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Dr. Muh Aris Marfai M.Sc and Dr. Danang Sri Hadmoko, M.Sc

Faculty of Geography, Universitas Gadjah Mada, Yogyakarta, 55281 Indonesia


Input paper

the 2nd HIA for ASEAN Workshop in Bangkok

4-6 October 2012


Indonesian archipelago, as a country with 1,904,569 km2 extent area and about 230
million inhabitants, is very vulnerable to natural hazard. The threatening event of natural hazard
is the main source of damages to human environment. Although various natural hazards are
continuously emerging in worldwide scale, the impact is higher in developing countries, such as
Indonesia (Marfai et al. 2008a). In addition to high magnitude and intensity of natural hazards
occurred in Indonesia, socio-economic aspects often produce higher risk. The hazards occurrence
in Indonesia is continuously increasing. This condition is not only caused by physical process,
but also combined by unsustainable human activities, especially due to inappropriate land use
management (Marfai and King 2008a).
Various natural hazards occur in Indonesia each year. This condition mainly related to the
geographic position of Indonesia, which located in very active tectonic plates. Tectonic setting of
Indonesia in general is located on the collision of three major tectonic plates, namely Eurasian,
Indian-Australian, and Pacific Plates. The movement of each plate makes the location to be very
susceptible to volcanic eruption, earthquake, and tsunami (GFDRR 2009; Sutikno 2007).
Detailed tectonic setting of Indonesia, as explained by Hall (2009), is shown in Figure 1.1.

Figure 1.1. Tectonic setting of Indonesian Archipelago. Red arrows indicate the movement
relative to each other: IND-EUR (Indian to Eurasian plate), PSP-EUR (Philippine Sea Plate to
Eurasian plate), and AUS-PAC (Australian to Pacific Plate). Source: Hall 2009

Besides the hazards generated by active tectonic movement, hazards due to other naturalenvironmental condition also exist. Worse disaster events are currently increasing due to
environmental degradation, as produced by unsustainable development. As summarized by
Marfai et al (2008a), Marfai and King (2008a), Marfai (2011a), Sartohadi et al (2009), and Ward
et al (2011), coastal erosion and inundation, river flooding, land subsidence, and landslide also
have been identified in many places. The hazards of coastal erosion, coastal inundation, river
flooding, and land subsidence are now threatening major urban coastal cities in Indonesia,
especially Jakarta and Semarang (Marfai and King 2007; Marfai and King 2008a; Marfai and
King 2008b; Marfai et al. 2008b; Ward et al. 2011). Indonesia also becomes highly prone area to
climatic hazards, such as drought and cyclone. Increasing extreme climatic condition, as driven
by climate change phenomena (IPCC 2007), is predicted cause higher magnitude and intensity of
drought and flood (Naylor 2007). Various natural hazards affecting Indonesian archipelago is
summarized in Figure 1.2. These hazards led Indonesia suffered many losses. One of the
important impacts of disaster is health sector. This chapter is intended to provide basic
understanding of Health Impact Assessment (HIA) in disaster management in Indonesia,
particularly in flood management.

Figure 1.2. Various natural hazards affecting Indonesian archipelago (adopted from Marfai

1.1. Indonesia: Facing with Various Disaster Events.

Indonesia is very prone to natural disaster events. Disaster events become is regularly
occurred and cannot be avoided by Indonesian communities. Historical record during 1907-2004
has shown that 55,418 people were totally killed and 12,688,833 people affected due to disaster
events in Indonesia. With considering the number of people killed, earthquake and tsunami is the
most dangerous hazard in Indonesia, following by volcanic eruption, drought, flood, and cyclone
(EM-DAT 2004). Large disaster events during 2004-2007, as summarized by Bappenas (2010),
took thousands of human live and economic losses. The total economic losses reached up to
almost 10 trillion rupiah (about 1 billion US dollars) (Table 1.1).
Table 1.1. Large disaster events during 2004-2007 and its impact
Type of
Earthquake and


