthcare
is urgently needed that is pre-financed on amutual basis: the rich for the poor, and thehealthy for the sick. As the WHO notes, thisis also the most efficient way of financing(WHO 2010).
One of the biggest problems that the countries of the South are facing is that the overwhelming majority of the population are notfinancially safeguarded in the event of illness(Moon und Omole 2013). As a rule, anyone
seeking health services has to make out-ofpocket payments. Such individualized healthfinancing does not make sense from a healthpolicy angle and, what is even more important, is highly unfair. It excludes those fromappropriate healthcare who need it most given their situation. To poor people and those
without means, who are usually sick more
often, out of pocket payments often represent
insurmountable obstacles. Since they simply
cannot afford it, sick people avoid seeing aphysician or going to hospital. Each year, theWHO estimates, 100 million people are driven into poverty because they have to finance“disastrous health expenditure” privately(WHO 2010).

Case study: South Sudan
The user fees that the World Bank advocated fora long time are highly controversial, too. Originally, they were supposed to serve as a barrier
to prevent an “overuse” of medical facilities.
But they pass on responsibility for health to thepoor, or, as WHO Secretary General Margret
Chan puts it, “user fees have punished the poor”(WHO 2010).
The individualization of health costs via private
payments is accompanied by the privatizationof public hospitals, a measure that tight publicbudgets serve as a reason for. Whereas pressure
on the public health system is mounting, thedevelopment of the private health sector continues, just like the World Bank has demanded formany decades. The debate on the pros and consof the private health sector is shaped considerably by ideological convictions, an analysis
of more than 2,300 scientific articles recently
revealed (Braithwaite et al. 2010). Especially inthe case of the developing countries, there is alack of data on the impacts of privatization onaccess to healthcare. Many countries in Africa,
Latin America and Asia have only weakly developed public healthcare systems. Underfinanced,
ailing public hospitals for the lion’s proportionof the population contrast with well-equipped
private hospitals for the elites.
However, it has not been possible to provescientifically that the private sector is more
efficient, can cope with more pressure and ismore effective medically. Rather, an increasing
amount of unnecessary examinations and surgeries are being performed some of which evenviolate medical standards (Basu et al. 2012).
What is overlooked is that the poor and impoverished can only assert their right to healthwhere a public-supported healthcare system
exists. Health is an important public good thatis linked to social responsibility and commitments. In contrast, in the case of a private
hospital operator or philanthropic associations,those in need can, at best, apply for support,
but they cannot take legal action to enforce it.

k continued from page 35
Effects of malnourishment, insufficient water supply, a low
vaccination density, a large number of unintentional and earlypregnancies and a high level of HIV/Aids cases are being
combated. AAHI is an international organization that is basedin Nairobi and engages in humanitarian and development
activities in East Africa.
The Republic of South Sudan is nearly twice as big as Germany, but it has a mere nine million inhabitants. There isvirtually no infrastructure, and the road network is hardly
developed. People have to go miles to get to the next healthcenters. This is why AAHI has set up a network of 100 healthfacilities covering the whole country. By providing medicine
and medical and logistical support, primary healthcare isensured for 8,000 people a month. Education activities andprimary healthcare services aim to combat maternal mortality, which, at more than 2,000 women per 100,000 births, isthe highest in the world. That every tenth child should die ofpreventable diseases such as diarrhea, undernourishment,
malaria or measles is soon to be a thing of the past. This comprehensive health program that AAHI is conducting benefits
more than half a million people.
For the future of people in South Sudan, the sustainable
development of an efficient health system is crucial. However,there is also a lack of medical personnel. Every second healthcenter has an insufficient number of physicians, midwives ornurses. In order to bridge this gap, AAHI is training personnel
on a continuous basis who are then taken on by the national health service. And through intensive dialogue between
AAHI and the government, far-reaching progress is being
made in government training programs for health personnel.
Furthermore, consulting provided for the Health Ministry andthe training of administrative personnel support the creationof capacity at Federal State level and the development of areliable health policy. For it will only be possible to improve
the health situation in South Sudan when local people arestrengthened and the government structures are in working
order. This would be an important contribution to getting outof the crisis.

Mareike Haase

WorldRiskReport 2013 ] 37

Furthermore, a well-established public healthservice is essential for good prophylaxis andsurveillance — especially in times of crisis.
But profit-oriented private providers ofhealth services are only interested in preventing diseases to a certain degree — unless
pharmaceutical, medical engineering or nutritional supplement products are employedthat earn them revenue.
The benefit of private healthcare also depends on whether it is capable of providing
for the population in times of disaster andcrisis. People who have suddenly lost theirpossessions or secure income can no longer
afford private supplementary insurances andcontributions and turn to public institutions,which is what the WHO also predicted inits 2009 Report (WHO 2009). In Greece,
for example, the intake of patients by public
hospitals increased by 20 percent between
2009 and 2011 (Kentikelenis und Papanicolas 2012).
Rethinking is vital
Public-financed, high-quality healthcare andprevention are essential to reduce a population’s vulnerability. The WHO, as well as
many renowned scientists, is therefore callingfor anti-cyclic health financing: more money in times of crisis — especially since there
can be no doubt that demand has increased
significantly (WHO 2009). Quite generally, the issue of sustainable health financing
urgently needs settling. The inequalities
described above are untenable from a humanrights perspective, and they are causing
unnecessary suffering. One way out would
be to replace development aid steered byvested interests with obligatory compensatory financing systems. Such a demand, which
was already raised by medico internationalin the late 1990s, was presented by Anand
Grover, UN Special Rapporteur for the Right
to Health in his report to the UN General
Assembly in 2012.: “Realization of the right38 [ WorldRiskReport 2013

to health in the developing world is thus also
dependent upon the availability of sustainableinternational funding for health, which should
ultimately be realized through an obligatory,treaty-based regime founded upon the principle of global solidarity.” (Grover 2012)
Most countries throughout the world continue
to lack systems of compensatory public, mutual health financing, whether it be via taxationor health insurances. It is not without reason
that the WHO also put the goal of Universal
Health Coverage (UHC) right at the top of theagenda in the planned revision of the Millennium Development Goals, which are to be newly
agreed in 2015. In stark contrast to this, social
security systems are presently being eliminated in Europe and many other countries. In
Greece, more than 30 percent of the population are no longer medically insured.
The human right to health is enshrined in
Article 12 of the International Covenant on
Economic, Social and Cultural Rights. Only ifsociety — and hence also its governments andits institutions — recognize healthcare as a collective task, as a public good that must not beleft up to the market, can it become and stay a
reality. In times of crisis, this simple insight is
all the more true.

Case study: El Salvador

Health politics from below
El Salvador faces the challenge of reducing the country’s
extreme social disparities. One of the most importantchanges is taking place in the healthcare system, which
was previously characterized by privatization. Now ideas
are coming to bear that were already being practiced by
the liberation movement during the civil war, when healthpromoters were looking after the people. The core element in the health reforms is the introduction of “Equipos
Comunitarios de Salud Familiar” (ECOS), which address the
population’s health problems at village and urban districtlevel and operate in a nationwide network.
As a rule, these healthcare teams consist of a physician,two nurses, and two health promoters who, in addition
to providing concrete healthcare, perform preventive
activities as well. They are making a crucial contribution
to healthcare also becoming available to people in poorand remote districts who previously had no access to it.
Since the beginning of the reforms in 2009, 380 of these
ECOS have started working in the 141 poorest communities
in El Salvador. In addition, there are 28 “ECOS
Especializados” with personnel specializing inareas such as dental medicine, midwifery or
dietetics who ensure that special treatment isavailable at local level.
Large numbers of promoters who weretrained and employed by civil society organizations suchas “Asociación de Promotores Salvadoreños” (APROCSAL),
which is supported by medico international, over thelast few years to provide primary healthcare services
have been integrated in the new ECOS. Furthermore, thenational rescue system has been improved through theintroduction of 170 ambulances whose area of operation
also includes remote villages. In addition, social determinants of health have been addressed in the context of
the reform process, for example by tackling the causes of
diseases such as contaminated drinking water and poor
housing conditions and discussing sustainable solutions incross-sector round-table debates Ninety percent of El Sal-

vador’s total area is regarded as a risk zone for extreme
natural events such as hurricanes and volcanic eruptions,causing this small Central American country — with its
21,000 square kilometers the size of Germany’s Federal
State of Hesseto regularly feature among
the ten countries with the highest disasterrisk. When floods developed throughout
the country following several days of continuous rainfall in late 2011, via the network of community health committees,
medico international were able to provide
immediate emergency relief for the people affected by
distributing food, hygiene kits, medicine and plastic tarps.
In 2014, elections will be held in El Salvador. The “Grassroots Health Reform” supported by medico international
for more than twenty years has been successfully andsustainably integrated in government policy. Above all,the level of democracy achieved in health policy thanks
to the people’s ownership gives rise to hopes that thisfar-reaching concept will also be continued after theelections.

