Ensuring healthy cities in the face of climate change: Lessons on urbanization, waste and infectious diseases in Nepal

Climate change is leading to patterns of disease outbreaks in new and unexpected ways in urban areas. This piece looks at how nature-based solutions can help address some of the challenges for urban health. However, lack of adequate research poses an obstacle to tackle infectious diseases especially in densely-populated cities.

Sustainable Development Goal 3 calls for health and well-being for all, including the ambitious target of ending epidemics like malaria and other communicable diseases by 2030. However, in rapidly growing cities of the Global South, critical infrastructure and services, such as sanitation and waste management, which are vital to preventing disease, can struggle to keep pace. Meanwhile, climate change is resulting in new and unexpected patterns of disease outbreaks.

A worrisome example of this is in Nepal which has seen an exponential rise in cases of Dengue fever – a mosquito-borne tropical illness that can be potentially fatal. Evidence shows that rising temperatures driven by climate change are increasing suitable breeding habitat for the disease-carrying mosquitos, spreading their reach to higher-altitude areas such as Nepal which were previously unaffected by outbreaks.

For the past five decades, malaria has been the key vector-borne disease in Nepal and claimed many lives. However, due to sustained national and international level interventions, Nepal is approaching the elimination of Malaria in the near future. Multiple effective techniques were identified to destroy the vector mosquitoes at their breeding and feeding sources.

One of the popular techniques widely adopted in Nepal to kill these vectors is fumigation. However, it was later understood that these “fool-proof” techniques were not good for biodiversity and public health as they led to the loss of beehives and increased respiratory disease. More than that, these techniques are found to be ineffective against rapidly increasing new diseases like Dengue.

“These emerging vectors of Dengue have totally different traits to that of other vectors the public knows of,” says Kumar Prasad Pokharel, the Vector Control Inspector of VBDTRC, who has been working on such vectors since last 36 years.

Dengue mosquitos breed in very small amounts of water including places that may contain rainwater like old tyres in junkyards, potholes in the road and household water storage containers.

Lessons from Bharatpur, Nepal

Nature-based solutions (NBS) have received strong attention in the development and climate change arena. For instance, Chapter 6 of the IPCC Working Group II report on Cities, Settlements and Key Infrastructure emphasizes hybrid and multifunctional measures that combine NBS with traditional “grey” infrastructure and integration in adaptation planning and hazard protection. Often, they can be cheaper and flexible compared to grey infrastructure alone, can be multifunctional and deliver a range of co-benefits – which is a strong incentive for developing cities that have constrained resources.

Despite this, the evidence base for mainstreaming and scaling remains underdeveloped, which leaves policymakers and practitioners reluctant to move outside of business-as-usual approaches. Moreover, despite evidence showing NBS can support facets of urban health, including urban cooling and mental health and wellbeing, there is a lack of research on the potential of NBS to tackle infectious disease.

In August 2023, the SEI team with its partner Youth Innovation Lab(YIL) visited the fast-growing city of Bharatpur – Nepal’s third largest – to understand some of the urban health challenges the city is facing and what the municipal government and local communities have been doing to tackle them.

Recognized as the “medical city” of Nepal, Bharatpur has more than a hundred hospitals. It also boasts the Chitwan national park, which attracts hundreds of thousands of domestic and international tourists every year. Despite a relatively advanced stage of infrastructural development, the city encounters several hazards to the health and wellbeing of its residents.

As well as vector-borne disease, Bharatpur lacks an official waste disposal site meaning that unofficial waste dumping takes place alongside the riverbank, leading to leakage of trash into the river. Household waste and sewage get mixed and flow untreated into the Narayani River. Sewage canals on the roadside of the Mahendra highway of Nepal, which is currently under repair remains open, which have resulted in foul odours and excellent sites for breeding of germs and flies.

As well as spoiling the river’s natural beauty and harming biodiversity, officials report that the polluted water has caused skin conditions, shortages of clean drinking water and outbreaks of water-borne diseases such as cholera, diarrhoea, dysentery and typhoid. Pollution levels spike during the monsoon rains when drainage canals and open sewage canals overflow – a situation which is expected to worsen as climate change leads to more extreme weather patterns.

After the 2015 earthquake in Nepal, Scrub Typhus is another disease which has been spreading and has since been classified as endemic. Its vector is chigger mite, which are carried by rodents, meaning that unmanaged garbage sites are a key breeding ground. With the changes in climate, incidence of these diseases is likely to worsen in the future and if compounded with poorly planned and managed infrastructure, Bharatpur residents face an escalating health challenge.

Municipality and community take action to improve health

During the inception workshop with representatives from the municipality, selected wards, civil societies and public, we learnt about several initiatives taken up by the public and government to address the health risks from these multiple hazards.

Local wards have undertaken public awareness programs for Dengue and have informed local people about potential sites of breeding for mosquitoes. Similarly, some local wards have been trying to secure a basic health insurance for their public.

Garbage disposal and sewage management were key concerns of the community. Some local patrol groups have been formed to discourage illegal garbage disposal in public spaces and canals. However, unmanaged and unfenced private lands are emerging as potentially problematic sites for garbage disposal. Privately owned land does not fall under the responsibility of local wards or municipalities, which makes it more difficult to manage potential vector breeding sites in these spaces. A public health representative also raised concerns about the segregation of medical waste generated from the hospitals and clinics and how they can be managed safely.

The municipality has been organizing sanitation clubs at schools to promote waste management and sanitation. We have also formed a private-public partnership model for waste management and have been distributing composting chambers to the public with training as well. Mosquito fumigation is no longer used in Bharatpur for 4–5 years.

Representative Health Officer from Bharatpur municipality

“While these efforts are currently being undertaken, they will not suffice for an uncertain future,” says Arjun, a human rights activist in Nepal. With the ever-changing climate and an expanding urban population, the existing medical capabilities and resources are already stretched to their limit. Integrated solutions are needed that involve urban planning, disaster risk reduction and public health.

The challenge ahead

The project aims to initiate a household survey to understand the correlation of health with potential drivers of hazards, such as waste dumps and bodies of water and to scope the potential of NBS, as well as urban planning, disaster risk reduction and community-based measures to tackle the identified hazards. An “Urban Living Lab” will be conducted which includes activities such as “serious games” in an iterative process to co-create solutions that reflect local needs and priorities.

While solutions will be tailored for the city of Bharatpur, findings will have broader relevance for developing cities of South and Southeast Asia, which are contending with similar compounding pressures of urbanization, climate change and infectious disease.

To avoid cities from becoming epicentres of disease, we need to look for innovative methods that draw upon integrated planning approaches together with the ingenuity of local communities to achieve future-proof solutions for urban health and wellbeing.