Nanggroe Aceh
Yogyakarta and
Central Java
Earthquake and Pangandaran



Property Losses

Dec 2004

165,708 people death

Rp. 4.45 trillion

May 2006

5,667 people death

Rp. 3.134 trillion

July 2006

658 people death

Rp. 967 billion

Feb 2007

145,774 houses

Rp. 967 billion

Source: Bappenas 2010

Almost all regions in Indonesia are susceptible to earthquake and tsunami. The area with
high susceptibility is generally located in which plate tectonic subduction zone taken place.
Highly susceptible areas are including Southwestern part of Sumatra, Southern part of Java, Bali,
and Nusa Tenggara, entire area of Moluccas, Eastern part of Celebes, and Northern part of Papua
(Bakosurtanal 2006) (Figure 1.3). Those areas are also known as Indonesian ring of fires, in
which consist of more than 400 volcanoes. About 130 active volcanoes are found in this zone,
threatening the local community from volcanic explosion. Among those active volcanoes, a
volcano called Merapi Volcano-Central Java, is categorized as one of the most active volcano in
the world (Lavigne 2000; Gertisser 2012). Merapi eruption is one of the most devastating

eruptions throughout the country. Since mid of 1500s, 61 reported eruption of Merapi volcano
killed about 7,000 people (Thouret et al. 2000)

Figure 1.3. Tsunami vulnerability map of Indonesia (Bakosurtanal 2006, with modification from
Marfai 2008a)
Although highest disaster victims are produced from earthquake and tsunami, the
occurrence is infrequent. In fact, 40% of disaster events in Indonesia are generated from flooding
(EM-DAT 2004; Dewi 2007). In addition to flooding due to overflowing water from the river,
flooding due to high tides is also common in the coastal area (Marfai et al 2008b). The flood
hazard is higher in west part of Indonesia, especially in Java Island (National Board of Disaster
Management/BNPB 2010). The map of flood hazard intensity in Indonesia is shown in Figure
Flood occurrence

Figure 1.4. Flood hazard occurrence of Indonesia during 1979-2009 (Source: BNPB 2010)

1.2 The role of the Indonesian government on the disaster management

Disaster risk reduction activities in Indonesia basically refer to international consensus of
Hyogo Framework for Action (HFA) for 2005-2015. HFA, as created by United Nations
International Strategy for Disaster in 2005, is intended to improve resilience of the nations and
communities. Improvement on disaster risk reduction activities, including its planning,
implementation, and evaluation is the main focus of ten years global HFA strategies (Djalante et
al. 2012). Evaluation of HFA implementation by UNISDR (2011) placed Indonesia in lower
middle position with score of 2.8 from the scale of 5 (Figure 1.5).

Figure 1.5. Indonesian position on implementing HFA (UNISDR 2011 with modification from
Djalante 2012)
Various organization, including local government, international agency, and nongovernment organization (NGO), are involved in present disaster management in Indonesia. In
2008, more than 600 stakeholders working on disaster risk reduction in Indonesia (including
government, NGO, and agencies) were listed in UN Office of Humanitarian Affairs (OCHA)
database (UNTWG-DRR 2008). In order to manage various stakeholders involved, national
coordination is taken by National Board of Disaster Management (BNPB). New structural
organization of BNPB on national level and BPBD in local/provincial level has been introduced

in 2008 (BNPB 2011). National coordination disaster management is now refers on this
structure, which is divided from local, provincial, and national level.
National regulation on disaster risk reduction is ruled through Law Number 27/2007 on
disaster risk reduction program. Following this regulation and HFA framework, several action
plans have been developed. The most recent is National Action Plan on Disaster Risk Reduction
(NAD-DRR) 2010-2012. NAP-DRR is the elaboration of Disaster Management Plan (RPB)
within the framework of national development plan. The plan is including Long Term National
Development Plan (RPJPN) and Medium Term National Development Plan (RPJMN) (Bappenas
2010). This framework can be separated into three different level, including regency/municipal
level, provincial level, and national level. Development plan on each level (RPJP/RPJPN) must
refer to Spatial Development Planning document (RTRW), in which the hazards has been
identified and mapped. Detailed structure of this framework is shown in Figure 1.6.