Kirsten Schubert

WorldRiskReport 2013 ] 3944 [ WorldRiskReport 2013

3. WorldRiskIndex 2013
Torsten Welle, Jörn Birkmann, Jakob Rhyner, Maximilian Witting, Jan Wolfertz

Extreme natural events such as earthquakes, storms, floods,
droughts or the future effects of sea level rise need not inevitably
result in a disaster for a country. For example, a society which isless susceptible in the field of health and enjoys a high level ofprosperity, can draw on experience with natural events, and byadapting to anticipated environmental and climate changes cansignificantly lower the risk of disaster and crisis and thus minimize
the numbers of victims as well as ecological, cultural and economic
losses and damage. The WorldRiskIndex shows the respective riskof becoming a victim of disaster pertaining to extreme natural
events for 173 countries. The risk is at its highest where a high levelof exposure coincides with very vulnerable societies.

WorldRiskReport 2013 ] 45

3.1 The conceptT

he WorldRiskIndex characterizes thedisaster risk for 173 countries that resultsfrom a combination of societal conditions andfactors as well as areas with a potential fornatural hazards to occur. The concept of theIndex is to demonstrate that it is not solely thestrength of an extreme natural event that is
responsible for a natural hazard turning intoa disaster but rather that a society’s social,economic and ecological factors also play a
crucial role (Birkmann et al. 2011; cf. IPCC
2012). The results of the WorldRiskIndex
enable a comparison of countries with one

another, providing a description of a potential
disaster. The Index cannot forecast individual
disasters.
The Index consists of 28 indicators referring
to data that is available worldwide and accessible to the public and is based on a modular
structure divided into the four components
of exposure to natural hazards, susceptibility,
coping and adaptation. The assignment of theindividual indicators to the components andweightings is represented in Illustration 4 onpages 48 and 49.

3.2 The termsT

he World Risk Index is calculated bymultiplying exposure by vulnerability. A
detailed description of the method applied todetermine the WorldRiskIndex is given in theWorldRiskReport 2011 (Birkmann et al., 2011)
and available at www.WorldRiskReport.org.
k Risk is understood as the interaction between a hazard (earthquakes, floods, cyclones,
droughts, sea level rise) and the vulnerabilityof societies. The results of the individual values for 173 countries are provided in the tablein the Annex. The graphic representations of
the Index are shown on Map C on the rightfold-out page of the cover and on the World
Map on pages 54 and 55.
k Exposure means that a certain good (generally: population, buildings, infrastructurecomponents, environmental areas) is exposedto the impacts of one or more natural hazards(earthquakes, cyclones, droughts and floods).
The World Map of Exposure (here: exposureof the population) can be seen in Map A on theright fold-out page of the cover.
k Vulnerability relates to social, physical,
economic and environment-related factorsthat make people or systems susceptible to46 [ WorldRiskReport 2013

the impacts of natural hazards and the negative
effects of climate change. The term vulnerability
also covers factors comprising the abilities andcapacities of people or systems to cope with andadapt to the negative impacts of natural hazards. Vulnerability includes the components ofsusceptibility, coping capacities and adaptive
capacities. The Vulnerability Map (Map B, rightfold-out page of the cover) shows the global
structures of vulnerability.
k Susceptibility is generally understood as theprobability of sustaining harm should a natural
hazard occur. Susceptibility thus describes a society’s structural characteristics and framework
conditions. Susceptibility is represented worldwide in Map B1 (left fold-out page of the cover).
k Coping refers to various abilities of societies to minimize the negative impacts of natural
hazards and climate change via direct action
and the resources at their disposal. Coping
capacities comprise measures and abilities thatare immediately available to minimize harmwhen a disaster strikes. For the calculation of
the WorldRiskIndex, the opposite value, i.e. thelack of coping capacities, has been applied. It is
the result of subtracting coping from the valueof 1 (Map B2, left fold-out page of the cover).

k Adaptation unlike coping, is understoodas a long-term process that also includes
structural changes (cf. Lavell et al. 2012;
Birkmann 2010) and measures, as well as
strategies to deal with the negative impacts ofnatural hazards and future climate change im-pacts. The lack of adaptive capacities, i.e. thevalue of 1 minus adaptation, that is includedin the WorldRiskIndex (Map B3, left foldout page of the cover) is analogous to coping
capacities.

3.3 Updating and modification of the indicators
For the calculation of the WorldRiskIndex
2013, a total of 15 out of the 28 indicators
have been updated — all of them in the areaof vulnerability. With regard to the remaining
indicators, the previous data was retained as
updated versions of the external data were
not available at this time. This also applies toexposure.
The worksheets for the 28 indicators, together
with the latest data sets and their sources, canbe viewed at www.WorldRiskReport.org.
Susceptibility
Within the component of susceptibility, updated sets of data are available for four of theseven indicators:++ Indicator C:	Share of population under-

nourished++ Indicator D:	Dependency ratio (share ofunder 15- and over 65-yearolds in relation to the working
population)++ Indicator E:	Share of the population livingon less than USD 1.25 per day(purchasing power parity)
Indicator
F:	
Per capita Gross Domestic++
Product (purchasing power
parity).

Coping capacities
Within the component of coping capacities,
updated sets of data are available for all indicators except for insurances:++ Indicator A:	Corruption Perception Index++ Indicator B:	Good governance (Failed
States Index)++ Indicator C:	Number of physicians per
10,000 inhabitants++ Indicator D:	Number of hospital beds per
10,000 inhabitants.
Adaptive capacities
Within the component of adaptive capacities,
updated sets of data are available for seven of
the eleven indicators:++ Indicator A:	Adult literacy rate++ Indicator B:	Combined gross school
enrollment++ Indicator C:	Gender parity in education++ Indicator D:	Share of female

representatives in the
National Parliament++ Indicator I:	Public health expenditure++ Indicator J:	Life expectancy at birth++ Indicator K:	Private health expenditure.

WorldRiskReport 2013 ] 47

Exposure

Susceptibility
Public infrastructure

Population
exposed to:AS hare of the population without
access to improved sanitationB	Share of the population without
access to an improved water
sourceA Earthquakes
B Storms
Insufficient global
data available

C Floods

Housing conditions
	share of the population living inslums; proportion of semi-solidand fragile dwellings

D Droughts
E Sea level rise

Nutrition
C	Share of population
undernourished

Number of people in a country who areexposed to the natural hazards
earthquakes (A), cyclones (B) and/or
flooding (C)Poverty anddependenciesD	
Dependency ratio (share of under15- and over 65-year-olds in relation to the

Number of people in this country who arethreatened by drought (D) and/or
sea level rise (E)working population)E	Extreme poverty population
living with USD 1.25 per day orless (purchasing power parity)(each weighted half owing to the uncertainty of the data base)

Economic capacity andincome distribution

Number of total population in country

F	Gross domestic product percapita (purchasing power parity)
G	Gini index

Exposure

33 %WorldRiskIndex
Figure 5: Calculation of the WorldRiskIndex

3.4 The WorldRiskIndex 2013It generally applies in scientific discoursethat modifications in indicators are difficult
to interpret over a short or limited period oftime since data quality and currency can varyconsiderably within the individual indicators(Freudenberg 2003; Meyer 2004). For an
optimum level of comparability, all indicators
would have to be from the same data source
for all countries, and both a uniform base48 [ WorldRiskReport 2013

year and a uniform method of establishingthe data would have to be applied. However,this cannot be put into practice, which is why
the data used can only provide an estimate.
Moreover, the method used in the calculations
and the subsequent method of classification
for the WorldRiskIndex provides a basis forthe comparison of individual countries with
one another. Thus minor differences in theInsufficient global
data available

Coping capacities

Adaptive capacities

Government and authorities

Education and researchA	Corruption Perceptions Index
B	Good governance (Failed States Index)

A	Adult literacy rate
B	Combined gross school
enrollment

Disaster preparedness and early
warning

Gender equity
C	Gender parity in education
D	Share of female
representatives in the
National Parliament	National disaster risk
management policy according
to report to the United Nations
Medical services

Environmental status /Ecosystem protectionC	Number of physicians per
10,000 inhabitantsD	Number of hospital beds per
10,000 inhabitants
Insufficient global
data available

E	
Water resourcesF	Biodiversity and habitat
protectionG	
Forest management
H	
Agricultural management

Social networks
	Neighbors, family andself-help
Material coverage

Insufficient global
data available

E	Insurances (life insurances excluded)

Adaptation strategies
	Projects and strategies toadapt to natural hazards andclimate change
Investment
I Public health expenditureJ	Life expectancy at birth
K	Private health expenditure

33 %individual indicators and hence the component values may result in shifts in ranking
compared to the previous year even thoughchanges in the country itself have been hardly
perceptible. For this reason, care ought to betaken when making direct comparisons of
the individual Index values with those of theWorldRiskIndex 2012. Nevertheless, bearing
these uncertainties and framework conditions
in mind, the values or country rankings of theprevious year’s and this year’s Index can be

33 %reviewed critically, and in particular, conspicuous shifts in the distribution of risks andvulnerabilities at global level can be analyzed.
Observations in the WorldRiskReport 2013
focus on vulnerability, since exposure relates
to the same data base as in 2012 because updates were not available. This year, therefore,changes in the risk of individual countries
can be traced back exclusively to changes invulnerability.