Figure 1.6. Disaster Management Planning Coordination Framework (Bappenas 2010)

1.3 Flood Disaster management in Indonesia

The impact of flooding is considered as destructive and devastating to the human live and
its environment (Marfai et al. 2008b; Nicholls 2004; Nicholls et al. 2008). Serious impact
generated by flooding is not only suffered by Indonesian communities. Fact that more than 1,800
events from total 2,654 hazard events recorded in 1993-2002 were generated by flooding and
windstorm, flooding therefore becomes serious problem that must be faced throughout the world
(Sivakumar 2005). In Asian countries, Indonesia places the third rank in the term of flood hazard
occurrence. This position is slightly lower than China and India (Dewi 2007). Detailed
information is shown in Figure 1.7.

Figure 1.7. Asian countries with highest flood occurrence (Dewi 2007)
As summarized by BNPB (2010), there were 2509 large flood hazard during period of
1979-2009. The number is even bigger if minor flood hazard is included, in which the annual
average of flood hazards in Indonesia is about 297 cases per year. Although the number of people
death due to flooding is lower, but the number of total casualties (including people moved and
evacuated) is the highest. Almost 94% of total casualties generated by natural hazards in
Indonesia are caused by flooding. During single year of 2009, 311 inhabitants were death and
5,232,081 inhabitants were evacuated due to flooding (BNPB 2009). Sorted by province, Jawa
Tengah (Central Java Province), Jawa Timur (East Java Province), and Jawa Barat (West Java
Province) are the province with highest flood hazard occurrence (Figure 1.8). In these provinces,
more than 200 large flood hazards occurred during 1979-2009.

Figure 1.8. Number of large flood hazard occurred in Indonesian Province during 1979-2009
(Modified from BNPB 2010)
Because the flood occurrence is highest in Java Island, in which more than 60%
Indonesian population live, flood hazard is considered to be very problematic. In Java, flooding
not only becomes major threat to the area alongside the riverbank, but also on lowland delta and
coastal area. Due to the dynamic of geomorphological processes on low and flat topography,
coastal area and lowland delta in the north part of Java Island is the most affected by flooding
(Bird and Ongkosongo 1980; Sunarto 2004).
In the term of urban coastal cities and megacities, Jakarta and Semarang, as located in
north part of Java, are the most affected by flooding. In addition to the threat of river flooding,
coastal flooding due to high tide also exists. In Jakarta, increasing coastal inundation due to sea
level rise is predicted to cause 14,900 - 15,100 ha losses of land and corresponding damage
between 20.8 to 21 billion USD (Ward et al. 2011). In Semarang, the scenario of increasing
coastal flooding of 120 cm and 180 cm high tide developed by Marfai and King (2008a), is
predicted to cause 4,567 5594 ha losses of land. Moreover, the economic losses due to
increasing coastal flooding in Semarang are predicted to range between 2.2 to 2.9 billion USD.
In reducing the impact of flooding, several adaptive response and mitigation actions have
been implemented by local government. As explained by The US Army Corps of

Engineering/USACE (2002) and Intergovernmental Panel on Climate Change/IPCC (2001), the

actions are including; (1) accommodation strategy, (2) protection strategy, and (3) retreat
strategy. Accommodation strategy is intended to make some adjustment so the community could
continue his/her daily activities in flood prone area. Protection strategy aims to build defense
system the prone area, mainly by implementing hard structures e.g., dikes, pumping station, and
retention area. Retreat strategy is focused on the evacuation of the people from the hazard prone
area. Most of the effort on flood management in Indonesia is now based on protection strategies
(Texier 2008).
With the new regulation of decentralization, in Indonesia, the prior task of disaster
management is now must be held by local government (district and/or provincial level).
Therefore, local government must pay particular attention about the most important issues on the
impact of hazards, especially flood hazard (Marfai and King 2008a). Jakarta and Semarang can
provide brief example of the flood management taken. In addition to the main structural
measures against flooding in Semarang (e.g. floodway, dike, and drainage system), the local
government has improved the spatial planning and land use management (Public Works
Department/PWD 2000; Development Planning Board/DPB 2000). Similar to Semarang,
physical measures is also the most common in Jakarta. The measures are not only including
floodway, dike and drainage system built by local government. Private adaptations by local
communities were also exist, especially by elevating the house level and built small dike from
sandbags (Caljouw et al. 2005). Moreover, Jakarta spatial planning to year 2030 provides more
clear direction in reducing the flood hazard in Jakarta (Ward et al. 2012).
Shifting towards more integrated flood management, especially in non-structural
mitigation, has been identified in several cities in Indonesia (Ward et al. 2012, Marfai and King
2008a). The shifting towards advanced flood management in Indonesia is including development
of non-structural measures framework. In general, organizational development in has been in
national, provincial, and local level in reducing the impact of disaster. In national level, disaster
coordination is taken by Bakornas-PBP. Local representative in provincial level taken by
Satkorlak-PBP, while in district level (kota/kabupaten) is taken by Satlak-PBP. The existence of
this institutional framework provides better support on mitigating the natural hazards in
Indonesia, especially on flood hazard (Marfai and King 2008a).


1.4 Flood Impact Assessment

Flooding is not considered to generating impact if there is no interaction with the human
environment. The impact only exists when the flooding is affecting natural and human made
environment. Thus, it generates negative state or condition towards human environment, such as
environmental damage, death, and disruption (Jha et al. 2012). Impact assessment is basically
part from disaster risk management cycle, in which consists of three phases. The phases consists
of before the hazard occurred (prevention), during the hazard (response/intervention), and after
the hazard occurred (recovery) (Bieri 2003). All of the phases construct the cycle as shown in
Figure 1.9. Related to disaster risk management cycle, impact assessment is positioned in the
prevention action. By knowing the potential impact of the hazard, future measures, including
development of technical and organizational measures, land use planning and emergency
planning can be implemented.

Figure 1.9. Disaster risk management cycle (Bieri 2003)

Impact assessment is slightly different than risk assessment. In technical setting, risk is
defined as the potential losses which is resulted from the probability of event (in this term we
refers to hazard event), and potential negative consequences of the event, as represents by
vulnerability. In assessing the risk, a methodology to determine the extent area affected by
hazard and the characteristic of area vulnerability is required (UNISDR 2009). Therefore, higher
risk is achieved if highly magnitude of hazard interacts with highly vulnerable area.

The term of impact assessment is more general than risk assessment. Impact assessment
is intended to identify potential damages and/or losses due to interaction of hazard with natural
and human made environment. Impact assessment defines the number of exposed people,
property, services, or everything related to the damages generated by hazard event. In order to
access the impact of flooding, Jha et al (2012), has classified the impact into two classes; consists
of direct and indirect impact of flooding. The direct impact is including impact towards people,
building and contents, animal and crops, etc. The indirect damage is including natural, Health,
environment, human and social impact, economic and financial impact, etc (Figure 1.10).

Figure 1.10. Example of direct and indirect impact of flooding (modified from Jha et al. 2012)
Health is one example of the indirect impact that is often emerging due to flooding
(Reacher et al. 2004; Jacubicka et al. 2010). In addition to immediate health impact of flooding
(e.g. drowning, injury, acute asthma, skin infection, gastroenteritis, and respiratory infection), the
health impact in the longer term (e.g. diarrhea, dysentery, and dengue fever) also exists (Noji
1991; Baxter et al. 2001; Howard et al. 1996). Regarding to the board range of health impact of
flooding, health impact assessment due to flooding is considered to be very important, especially
in developing countries. The low environmental quality that often found in developing countries,
such as Indonesia, might trigger higher health impact due to flooding. Therefore health impact
assessment towards Indonesian flood prone area provides significant value in the disaster risk
management cycle, in which become the basis for prevention action.