WorldRiskReport 2013 ] 49

Vulnerability can be successfully reduced inthree ways: first, by reducing the susceptibility of societies, second, by improving coping
capacities which are relevant in the case of adisaster, and third, by establishing and supporting long-term and sustainable structures
within a society which we refer to as adaptive
capacities (cf. Bündnis Entwicklung Hilft2012).
In the following, for the components of susceptibility, lack of coping capacities and lackof adaptive capacities, some countries are given as examples of the updates having resulted
in changes in the respective component values
and these being the cause of a change in ranking and, partly, of a shift to another class inaccordance with the quantile method.
Susceptibility
The countries with a very high level of susceptibility (Map B1, left fold-out page of thecover) are first and foremost the countries of
the Sahel zone and those in the tropical regions of Africa. The 15 countries with the highest susceptibility values comprise 14 Africancountries and Haiti.
Madagascar shows a conspicuous leap with regard to susceptibility. The susceptibility valueof Madagascar has deteriorated, rising from64.39 to 67.42, leading to a shift in positionof six ranks. The reasons for this include thenumber of people who are undernourished,a figure that has risen from 25 percent to33 percent. Furthermore, the proportion ofpeople living on less than 1.25 USD per day
has increased from two thirds (67.8 percent)to four fifths (81.3 percent) in comparison to
the values of the WorldRiskIndex 2012. In
addition, per capita Gross Domestic Product(purchasing power parity) is lower than it wasin the previous year. In the “high susceptibility” class, El Salvador has moved from 28.92
percent and rank 79 in the previous year to29.50 percent and rank 71. This is due both

50 [ WorldRiskReport 2013

to an increase in the share of the population
undernourished by 3.3 percent and to a rise in
the proportion of the population living on lessthan 1.25 USD per day.
The 15 countries with the highest susceptibility
worldwide:Country

Madagascar
Mozambique
Tanzania
Liberia
Chad
ZambiaEritrea
BurundiHaiti
Niger
Sierra Leone
Central African Republic
Comoros
Zimbabwe
Ethiopia

Susceptibility (%) Rank

67.42
65.54
65.05
64.05
63.62
62.94
62.98
62.50
61.64
61.26
60.68
60.01
59.98
58.12
57.24

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

In contrast, according to the data available,
the values for Niger and Armenia have
improved. Following 64.87 and ranked
fifth in 2012, the susceptibility value for
Niger this year is at 61.26, and it is ranked
tenth. However, this still leaves Niger inthe class with “very high” susceptibility.
The improvement in the value is mainly
due to the decline in the proportion of the
population undernourished (by 3.4 percent)and the fact that the proportion of the
population living on less than USD 1.25 a day
has fallen significantly (by 22.3 percent incomparison to the previous year). Armenia
remains in the class of countries with“medium” susceptibility, but its value has
dropped from 24.02 last year to 21.47, andit has risen by ten ranks. This is due to botha reduction in the share of the population
undernourished and to a decrease in theshare of people living on less than USD
1.25 per day. In addition, per capita Gross
Domestic Product (purchasing power parity)
has grown significantly.

Lack of coping capacities
The cartographic representation of the lackof coping capacities (Map B2, left fold-out
page of the cover) shows that countries withlow capacities and resources for coping with adisaster event can be found predominantly in
Asia and Africa, just like last year. A negative
development in the value for the lack of coping capacities is particularly conspicuous in
Zimbabwe. At 89.64, Zimbabwe is once again
significantly worse off than it was in the previous year, at 87.74. This is predominantly due
to poor values in the area of corruption and, inparticular, in the area of healthcare.
The 15 countries with the highest lack of
coping capacities worldwide
Country

Afghanistan
Sudan
Chad
Zimbabwe
Haiti
Yemen
GuineaMyanmar
Iraq
Central African Republic
BurundiGuinea-Bissau
Nigeria
EritreaCôte d’Ivoire

Lack of C. C. (%)

93.44
92.42
91.62
89.64
89.63
89.50
89.39
89.11
88.92
88.62
88.06
87.99
87.67
87.44
87.13

Rank

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Looking at all 173 countries, there havebeen individual major changes within
the component of coping. For example, asignificant worsening of coping capacities
can be observed in Syria and Libya. In Syria,
the value for the lack of coping capacities has
risen by 1.61 points from 80.19 in 2012 to81.80, and in Libya by 2.82 points, from 72.45
last year to 75.26. One of the reasons for thesenegative trends is an extreme worsening of thegovernance indicator “Good governance”. In
comparison to the previous year for Syria, thisindicator alone has moved from 85.9 points

previously to 94.5 points (higher values reflect
worse situations). In the case of Libya, theindicator has even worsened by 61 ranks andby 61 points to 84.9 points.
In terms of the data available, Ethiopia hasscored the highest positive jump, with its
coping value rising by 8.29 percent. As aresult, in the ranking of the lack of coping
capacities, Ethiopia shifts back by 43 ranks
and therefore moves out of the class of a “veryhigh lack” from last year to the class of a “highlack”. One of the reasons for this is improved
values in the area of corruption and healthcare(for example with regard to the number ofhospital beds).
Within Europe, Moldova has improved by
4.34 points and by 13 ranks, which can be attributed to an improvement in the governanceindicators of “Corruption” and “Good governance” as well as an increase in the “numberof physicians per 10,000 inhabitants”. Thus
Moldova is no longer among the countries
with a “medium lack of coping capacities” butin the class with a “low lack”.
Lack of adaptive capacities
The hotspot regions with regard to the lackof adaptive capacities (Map B3, left foldout page of the cover) can be recognized in
the Southeast Asian region and in Africa.
Compared to the previous year, on the African
continent, Burundi and Ghana have newly
entered the class showing a “very high” lackof adaptive capacities, whereas Morocco has
moved from the class of “very high” to theclass of “high”.
Looking at all 173 countries, Saudi Arabia
appears as a country with a high negativechange in its adaptive capacities (from rank
103 at 44.78 percent in 2012 to rank 90 at
46.24 percent). One of the reasons for thisis a reduction in combined gross school
enrollment by 3.4 percent, a reduction in

WorldRiskReport 2013 ] 51

gender parity in education and low public(19.3 percent less than in 2012) and private(26.3 percent less than in 2012) healthexpenditure. However, Saudi Arabia remains
in the class of countries with a “medium”
lack of adaptive capacities.
The 15 countries with the highest lack of adaptive
capacities worldwide
Country

Afghanistan
Eritrea
Niger
Mali
Haiti
Chad
Pakistan
Sierra Leone
Mauritania
Burkina Faso
GuineaBenin
Liberia
Nigeria
Comoros

Lack of A. C. (%)

Rank

76.11
72.57
71.76
69.25
67.88
67.61
65.94
65.82
64.86
64.44
63.88
63.54
63.28
63.07
63.00

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

In contrast, in the same class, the value andthe rank of Nicaragua have seen significant
improvements (from 48.21 and rank 77
in 2012 to 45.65 and rank 94), which is,among other factors, due to an increase inpublic and private health expenditure aswell as improvements in “gender parity”
thanks to a higher proportion of female
representatives in parliament. In Europe,
Turkey has improved from 49.40 andrank 69 in 2012 to 47.88 and rank 77.
This development is based on an increasein combined gross school enrollment by
five percent, a five-percent increase rise in
the proportion of female representatives
in parliament and higher public ( (19.8
percent more than 2012) and private(21.7 percent more than in 2012) healthexpenditure.

52 [ WorldRiskReport 2013

Vulnerability
On a worldwide scale, vulnerability is at its
highest in Africa, followed by Southeast Asia
and South Asia. These global distribution patterns of vulnerability are shown in the Vulnerability Map (Map B, right fold-out page of thecover). As a rule, the particularly vulnerable
countries are also very highly susceptible while
simultaneously bearing very low coping andadaptive capacities.
The 15 countries with the highest vulnerability
worldwideCountry

Afghanistan
Chad
Eritrea
Niger
Haiti
Sierra Leone
Liberia
Central African Republic
Mozambique
GuineaMadagascar
BurundiNigeria
Mali
ComorosVuln. (%)

Rank

75.41
74.28
74.23
73.21
73.05
70.75
70.31
69.98
69.85
69.20
69.18
69.17
68.99
68.90
68.56

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Exposure to natural hazards
Since no updates on exposure were available,
the World Map of Exposure (Map A, right foldout page of the cover) shows the same hotspot
regions as in 2012: Southeast Asia, Central
America, the Pacific islands, parts of West Africa and Southeastern Europe and the countries
along South America’s Pacific Coast. Therefore,
the description in the WorldRisk Report 2012
(Welle et al. 2012) is recommended for a closer
look at exposure to natural hazards.