2.1. Definition of Health Impact Assessment (HIA)
Health is a prime issue of human live. Health can determine of wealthy well-being.
Modern humanization in this century intensely takes concern of healthy. Secure and good
environment within unpolluted air, water and soil is a significant element to describe it. World
Health Organization (WHO) defines health as a condition of people complete in physical, mental
and social without disease of infirmity. Condition of surrounding environment affect the terms of
health. Health impacts are the entire direct or indirect effects of a policy, strategy, program or
project on the health of a population. Furthermore Health Impact Assessment (HIA) is a
combination of procedures, methods and tools by which a policy, program or project may be
judged as to its potential effects on the health of a population, and the distribution of those
effects within the population (Gothenburg 1999). Another definition comes from WHO defines
Health Impact Assessment (HIA) as a combination of procedures, methods and tools by which a
policy, project or hazard may be judged as to its potential effects on the health of a population,
and the distribution of those effects within the population.
Certain Direction of HIA is to maximize the positive health impacts and in reverse to
minimize the negative health impacts of proposed policies, programs or project. Characteristics
of HIA include a broad definition of health is including economic, social or environment of
affected stakeholders; exalt concerns about social justice and a commitment to transparency
(Quigley et al. 2006). The stages of HIA are mostly similar to other forms of impact assessment
(e.g., environmental, social, and strategic). Procedures of HIA include:
1. Screening
Assess the value, feasibility, and utility of the HIA in the decision-making process
2. Scooping
Determine potential significant health effects of the decision
Prioritize research questions with stakeholder and decision-maker input
Identify evidence and research methods
Establish roles for assessors, stakeholders, and decision-makers
Establish timeline for the process
3. Assessment of Health Effects
Mobilize evidence to characterize baseline health conditions
Characterize expected health effects
Evaluate uncertainty

4. Recommending Mitigations and Alternatives

Identify and evaluate the efficacy and feasibility of mitigations, design strategies,
or decision alternatives to promote and protect health
Prioritize recommendations with stakeholder input
Develop a health management and monitoring plan
5. Reporting and Communication
Document the process, findings, and recommendations
Solicit and respond to stakeholders comments
Communicate the HIA to decision-makers, decision proponents, and other
6. Monitoring
Monitor decision and mitigation implementation
Monitor health determinants and outcomes affected by decision
Some of the more common types of evidence and methods in HIA include:
1. Existing population demographic and health statistics (e.g., census, surveys, vital
statistics, surveillance programs, and agency reports) to profile health status and
health determinants
2. Environmental measures to assess hazardous physical agents, such as hazardous
substances or contaminants in air, soil, and water; noise; and radiation or hazardous
conditions, such as floods, fires, landslides, or injury hazards. Environmental
measures are also used to assess public health assets and resources, including water
bodies, land, farms, forest, and infrastructure, schools, and parks.
3. Maps of demographics, health statistics, or environmental measures to identify spatial
relationships between places, populations, and environmental conditions and hot
spots or spatial differences in the intensity of hazards.
4. Empirical research, particularly epidemiological research, to provide evidence to
characterize relationships between health determinants and health outcomes and to
quantify those relationships when possible
5. Qualitative methods, including focus groups and structured and unstructured
interviews, to help assessors access knowledge or perceptions about conditions,
vulnerabilities, day-to-day experiences of community members, and experienced and
perceived threats.
2.2. Health Impact Assessment in Disaster Management


Natural disasters have been a main factor of mortality. By the year of 2008, 321 disasters
killed over 235.000 people, affected the lives of more than 211 million victims and cost over
US$ 181 billion (UNISDR 2009). Disaster Management could be included to actions such as
adaptation and mitigation. In this case, Health impact assessment is additional to increase the
quality of disaster management. For additional, climate change seems to increase the number of
disadvantages of natural disasters. Climate change causes the increasing of natural disaster such
as flood due to sea level rise, drought, fire wild due to the warmer temperature, typhoon, and etc.
This makes health impact assessment as one of mitigation act is necessary needed. The
determinants of health and well-being are the condition of the surrounding live, such as political
factors, community, public services, livelihood, housing, health behavior and environment.
Furthermore, environment which affects health are air quality, soil contamination, noise, disease
vectors, water resources, food resources, and disasters. Figure 2.1 explains factors affected to
health, and natural disasters (such as flood and landslide hazard) are counted to be one of the
In addition, climate change as the hot global issues has already makes numerous
damaging on human lives. It is not only affection to ecosystems changes but also species live in
it. Increasing of temperatures averages and changing of climatic pattern caused impact on human
health. These causes spread infectious diseases, longer and hotter heat waves, and extreme
weather and take thousands of victims.