WorldRiskIndex
Just like in 2011 and 2012, the risk hotspot
regions are in Oceania, Southeast Asia, Central America and the southern Sahel, where ahigh level of exposure to natural hazards andthe impacts of climate change coincide withparticularly vulnerable societies. The results of
the individual values for 173 countries are listed in the two tables in the Annex. The graphic
representations of the Index can be seen in
Map C on the right fold-out page of the coverand on the World Map on pages 54 and 55.
Taking all 173 countries into account, a severechange for the worse becomes apparent for
the Republic of the Congo, which has risen
from 7.38 percent and rank 71 in the “medium” class to 7.57 percent, and hence ranked
64th, in the class with a “high” risk. Reasonsfor this include an increase in the proportionof the population undernourished and lower
combined gross school enrollment. Ethiopia,
however, can boast positive developments. It
has risen from 7.81 points and rank 62 in 2012
to 7.38 points and rank 70, bringing it fromthe “high risk” class into the “medium risk”
class. This is due to aspects such as improvements in the “governance” indicators and arise in the adult literacy rate of ten percent.
In Europe, the Netherlands has continued toworsen — although it is already ranked in the“high risk” class in any case. Having been at
8.49 points (rank 51) in 2012, the risk has now
risen to 8.76 points (rank 46). The reasonsfor this are a worsening of coping capacities(e.g. “governance” indicators and per capita
healthcare). In contrast, Bosnia and Herzegovina have improved from 6.63 points and rank
86 to 6.42 points and rank 91 within the “lowrisk” class, which, among other aspects, is due
to improvements in the “governance” indicators and an increase in combined gross school
enrollment.

The concept of the WorldRiskIndex showsthat the risk of a country can be reduced bychanges in vulnerability, i.e. in the societal
sphere. For example, the results display that
improvements in the “governance” indicators
or, also, in the field of medical infrastructure,promote significant changes in coping capacities and hence reduce the index value for acountry’s disaster risk. Recent international
reports such as the Global Assessment Report2013 (GAR) also show that e.g. improved
healthcare facilities can reduce a country’s
vulnerability and hence its overall level of risk
(UNISDR, 2013).
The 15 countries that are most at risk
worldwideCountry

Risk (%)

Rank

Vanuatu
Tonga
Philippines
GuatemalaBangladesh
Solomon Islands
Costa Rica
Cambodia
El Salvador
Timor-Leste
Papua-New Guinea
Brunei Darussalam
Mauritius
Nicaragua
Japan

36.43
28.23
27.52
20.88
19.81
18.11
16.94
16.90
16.85
16.37
15.90
15.80
15.18
14.89
14.10

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

WorldRiskReport 2013 ] 53

56 [ WorldRiskReport 2013

4. What’s missing: political
determination and consistent
implementation
Peter Mucke, Peter Schmitz

In all cultures and societies, health is a vital good of key significanceto all people. Insufficient access to healthcare and prevention
programs, poorly developed health promotion and a lack ofinfrastructure for the provision of water and sanitation alreadyresult in disease or even death in “normal times” — in disaster andcrisis situations, things dramatically come to a head. Often, it is thepoorest who become victims: the poorest of countries and thepoorest in society. But among most national governments, as well as
in the context of the international community, there has so far beena lack of consistent readiness to take action. Usually, responses are
only triggered by disasters and crises, when there is extensive media
reporting and the need for action can no longer be denied.

WorldRiskReport 2013 ] 57

In the main, it is structural circumstances anda lack of willingness to spend money that are
responsible worldwide, and in particular in thepoorest countries, for the severe shortcomings
in the health sector and in disaster prevention.
These shortcomings cannot be eliminatedmerely by stepping up development aid. A newform of global health governance is needed
at national, regional and international level — together with a coordinated, determined
approach in implementing the international
agreements and commitments.

++ Four essential political negotiation process-es are relevant in this context that are all
going to feed into respective world summits
in 2015:++ Post-2015 Process: discussion of a new
global development agenda, preparation offollow-up agreements on the Millennium
Development Goals (MDG) and compilation of Sustainable Development Goals(SDG)++ World Climate Conference: negotiation of a
Kyoto follow-up agreement++ World Conference on Disaster Reduction:++ follow-up agreement on the Hyogo Framework for Action++ World Humanitarian Summit: discussionof general humanitarian aid issues.
Post 2015: Comprehensive strengthening ofhealth systems required
The internationally agreed Millennium
Development Goals (MDG) come to an end
in 2015, although they will continue to be an
important reference frame in the Post-2015
Process. They have given important impetus
to further developments in the field of healthand healthcare. By defining measurable goals,
at least as far as the verifiability of results
is concerned, an important step has beentaken in the right direction. The UN lists
the following among successes achieved in
implementation regarding health (UN 2013,
abridged):

58 [ WorldRiskReport 2013++ In the developing regions, the proportionof people having to survive on less than
1.25 dollars a day dropped from 47 to 22
percent between 1990 and 2010. Thus in
2010, around 700 million fewer people
were living in extreme poverty than in1990.
++ Over the last 21 years, more than 2.1
billion people gained access to improved
sources of drinking water. The proportion of the population making use ofsuch sources rose from 76 to 89 percent
between 1990 and 2010.
++ Between 2000 and 2010, malaria
mortality dropped worldwide by morethan 25 percent. An estimated 1.1 million
malaria fatalities were prevented in thisperiod. By 2015, tuberculosis mortality
is expected to have been halved incomparison to 1990 on a world scale andin several regions.
++ The proportion of undernourished peoplesank worldwide from 23.2 percent in the
period of 1990-1992 to 14.9 percent in the
period of 2010-2012.
Despite this, there continues to be anenormous need for action in the health sector(UN MDG 2013, abridged):++ At 51 mortalities per 1,000 livebirths

in 2011 (1990: 87), the mortality rate
among children under the age of five years
has dropped worldwide by 41 percent.
However, this is not yet enough to reachthe target of reducing child mortality by
two thirds by 2015.
++ Worldwide, maternal mortality has
dropped by 47 percent over the lasttwo decades: from 400 mortalities per
100,000 livebirths in 1990 to 210 in 2010.
However, the Millennium Goal target of
reducing the rate by three quarters has
not yet been reached.
++ Whereas the number of new infections
had sunk, an estimated 34 million people
were HIV-positive in late 2011.

++ From 1990 to 2011, an additional 1.9 billion

people gained access to a latrine, flush
toilet or other improved sanitary facilities.
However, the Millennium Goal target has
not been reached so far.
++ Areas where an urban-rural divide continues to exist include access to reproductive
health and to clean drinking water. In 2011,
in rural regions, just 53 percent of deliveries were performed by skilled medical personnel, compared to 84 percent in urban
regions. Eighty-three percent of the population without access to an improved sourceof drinking water live in rural regions.
The MDG were above all also criticized regarding a lack of financing regulations and an
insufficient level of transparency. In addition,owing to the agreed, binding sub-targets,
attention was often drawn more to individual
aspects or segments rather than to a comprehensive understanding of health and healthcare.
Reminding international financiers of theirdutiesThe Post-2015 Process has to link up withthe goals achieved, taking the deficits alreadyidentified into consideration, but it simul­
taneously needs to reach beyond them.
Regarding improvements in healthcare,
especially also in crisis situations, a comprehensive approach is required to strengthen
health systems.
On behalf of its member organizations, thedevelopment umbrella organization VENRO,
to which the seven relief organizations ofAlliance Development Works also belong,
therefore demands in its latest policy paper(VENRO 2013):++ “Enshrining the creation of effective andhigh-quality healthcare systems for all
in the Development and Sustainability­Agenda.

++ Stipulating the enforcement of access toeffective, safe and high-quality healthproducts and services for all in a new
global agenda. This applies in particular to
women and girls, and is aimed at further
reductions in maternal and child mortalities as well as among the poorest and themost marginalized groups.
++ That indicators be developed with which
the availability of appropriate resources
for the treatment of all diseases, whether
they be infectious or not, can be established in the development and extension ofhealth systems.
++ Adopting the human right to clean waterand sanitation in a new framework.
++ That the targets and indicators consider
barrier-free access to WASH at domestic
level, in schools and health centers andat workplaces and the necessary links
between WASH and other topics (health,education, gender, economic development
and environmental protection) are reflected.
++ Making information and education activities on breaking taboos regarding sanitary care part of a new agenda so that thesignificance of hygiene can be understoodby everyone.
++ Adopting a reduction of the disaster riskfor particularly susceptible population
strata and groups such as poor people,
children and people with disabilities in the
new agenda and establishing a strengthening of resilience as a goal.”
What will count is an accurate establishmentof the responsibilities held by the inter­national financiers, i.e. the national governments and the international institutions andthus providing for a democratic control ofboth financing and the implementation of theagreed measures. This has to be linked to acoordination of the measures between thefinanciers and the governments on the basisof what those concerned themselves deem
necessary.

WorldRiskReport 2013 ] 59

Developing strategies against progressive
climate changeThis includes diseases transmitted by mosquitoes, such as dengue fever and malaria.

Climate change has a wide range of impacts.
While the types and the extent of these impacts are global, they may nevertheless differ
within continents and, partly, within countries. It is undisputed that in particular the developing countries and the people living there
are exposed to massive risks and are expected
to bear the main burden of climate change.
Climate change is also going to affect people’s
health, with direct and indirect impacts on:

The health services therefore have to prepare
for what are partly new disease patterns and,in some regions, an increased incidence of various different diseases. Preventive measures,
hygiene, improvements in water supply andsanitation and the development of environmental medicine therefore gain considerable
significance. Just like the present Millennium Goals, the new development goals thatare to be agreed will be in jeopardy if climatechange is not checked. Thus the 2015 Climate
Conference belongs to the range of world
summits that are highly relevant to health and­healthcare.

++ disease patterns, incidence of diseases andcauses of mortalities++ food security and nutrition++ water supply and sanitation++ accommodation, settlement and the habitat
available++ frequency of extreme weather and climate
events++ flight and migration.
For example, rises in temperature and heatwaves have a direct impact on health. Thereis an increased incidence of cardiovascular
problems or heatstrokes. Even in comparatively rich Europe, the heatwave in France
in 2003 was already enough to stretch thecountry’s healthcare to its limits. However, thehealth services in the developing countries are
nowhere near as capable of caring for the additional patients in extreme weather events.
The increased occurrence of floods,
cyclones or drought periods leads to a risein infectious diseases because they often hit
sanitary infrastructure and water supply
for the population. For example, there
will be an increased incidence of diarrhea
and pneumonia if sanitation is insufficient(see Map of the World on pages 40/41). In
addition, changes in weather conditions andtemperature can result in carriers of diseases
spreading and wandering to regions in which
they were previously unknown.

60 [ WorldRiskReport 2013

Equal access for all
In future, it has to be ensured internationallythat equal access to healthcare is not influenced by economic and market interests. In
1978, the WHO adopted the Alma-Ata Declaration, in which participation and solidarity
are established as principles and “Health forAll” is demanded (WHO 1978). The central e­ lement referred to for this objective is­Primary Health Care (PHC). This course was­reaffirmed internationally by the WHO in
2008, in its “World Health Report: Primary
Health Care — Now More Than Ever” (WHO2008). This can be achieved locally if, as­stipulated in the PHC approach, the population can codetermine and co-decide issues.
In disaster aid, participatory approaches andcooperation with local organizations andgroups can make a crucial contribution to
involving victims as self-determined actors
and decision-makers and to mobilizing andstrengthening local resources. It is a global
challenge to prevent dependence of decisions,
including those made by the WHO, solely on
the financially powerful donors. This applies
both to the pharmaceutical industry and to
private institutions such as the Bill & Melinda
Gates Foundation.

Millennium Development Goals
Eradicating extreme poverty and hunger
kkHalving the share of people living on less than $ 1.25 a day between 1990 and 2015
kkAchieving full and productive employment and decent work for all, including womenand young people
kkHalving the share of people who suffer from hunger between 1990 and 2015
Achieving universal primary education
kkEnsuring that all children, girls and boys, can complete a full course of primaryschooling by 2015
Promoting gender equality and empowering women
kkEliminating gender disparity in primary and secondary education preferably by 2005,
and at all education levels by 2015 at the latest
Reducing child mortality rates
kkReducing the under-five mortality rate by two-thirds between 1990 and 2015
Improving maternal healthkkReducing the maternal mortality ratio by three quarters between 1990 and 2015
Combating HIV/AIDS, malaria, and other diseases
kkHaving halted and begun to reverse the spread of HIV/AIDS by 2015
kkAchieving universal access to treatment for HIV/AIDS for all those who need it by 2010
kkHaving halted and begun to reverse the incidence of malaria and other major diseases
by 2015
Ensuring environmental sustainability
kkIntegrating the principles of sustainable development into country policies andprograms and reversing the loss of environmental resources
kkReducing biodiversity loss, achieving a significant reduction in the rate of loss by 2010
kkHalving the share of the population without sustainable access to safe drinking waterand basic sanitation by 2015
kkHaving achieved a significant improvement in the lives of at least 100 million slumdwellers by 2020
Developing a global partnership for development
kkAddressing the special needs of the Least Developed Countries, the landlocked
developing countries and the small island developing states
kkDeveloping further an open, rule-based, predictable and non-discriminatory trading andfinancial system
kkDealing comprehensively with the debt problems of the developing countries
kkEnsuring, in cooperation with the private sector, that the benefits of new technologies,
especially information and communications technologies, are made available

WorldRiskReport 2013 ] 61

Creating the necessary political framework

Health is ahuman right:
Universal Declarationof Human Rights,
Article 25
1. Everyone has theright to a standard ofliving adequate forthe health and wellbeing of himself andof his family, including
food, clothing, housing
and medical careand necessary social
services, and the rightto security in the eventof unemployment,
sickness, disability,
widowhood, old age orother lack of livelihoodin circumstances
beyond his control.
2. Motherhood andchildhood are entitledto special care andassistance. All children,whether born in orout of wedlock, shallenjoy the same social
protection.
(Resolution 217 A (III)of the United Nations
General Assembly,
December 10, 1948)

The impacts of crises and disasters aremeasured by the amount of victims, by how
many are harmed by disease or injury and by
how many lives have been claimed directly or
indirectly. Today, standards are defined andbacked by corresponding indicators and definitions on how healthcare can be ensured indisaster relief operations and in development
cooperation. Health and nutritional status aswell as the possible effects of deficiencies anddeficits can be analyzed. In an acute disastersituation, this enables decisions to be taken
on whether the provision of healthcare or, forexample, water supply for the people corresponds to recognized minimum quantity andquality standards. Special measures can bederived from this in order to keep the numberof sick or injured people at a minimum level.
In addition, the indicators and standards are
suitable for a forward-looking assessment of
whether a society that comes into an emergency situation owing to crises or disasters will beable to cope with the ensuing problems andchallenges.
So by and large, the methods are known. But
political determination and consistent implementation are still lacking. This applies not
only to the area of disaster relief. As a whole,
both humanitarian aid and development cooperation are falling short of needs at present.
Selective changes and selective aid may beachieved, but the need to take political action
reaches much further. Far-reaching problems
have to be solved, and this requires that fundamental political decisions be taken. Those
who only think in the category of individual
disasters and crises have the necessary measures at their disposal to address them. Risk
and need analyses are familiar and suitable
instruments that are widely made use of. But

62 [ WorldRiskReport 2013

all too often, this only happens in individual
sectors. The measures taken in the event ofcrises and disasters are often fragmented
and are carried out in a multitude of projects which, as a rule, lack coordinating. But
successful disaster risk reduction, prevention and planning of adaptation call for acomprehensive approach. And they requirebinding international framework conditions.
What is needed is development oriented onsustainability that not only combats symptoms but addresses the causes and does not
eclipse critical issues: basic security benefiting everyone — comprehensive social security
systems — abandoning the pursuit of profit in
the health sector — global burden sharing ofhealth financing.
Health is a human right
The discussion in international bodies on
health as a public good that has to be protected is nothing new. On the 10th December
1948, the UN General Assembly also adopted the right to health in the context of the
Universal Declaration of Human Rights (UN1948). This UN resolution continues to be thecentral reference frame for demands on national governments and international institutions. And today, the human right to health isstill being violated in many places throughout
the world, and in many ways. Asserting thishuman right — just like the rights to food andaccess to drinking water and sanitation inthis context — continues to be on the agenda.

WorldRiskIndex, countries in alphabetical orderCountry

WRI

Rank

Country

WRI

Rank

Country

WRI

Rank

Country

WRI

Rank

Afghanistan
Albania
Algeria
AngolaArgentina
Armenia
Australia
Austria
Azerbaijan
BahamasBahrain
Bangladesh
Barbados
BelarusBelgium
BelizeBenin
BhutanBolivia
Bosnia andHerzegovina
Botswana
BrazilBrunei Darussalam
Bulgaria
Burkina Faso
BurundiCambodia
Cameroon
CanadaCape VerdeCentral African
Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
CyprusCzech Republic
DenmarkDjibouti
Dominican
Republic
EcuadorEgypt
El Salvador
Equatorial Guinea

9.93
10.01
8.13
6.48
3.76
6.97
4.51
3.80
6.28
3.99
1.81
19.81
1.16
3.31
3.42
6.62
11.32
7.98
5.08
6.42

39.
37.
54.
89.
133.
79.
119.
132.
95.
126.
166.
5.
171.
145.
142.
84.
25.
57.
109.
91.

6.34
6.19

94.
96.

16.37
10.34
28.23
7.65

10.
36.
2.
63.

5.90
5.52
6.57
6.69
3.14
2.10

100.
106.
86.
83.
149.
165.