Figure 2.1. Factors Affected to Health (Bhatia 2011)


The health impacts of climate changes in Indonesia (Haryanto 2009) are as follows:

Cardiovascular respiratory mortality and heat stroke mortality

Allergic rhinitis
Respiratory and cardiovascular diseases and mortality
Death and injures caused by floods, landslides and windstorms
Infectious diseases and mental disorders because of disruption of water supply, sanitation


systems, etc
Starvation, malnutrition and diarrhea and respiratory diseases
Mosquito, tick-borne diseases and rodent-borne diseases because of warmer temperature
Malnutrition and undernutrition because of food supply decreasing.
Waterborne and foodborne diseases

Health Impact assessment of climate changes include:

An evaluation of the impact of climate variability and change in a range of areas and
populations, especially among vulnerable populations and, when possible, to determine
the attributable burden of weather and climate, including extreme events, to climate-

sensitive diseases
An evaluation of possible threshold effects
An evaluation of the effects of multiple stresses, including changes in socioeconomic

An evaluation of uncertainty and its implications for risk management
An evaluation of the effects of reducing emissions, such as by comparing the impact

under scenarios with business-as-usual and stabilization of emissions

An evaluation of coping capacity, especially under different socioeconomic futures and in
the context of sustainable development


3.1. Health Impact Assessment: Case Study of Jakarta City

Jakarta is capital city of Indonesia which has become a centre of politics and economics
in Indonesia. As a centre of economic, Jakarta contributed more than 17% to the national GDP. It
has high economic growth and high number of population. Geomorphologically, Jakarta is
susceptible to flooding. Jakarta is located in the northern part of Java which is directly bordered
to Java Sea and intersected by thirteen rivers (Figure 3.1). Most of area in Jakarta is located in a
flat-low lying areas and some of them is located below sea level. Jakarta has a complex history
of flood. Flood history of Jakarta was started since the 17 th century. However, flooding became

great problems for people in the end of 19th century. Historical data of river flood event in
Jakarta is shown in Table 3.1. There is no recorded data of flood events in year 1621, 1654 and
1876. Flood event in January 1932 inundated several houses in Dabang and Thamrin Streets.
Then, in 1st January 1932 flooding caused 200.000 people evacuated. During 1977 until 2008
have occurred 8 times big flood event. Flood event in 2007 is being the worst event in its
recorded data (Texier, 2008). It caused 150.000 people evacuated and approximately 60 % area
of Jakarta was inundated. Heavy rainfall occurred during in the beginning of February, detailed
rainfall data in 3 February 2007 is shown in Figure 3.2.

ure 3.1. Rivers intersected in Jakarta


Figure 3.2. Rainfall data from Ciliwung river recording stations (3 February 2007)
Source: BMKG in ADPC, 2010
Table 3.1 Historical River Flood Hazard in Jakarta

Damage and risk due to flooding

1621, 1654, 1876

No recorded data

9 January 1932

Several houses in Dabang and Thamrin Streets were inundated

1 February 1976

More than 200000 people were evacuated

19 January 1977

About 100000 people were evacuated

8 January 1984

About 291 neighborhood areas with 39729 inhabitants were


13 February 1989

4400 families were evacuated

13 January 1997

745 houses and 2640 inhabitants were inundated

26 January 1999

Flash flood occurred in Tangerang, Bekasi and Jakarta with 6

people died and 30000 people were evacuated.

29 January 2002

Big flood occurred in Jakarta, Tangerang, and Bekasi caused 2

people died and 40000 people were evacuated

2-4 February 2007

150000 inhabitants have been evacuated. 60% of Jakarta City

was inundated


February 2008

Flood occurred in Jakarta and Tangerang. 26000 houses were

inundated and 1550 people were evacuated.

Source: Balai Besar Wilayah Sungai Ciliwung dan Cisadane, Department of Public Work (DPU)
in Frenkel (2011) and Marfai (2012)

Flood event in Jakarta caused damages and losses in every aspects of human life, include
human health. Environmental problem due to flooding caused health problems. Waste disposal
and garbage along the river become serious problems in some area (Figure 3.3). Several diseases
can be transmitted by water inundation such as skin infections, respiratory infections, and
gastrointestinal infections. Flood inundation indirectly can be used as breeding places for
mosquitoes which can spread other diseases such as dengue fever and malaria. Harmful disease
arisen due to flooding is leptosirosis. It is caused by bacteria found in rats urine. During flood,
flood water mixed with various waste include rats urine. Figure 3.4 explains one condition of
inundations area in Jakarta City.