3.71
7.99

135.
56.

3.85
7.08
27.52
3.46
3.80
0.10
5.05

129.
77.
3.
141.
131.
173.
111.

3.99
4.09
8.66
36.43
6.16
12.81
6.03
7.46
9.96

127.
125.
47.
1.
97.
18.
98.
68.
38.

6.61
3.78
7.43
4.51
3.35

85.
133.
69.
120.
143.

29.
19.
80.
81.
66.
64.
7.
43.
124.
88.
153.
139.
151.
40.
26.

3.48
5.05
7.09
7.71
3.93

140.
110.
76.
60.
128.

7.77
2.34
16.85
4.49

59.
162.
9.
121.

3.18
2.68
11.09
8.02
6.45
8.65
0.61

148.
155.
28.
55.
89.
48.
172.

Mauritania
Mauritius
MexicoMongolia
MoroccoMozambique
MyanmarNamibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
NorwayOman
Pakistan
PanamaPapua New
GuineaParaguay
Peru
Philippines
PolandPortugal
Qatar
Republic ofMoldova
Romania
RussiaRwandaSamoa
Sao Tome andPrincipe
Saudi Arabia
SenegalSerbiaSeychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
SwedenSwitzerland
Syrian Arab Rep.
Tajikistan

ThailandThe former
Yugoslav Republicof Macedonia
Timor-Leste
Togo
Tonga
Trinidad andTobagoTunisia
TurkeyTurkmenistan
UgandaUkraineUnited ArabEmirates
United Kingdom
United Republic of
Tanzania
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Yemen
ZambiaZimbabwe

11.06
12.28
6.91
6.90
7.52
7.57
16.94
8.96
4.24
6.51
2.77
3.61
3.10
9.84
11.28

92.
158.
70.
16.
163.
152.
99.
22.
82.
146.
45.
71.
169.
4.
51.
17.
23.
21.
31.
103.
168.
74.
33.
113.
116.
117.
160.
115.
20.
15.
114.
130.
78.
167.
112.
136.
50.
102.

53.
13.
92.
150.
75.
44.
42.
104.
106.
46.
118.
14.
24.
52.
161.
154.
73.
67.
11.

108.
123.
12.
122.
41.
34.
8.
27.
147.
32.
86.

6.35
2.52
7.38
13.56
2.28
2.79
5.93
11.71
6.83
3.24
8.81
7.36
1.44
20.88
8.32
13.09
11.65
11.88
10.91
5.69
1.55
7.17
10.54
4.92
4.83
4.69
2.49
4.88
12.15
14.10
4.88
3.84
7.02
1.78
4.94
3.70
8.43
5.71

8.26
15.18
6.39
3.10
7.13
8.89
9.10
5.68
5.53
8.76
4.69
14.89
11.62
8.32
2.35
2.74
7.21
7.49
15.90

5.37
4.26
15.80
4.43
9.72
10.46
16.90
11.23
3.18
10.80
6.57

Eritrea
Estonia
Ethiopia
Fiji
FinlandFranceGabon
GambiaGeorgia
Germany
Ghana
GreeceGrenadaGuatemalaGuineaGuinea-Bissau
GuyanaHaiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
IrelandIsraelItaly
JamaicaJapan
JordanKazakhstan
Kenya
Kiribati
Korea, Republic of
KuwaitKyrgyzstan
Lao People's
Democratic
Republic
LatviaLebanonLesothoLiberia
Libyan Arab
Jamahiriya
Lithuania
Luxembourg
Madagascar
MalawiMalaysia
Mali
Malta

1.32
10.99
7.53
2.58
10.37
2.49
3.63
3.69
18.11
5.80
3.38
7.67
7.87
8.55
7.65
2.26
2.61
5.67
7.35

170.
30.
65.
157.
35.
159.
138.
137.
6.
100.
143.
61.
58.
49.
62.
164.
156.
105.
72.

Countries not listed in theWorldRiskIndex
AndorraAntigua and Barbuda
Dem. People’s Republic of Korea
Democratic Republic of the Congo
Dominica
Federated States of Micronesia
Liechtenstein
Maldives
Marshall Islands
MonacoMontenegro
Nauru
Palau
San Marino
SomaliaSouth Sudan
St. Kitts and Nevis
St. Lucia
St. Vincent and the Grenadines
TuvaluWorldRiskReport 2013 ] 63

WorldRiskIndex overview

Rank

Country

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.

Vanuatu
Tonga
Philippines
GuatemalaBangladesh
Solomon Islands
Costa Rica
Cambodia
El Salvador
Timor-Leste
Papua New Guinea
Brunei Darussalam
Mauritius
Nicaragua
Japan
Fiji
Guinea-Bissau
Viet Nam
Chile
Jamaica
Haiti
GambiaGuyanaNiger
Benin
Dominican Republic
Cameroon
Madagascar
Chad
SenegalHondurasCape Verde
Indonesia
BurundiSierra Leone
Togo
Albania
Zimbabwe
Afghanistan
Djibouti
Burkina Faso
MyanmarCote d'Ivoire
Mozambique
Ghana
Netherlands
Uzbekistan
Mali
Suriname
Kyrgyzstan
GuineaNigeria
Mauritania
Algeria
Malawi
United Republic of Tanzania
BhutanSudan
Ecuador64 [ WorldRiskReport 2013

WorldRiskIndex

Exposure

Vulnerability

Susceptibility

Lack of coping
capacities

Lack of adaptive
capacities

36.43 %
28.23 %
27.52 %
20.88 %
19.81 %
18.11 %
16.94 %
16.90 %
16.85 %
16.37 %
15.90 %
15.80 %
15.18 %
14.89 %
14.10 %
13.56 %
13.09 %
12.81 %
12.28 %
12.15 %
11.88 %
11.71 %
11.65 %
11.62 %
11.32 %
11.28 %
11.23 %
11.09 %
11.06 %
10.99 %
10.91 %
10.80 %
10.54 %
10.46 %
10.37 %
10.34 %
10.01 %
9.96 %
9.93 %
9.84 %
9.72 %
9.10 %
8.96 %
8.89 %
8.81 %
8.76 %
8.66 %
8.65 %
8.55 %
8.43 %
8.32 %
8.32 %
8.26 %
8.13 %
8.02 %
7.99 %
7.98 %
7.87 %
7.77 %

63.66 %
55.27 %
52.46 %
36.30 %
31.70 %
29.98 %
42.61 %
27.65 %
32.60 %
25.73 %
24.94 %
41.10 %
37.35 %
27.23 %
45.91 %
27.71 %
19.65 %
25.35 %
30.95 %
25.82 %
16.26 %
19.29 %
22.90 %
15.87 %
17.06 %
23.14 %
18.19 %
16.03 %
14.89 %
17.57 %
20.01 %
20.26 %
19.36 %
15.13 %
14.65 %
15.56 %
21.25 %
14.96 %
13.17 %
16.34 %
14.32 %
14.87 %
13.67 %
12.73 %
14.48 %
30.57 %
16.18 %
12.55 %
18.12 %
16.63 %
12.03 %
12.06 %
12.47 %
15.82 %
12.34 %
12.01 %
14.81 %
11.86 %
16.15 %

57.23 %
51.07 %
52.46 %
57.53 %
62.50 %
60.40 %
39.75 %
61.12 %
51.69 %
63.61 %
63.77 %
38.44 %
40.64 %
54.69 %
30.71 %
48.93 %
66.58 %
50.53 %
39.66 %
47.07 %
73.05 %
60.69 %
50.87 %
73.21 %
66.34 %
48.74 %
61.71 %
69.18 %
74.28 %
62.55 %
54.51 %
53.31 %
54.46 %
69.17 %
70.75 %
66.49 %
47.09 %
66.60 %
75.41 %
60.22 %
67.86 %
61.22 %
65.58 %
69.85 %
60.79 %
28.67 %
53.52 %
68.90 %
47.20 %
50.71 %
69.20 %
68.99 %
66.19 %
51.39 %
65.00 %
66.49 %
53.89 %
66.40 %
48.14 %

34.66 %
27.72 %
33.74 %
38.57 %
40.92 %
43.96 %
21.58 %
43.47 %
29.50 %
52.16 %
51.22 %
14.48 %
18.96 %
37.09 %
16.84 %
26.14 %
53.39 %
28.08 %
20.71 %
27.10 %
61.64 %
42.31 %
28.69 %
61.26 %
53.29 %
28.31 %
41.30 %
67.42 %
63.62 %
46.54 %
35.59 %
35.53 %
33.01 %
62.50 %
60.68 %
52.49 %
20.67 %
58.12 %
56.67 %
39.49 %
55.60 %
36.65 %
48.58 %
65.54 %
46.65 %
14.03 %
31.39 %
55.80 %
29.19 %
27.20 %
54.33 %
56.22 %
48.77 %
23.04 %
55.76 %
65.05 %
32.41 %
51.33 %
27.00 %