Figure 3.3. Garbage along the swampy area


Figure 3.4. Inundation in Jakarta City (Foto Courtesy: Marfai 2009)

Flood event in Jakarta has caused some problems in public health. Many people suffered
several diseases after flooding in Jakarta. For example is in flood event 2002. Diseases which
frequently occurred are diarrhoea, respiratory infections, gastrointestinal infections, pneumonia,
skins infections and eye infections (Figure 3.5). Based on data of Department of Health of
Jakarta, most of people suffered respiratory infections (44.8 % of all patients).

Figure 3.5. Proportion of patients due to flooding in 2002 (Jakarta Public Health Department,
Other diseases occurred are leptosirosis and dengue haemorrhagic fever. These diseases
appeared later and caused serious impact. Leptosirosis is more harmful than other because some

patients were died. Numbers of leptosirosis patients after flooding in 2002 are 70 patients and 17
of them were died (Department of Health, 2002). Leptosirosis found in 38 subdistricts in Jakarta
and the biggest case occurred in West Jakarta. Main cause of this disease is rats urine which
mixed in flood water. Flood water is contaminated by various wastes which can disrupt human
Problems in public health didnt reduce in line with receding of flood. Data indicated that
number of patients was increasing when flood started to recede (Figure 3.6). Flood always leave
trash and waste surrounding the settlement. It brings negative impact for human health. So many
bacteria and viruses transmitted from trash and waste. So, it is potential for spreading the
diseases after flooding.

Figure 3.6. Cumulative number of patients due to flooding in 2002

Most of patients due to flooding are children. Data in Figure 3.7 is shown that 17,6 % of
patients are infant, 25,8 % are children under 5 years and 56,7 % are children more than 5 years.
Most of them suffered diarrhoea. Infant and children are very vulnerable to diarrhoea. They
havent good immune system to protect their body from diseases. Environmental conditions
during flooding were bad, so it supported diarrhoea transmission.


Figure 3.7. Percentage of People suffered diarrhea (Jakarta Public Health Department, 2002))

3.2. Health Impact Assessment: Case Study of Semarang City

Semarang, as the capital of Central Java Province, is geographically located on the
northern part of the province (658 S and 11025 E). As one of largest city in Indonesia, rapid
urbanization in Semarang has significantly increased the number of vulnerable community
towards flooding. At present, more than 1.5 million urban populations live in Semarang, with the
total area of only 373.7 km2 (BPS Semarang 2002). Since 1990, the coastal and low land areas in
the north of Semarang have been experiencing rapid growth of urban development (Marfai and
King 2008a). Rapid urban growth has become major source for environmental deterioration in
coastal and low land areas. Due to urban development, the local communities in North Semarang
are now suffering from various direct and indirect impacts of the environmental deterioration.
Basically, the topography of Semarang consists of two different reliefs. In the southern
part, it consists of hilly topographical area with mean elevation of 400 m and slope between 1540%. Flat topographical area with elevation less than 10 m can be found in the northern part of
Semarang (Figure 3.8). Due to the difference in topographical condition, long time sedimentation
from the rivers occurs in the coastal and low land areas. This sedimentation comes from several
major rivers, such as Garang River (East Floodway River), Blorong River, Beringin River,
Silandak River, Babon River, and East Floodway River. Besides the effect on sedimentation


process, most of the rivers are responsible to the threat of flooding in Semarang (Marfai and
King 2007).

Figure 3.8. Topographical condition of Semarang (Marfai and King 2007)

The geological condition of Semarang coastal area also brings higher exposure towards
coastal inundation. In general, coastal area of Semarang is composed of alluvial clay and sand
sedimentation. Identification by Kobayashi (2003) has revealed several micro regions at the
coastal area, namely (1) sand and clay material on the beach area, (2) alluvium sediment on tidal
area, (3) combination of alluvium-mud sediment on mangrove-forest area, and (4) reclamation
area on harbor and tourism area. According to Suhandini (1988), the rate of sedimentation at
coastal area is about 8-15 m per year. Since the age of sediment is only hundreds year old, the
material is not compacted yet. Thus, it triggers the phenomena of land subsidence in Semarang
(Soedarsono 2011). In addition to the material condition, excessive groundwater withdrawal and
increase of the load due to building construction is also considered as the major triggers (Public
Works Department of Semarang/PWD 2000).
Land subsidence is not something new- phenomena in Semarang. This city has
experiencing land subsidence for long time (Sutanta 2002; Kobayashi 2003, Marfai and King
2007). The subsidence varies from less than 10 cm per year to the maximum of higher than 20
cm per year (Soedarsono and Marfai 2012). Due to land subsidence, the ground elevation
becomes lower and is now exposed to coastal inundation. The height of inundation is now
reaching up to 60 cm from the ground (Soedarsono 1996; Kobayashi 2003). Sinking area below