81.27 %
80.56 %
80.47 %
80.80 %
86.23 %
84.15 %
64.10 %
86.60 %
75.69 %
79.36 %
83.99 %
64.69 %
60.61 %
81.32 %
40.08 %
75.30 %
87.99 %
76.71 %
58.65 %
72.09 %
89.63 %
82.39 %
79.37 %
86.62 %
82.20 %
73.06 %
84.97 %
82.68 %
91.62 %
81.29 %
81.80 %
69.98 %
81.79 %
88.06 %
85.73 %
85.01 %
74.74 %
89.64 %
93.44 %
81.78 %
83.53 %
89.11 %
87.13 %
83.88 %
77.58 %
42.16 %
78.07 %
81.66 %
70.73 %
76.28 %
89.39 %
87.67 %
84.95 %
77.36 %
83.07 %
82.64 %
75.44 %
92.42 %
74.72 %

55.77 %
44.94 %
43.16 %
53.21 %
60.34 %
53.09 %
33.58 %
53.28 %
49.88 %
59.31 %
56.10 %
36.15 %
42.35 %
45.65 %
35.22 %
45.35 %
58.36 %
46.80 %
39.63 %
42.01 %
67.88 %
57.38 %
44.54 %
71.76 %
63.54 %
44.86 %
58.87 %
57.43 %
67.61 %
59.83 %
46.15 %
54.41 %
48.57 %
56.94 %
65.82 %
61.96 %
45.87 %
52.05 %
76.11 %
59.38 %
64.44 %
57.89 %
61.02 %
60.13 %
58.15 %
29.82 %
51.11 %
69.25 %
41.68 %
48.64 %
63.88 %
63.07 %
64.86 %
53.77 %
56.17 %
51.80 %
53.82 %
55.45 %
42.69 %

Rank

Country

60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.

Liberia
Sri Lanka
Swaziland
Trinidad and Tobago
Congo
SerbiaComoros
PanamaZambiaRwandaEthiopia
GreeceTajikistan
Pakistan
India
MoroccoLesothoPeru
Kenya
Armenia
China
Colombia
Georgia
UgandaBelizeRomania
Turkmenistan
Central African Republic
Cuba
AngolaMalaysia
Bosnia and Herzegovina
MexicoEritreaThailand
Azerbaijan
The former Yugoslav
Republic of Macedonia
Venezuela
Yemen
Gabon
TunisiaSouth Africa
Lao People's Democratic
Republic
Hungary
Namibia
Syrian Arab Republic
Nepal
TurkeyBotswana
Bolivia
LebanonRepublic of Moldova
Korea. Republic of
IranJordanItaly
Iraq
Ireland

96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.

WorldRiskIndex

Exposure

Vulnerability

Susceptibility

Lack of coping
capacities

Lack of adaptive
capacities

7.71 %
7.67 %
7.65 %
7.65 %
7.57 %
7.53 %
7.52 %
7.49 %
7.46 %
7.43 %
7.38 %
7.36 %
7.35 %
7.21 %
7.17 %
7.13 %
7.09 %
7.08 %
7.02 %
6.97 %
6.91 %
6.90 %
6.83 %
6.69 %
6.62 %
6.61 %
6.57 %
6.57 %
6.51 %
6.48 %
6.45 %
6.42 %
6.39 %
6.35 %
6.34 %
6.28 %

10.96 %
14.79 %
12.76 %
17.54 %
11.65 %
18.05 %
10.97 %
16.45 %
11.37 %
11.98 %
11.12 %
21.11 %
12.98 %
11.36 %
11.94 %
13.25 %
11.40 %
14.40 %
10.69 %
14.51 %
14.43 %
13.84 %
14.69 %
10.16 %
13.31 %
15.77 %
13.19 %
9.39 %
17.45 %
10.18 %
14.60 %
14.02 %
13.84 %
8.55 %
13.70 %
13.16 %

70.31 %
51.83 %
59.95 %
43.60 %
64.96 %
41.75 %
68.56 %
45.50 %
65.67 %
62.01 %
66.37 %
34.88 %
56.64 %
63.45 %
60.06 %
53.80 %
62.24 %
49.17 %
65.73 %
48.04 %
47.87 %
49.90 %
46.54 %
65.82 %
49.70 %
41.95 %
49.83 %
69.98 %
37.33 %
63.68 %
44.18 %
45.78 %
46.17 %
74.23 %
46.26 %
47.72 %

64.05 %
27.33 %
44.89 %
18.81 %
55.63 %
18.67 %
59.98 %
27.97 %
62.94 %
55.98 %
57.24 %
16.89 %
35.61 %
37.69 %
39.31 %
28.97 %
50.97 %
29.48 %
55.94 %
21.47 %
27.93 %
28.97 %
27.37 %
56.38 %
28.10 %
21.84 %
25.98 %
60.01 %
19.15 %
54.20 %
20.60 %
19.33 %
23.05 %
62.68 %
20.71 %
22.94 %

83.59 %
78.70 %
80.84 %
69.54 %
85.28 %
66.96 %
82.70 %
67.15 %
80.38 %
79.15 %
80.05 %
52.01 %
76.96 %
86.72 %
80.31 %
75.82 %
79.35 %
73.97 %
85.40 %
71.29 %
70.03 %
78.33 %
63.89 %
87.00 %
74.23 %
61.31 %
75.80 %
88.62 %
57.04 %
84.73 %
68.35 %
69.88 %
72.32 %
87.44 %
75.53 %
71.16 %

63.28 %
49.46 %
54.14 %
42.45 %
53.99 %
39.61 %
63.00 %
41.37 %
53.68 %
50.91 %
61.82 %
35.74 %
57.35 %
65.94 %
60.55 %
56.61 %
56.39 %
44.06 %
55.85 %
51.36 %
45.64 %
42.41 %
48.36 %
54.09 %
46.76 %
42.71 %
47.71 %
61.32 %
35.79 %
52.12 %
43.57 %
48.13 %
43.14 %
72.57 %
42.53 %
49.06 %

6.19 %
6.16 %
6.03 %
5.93 %
5.90 %
5.80 %

14.38 %
13.15 %
9.04 %
11.95 %
12.45 %
12.08 %

43.01 %
46.85 %
66.67 %
49.63 %
47.37 %
48.07 %

20.59 %
23.50 %
48.40 %
33.03 %
22.53 %
29.52 %

64.70 %
74.84 %
89.50 %
74.61 %
72.08 %
69.25 %

43.75 %
42.22 %
62.12 %
41.24 %
47.50 %
45.44 %

5.71 %
5.69 %
5.68 %
5.67 %
5.53 %
5.52 %
5.37 %
5.08 %
5.05 %
5.05 %
4.94 %
4.92 %
4.88 %
4.88 %
4.83 %
4.69 %

9.55 %
15.61 %
10.41 %
10.56 %
9.16 %
12.25 %
10.55 %
8.98 %
11.14 %
11.11 %
14.89 %
10.19 %
10.53 %
13.85 %
8.08 %
14.74 %

59.86 %
36.43 %
54.56 %
53.74 %
60.43 %
45.06 %
50.83 %
56.64 %
45.35 %
45.45 %
33.19 %
48.25 %
46.33 %
35.22 %
59.79 %
31.85 %

42.29 %
16.08 %
45.84 %
25.65 %
43.56 %
19.38 %
36.38 %
43.58 %
20.18 %
23.32 %
14.34 %
18.40 %
24.05 %
16.11 %
34.31 %
15.19 %

86.17 %
52.19 %
71.12 %
81.80 %
81.51 %
67.94 %
67.56 %
78.76 %
68.69 %
66.49 %
47.05 %
79.08 %
67.95 %
56.07 %
88.92 %
46.26 %

51.13 %
41.01 %
46.72 %
53.77 %
56.23 %
47.88 %
48.55 %
47.60 %
47.17 %
46.54 %
38.18 %
47.26 %
47.00 %
33.49 %
56.14 %
34.10 %

WorldRiskReport 2013 ] 65

RankCountry

118.
119.
120.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.

New ZealandAustralia
Samoa
Equatorial Guinea
Bulgaria
BrazilCroatia
Uruguay
BahamasUnited States
Libyan Arab Jamahiriya
Paraguay
Kazakhstan
Portugal
Austria
RussiaArgentina
United Kingdom
KuwaitSlovenia
Slovakia
Czech Republic
LatviaPolandBelgium
Spain
Sao Tome and Principe
BelarusGermany
CanadaLithuania
UkraineMongolia
Denmark
FranceCyprusOman
Luxembourg
Switzerland
Seychelles
Estonia
Singapore
Israel
NorwayEgypt
FinlandSwedenUnited Arab Emirates
Bahrain
Kiribati
Iceland
GrenadaSaudi Arabia
Barbados
Malta
Qatar

66 [ WorldRiskReport 2013

WorldRiskIndex

Exposure

Vulnerability

Susceptibility

Lack of coping
capacities

Lack of adaptive
capacities

4.69 %
4.51 %
4.51 %
4.49 %
4.43 %
4.26 %
4.24 %
4.09 %
3.99 %
3.99 %
3.93 %
3.85 %
3.84 %
3.80 %
3.80 %
3.78 %
3.76 %
3.71 %
3.70 %
3.69 %
3.63 %
3.61 %
3.48 %
3.46 %
3.42 %
3.38 %
3.35 %
3.31 %
3.24 %
3.18 %
3.18 %
3.14 %
3.10 %
3.10 %
2.79 %
2.77 %
2.74 %
2.68 %
2.61 %
2.58 %
2.52 %
2.49 %
2.49 %
2.35 %
2.34 %
2.28 %
2.26 %
2.10 %
1.81 %
1.78 %
1.55 %
1.44 %
1.32 %
1.16 %
0.61 %
0.10 %

15.44 %
15.05 %
9.10 %
8.22 %
11.66 %
9.53 %
11.53 %
11.10 %
10.71 %
12.25 %
7.80 %
7.03 %
9.11 %
10.93 %
13.60 %
9.38 %
9.55 %
11.60 %
9.04 %
11.59 %
10.21 %
10.82 %
9.26 %
9.79 %
11.66 %
10.23 %
5.81 %
8.46 %
11.41 %
10.25 %
8.88 %
7.50 %
6.52 %
10.87 %
9.25 %
7.44 %
6.41 %
9.12 %
9.56 %
5.99 %
7.23 %
7.82 %
6.41 %
8.58 %
4.72 %
8.19 %
7.97 %
5.93 %
4.27 %
3.05 %
5.67 %
3.13 %
2.93 %
3.46 %
1.65 %
0.28 %

30.38 %
29.99 %
49.58 %
54.62 %
38.03 %
44.73 %
36.81 %
36.84 %
37.26 %
32.57 %
50.39 %
54.71 %
42.20 %
34.77 %
27.93 %
40.34 %
39.38 %
32.00 %
40.90 %
31.80 %
35.59 %
33.40 %
37.57 %
35.35 %
29.35 %
33.00 %
57.71 %
39.17 %
28.39 %
31.02 %
35.78 %
41.92 %
47.60 %
28.54 %
30.11 %
37.25 %
42.68 %
29.33 %
27.30 %
43.14 %
34.81 %
31.84 %
38.89 %
27.38 %
49.51 %
27.80 %
28.40 %
35.47 %
42.37 %
58.48 %
27.35 %
46.18 %
44.83 %
33.40 %
37.01 %
36.46 %

16.13 %
14.36 %
27.77 %
29.25 %
16.85 %
25.45 %
17.27 %
20.57 %
16.79 %
16.76 %
24.48 %
35.02 %
18.50 %
17.27 %
13.57 %
21.12 %
22.70 %
15.71 %
12.48 %
14.41 %
13.85 %
14.46 %
20.68 %
17.19 %
14.98 %
15.25 %
46.09 %
16.76 %
14.56 %
14.34 %
19.98 %
19.21 %
33.62 %
14.37 %
15.45 %
13.95 %
17.52 %
11.58 %
13.86 %
20.74 %
17.84 %
14.01 %
18.61 %
13.74 %
21.99 %
14.82 %
14.39 %
10.54 %
13.91 %
42.90 %
14.34 %
24.76 %
17.73 %
15.20 %
14.36 %
9.50 %

44.57 %
40.84 %
73.12 %
84.89 %
56.81 %
67.04 %
57.36 %
50.87 %
53.28 %
48.78 %
75.26 %
78.72 %
62.30 %
48.51 %
37.63 %
58.80 %
59.81 %
47.88 %
66.10 %
50.51 %
55.81 %
50.15 %
57.44 %
54.43 %
41.05 %
49.68 %
75.04 %
61.40 %
38.09 %
45.37 %
51.66 %
61.55 %
65.35 %
39.91 %
42.74 %
56.27 %
63.74 %
41.98 %
37.75 %
63.06 %
52.24 %
48.47 %
59.87 %
39.78 %
76.47 %
39.13 %
41.38 %
56.14 %
64.81 %
82.49 %
40.19 %
69.12 %
70.53 %
49.91 %
53.13 %
56.15 %

30.46 %
34.76 %
47.84 %
49.72 %
40.42 %
41.71 %
35.79 %
39.09 %
41.73 %
32.17 %
51.42 %
50.40 %
45.81 %
38.52 %
32.61 %
41.09 %
35.65 %
32.40 %
44.13 %
30.48 %
37.09 %
35.61 %
34.59 %
34.44 %
32.01 %
34.08 %
51.99 %
39.34 %
32.52 %
33.35 %
35.72 %
45.00 %
43.82 %
31.34 %
32.13 %
41.54 %
46.78 %
34.44 %
30.29 %
45.62 %
34.35 %
33.04 %
38.19 %
28.62 %
50.07 %
29.44 %
29.44 %
39.74 %
48.39 %
50.06 %
27.52 %
44.65 %
46.24 %
35.10 %
43.55 %
43.73 %

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Publisher:
Bündnis Entwicklung Hilft (Alliance Development Works),
In charge of publishing: Peter Mucke
Concept and implementation:Peter Mucke, Bündnis Entwicklung Hilft, Project leader
Dr. med. Peter Schmitz, Universität Bonn, Institut für Hygieneund Öffentliche Gesundheit
Lars Jeschonnek, MediaCompany
Scientific advisor for the WorldRiskIndex:
PD Dr. Jörn Birkmann, United Nations University,
Institute for Environment and Human Security (UNU-EHS)
Scientific advisors for the focal topic:
Prof. Dr. med. Thomas Kistemann und Stephan Luther, Universität Bonn,
Institut für Hygiene und Öffentliche Gesundheit
Dr. med. Joost Butenop und Joachim Rüppel, Missionsärztliches Institut
Würzburg
Authors:
Dr. med. Joost Butenop, Missionsärztliches Institut Würzburg
Prof. Dr. med. Thomas Kistemann, Universität BonnPD Dr. med. Michael Marx, Institut für Public Health,
Universitätsklinikum Heidelberg
Peter Mucke, Bündnis Entwicklung Hilft
Dr. Katrin Radtke, Welthungerhilfe
Dr. med. Peter Schmitz, Universität Bonn
Kirsten Schubert und Thomas Gebauer, medico international
Dr. Sonja Weinreich, Brot für die Welt
Dr. Torsten Welle, PD Dr. Jörn Birkmann, Prof. Dr. Jakob Rhyner,
Maximilian Witting und Jan Wolfertz, alle UNU-EHS
In collaboration with:Tina Braun, Bündnis Entwicklung Hilft
Mareike Haase, Brot für die Welt
Wolf-Christian Ramm, terre des hommes
Ulrike Veismann, Christoffel-Blindenmission
Editors:
Lars Jeschonnek, MediaCompany
Graphic design and information graphics:
Naldo Gruden, MediaCompany
Translation:
Michael Gardner
Cooperation partners:
United Nations University, Institute for Environment andHuman Security (UNU-EHS), Bonn
Universität Bonn, Institut für Hygiene und Öffentliche Gesundheit
ISBN 978-3-9814495-3-2
With the kind assistance ofStiftung Umwelt und Entwicklung
Nordrhein-Westfalen

Picture credits:
Cover photo: Hygiene training at Roger Delmas School in Jacmel(Haiti). © Thomas Lohnes/Brot für für die Welt
Pages 4/5: Healthcare for cholera patients in Haiti. © Herzau/
Welthungerhilfe
Pages 10/11: Slum-dwellers in Naglamachi, on the outskirts of New
Delhi. © Jörg Böthling/Welthungerhilfe
Page 19: Robert Koch. © wikipedia
Page 21: Men building a weir. Swat Region/Pakistan. © Thomas
Lohnes/Brot für die Welt
Page 25: Syria during the civil war. © wikipedia
Page 29: Building a house in Haiti. © Christoph Püschner/Brot für die
WeltPage 33: Artificial limbs. © Howarth/CBM
Page 35: Returning from the North at the bus station in Juba (South
Sudan). © Christoph Püschner/Brot für die Welt
Page 39: People sitting together in a meadow, El Salvador. © Werner
Rostan/Brot für die Welt
Pages 44/45: The river eats away three meters a day. Charsada (SwatRegion, Pakistan). © Thomas Lohnes/Brot für die Welt
Pages 56/57: Koyom District Hospital, father Felix Gyegoye holding his
six-year-old son Didye’s hand (Chad). © Christoph Püschner/Brot fürdie Welt
Online:Detailed scientific explanations, further detailed information andtables are available at www.WorldRiskReport.org and can be called up
as downloads.

Publisher:

Bündnis Entwicklung Hilft
Alliance Development Works
Chausseestraße 128/129
10115 Berlin
Phone +49 30 – 278 77 390
Fax+49 30 – 278 77 399
kontakt@entwicklung-hilft.dewww.entwicklung-hilft.deISBN 978-3-9814495-3-2

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