the sea level due to land subsidence is now common. Sinking area is predicted to gradually
increase from 365 ha to 1,377.5 ha during 2010-2015 (Marfai and King 2007). The land
subsidence is mostly affecting the Northeast part of Semarang coastal area. Several villages are
now under the threat of higher coastal inundation due to subsidence (Table 3.2).
Table 3.2. Villages affected by higher coastal inundation due to land subsidence
Area Inundated (Ha)
Source: North Semarang Government (2002)

Settlement inundated (house)


Massive damages and losses towards the property and infrastructure due to coastal inundation
has occurred in Semarang (Soedarsono1996; Yusup 1999; Kobayashi 2003; Marfai 2003; Marfai
2004; Dewi 2007; Marfai and King 2007). The efforts in reducing the impact of coastal inundation
have been taken. Although dike, pumping station, and polder system as physical measures has built
and installed, the flooding is continuously inundating the coastal area (Marfai and King 2008a;
Marfai et al. 2008b). The inundated settlements were increasing during period of 1996-2010.
Detailed changes on the area inundated are shown in Table 3.3.
Table 3.3. Changes of inundated area during 1996-2010

Area Inundated (Ha)

Source: Soedarsono 1997; Soedarsono 2011



Figure 3.9. Inundation on the coastal area; inundation on the road (a) and in the residential areas
(b,c) (Marfai and King 2007)
The serious impact of coastal inundation becomes higher because most of the inundated
areas are dense populated settlements (see Figure 3.9). The inundation on these areas is
potentially causing the damages on building. Non-permanent building, which is one of the
products of unmanaged development, is the most suffered from the inundation. Those buildings
were constructed from low quality material and formed un-uniform pattern between each other.
Poor environmental condition is also found in this area. Unstructured drainage channel with high
sediment load, combined with the complex environmental sanitation problems, is predicted to
higher health impact to the local community live in this area.
Severe impact of the inundation is not solely related to magnitude of the coastal
inundation itself. Regarding to this, Soedarsono (2011) has identified several factors that
generate higher impact. In addition to flat topographical condition in which resists the water to
back to the sea, the soil also saturated because it is often inundated. This condition makes the
water cannot well infiltrated to the ground. Shallow groundwater table also becomes the main
reason of this problem. The site location on the river outlets, in which has high magnitude of land
subsidence, produce higher inundation from year to year. Dense un-uniform settlement and poor
drainage makes longer flooding duration, as it requires several hours to the water level to be
Water that inundates the settlement in Semarang is the main source for the diseases.
Worse condition found due to the poor environmental condition, in which solid waste pollution
and water pollution taken place. Solid waste pollution is common due to lack of solid waste
management. The source of water pollution mainly comes from household, including pollution
from detergent, feces, and urine. Although some of them can access clean water from the water
company pipe system, about 40% of them still use groundwater as the main source for daily
requirements. Therefore, diseases spreading in this area possibly come from two major sources.
In addition to the diseases that come from the water that inundates for long duration, the diseases
are also emerging from the water polluted by household waste. Several diseases that often found
in this area are shown in Table 3.4.
Table 3.4. Diseases related to environmental health and number of people suffered


Number of people suffered per year

1999 2000 2001 2002 2003 2004 2005 2006

16025 13467 10474 12829 13324 14775 12265 14166
3231 2701 2654 2909 3868 2061 1527 1577
1170 1254 1609
Cholera and
Source: Bandar-harjo Health Clinic 2010, in Soedarsono 2011

2007 2008
16111 22597






Sanitation is the major problem on this area, in which not all of the inhabitants have
private toilet and septic tank on their house. Therefore, part of the inhabitants flow liquid
household waste directly to the open channel around the settlement. Due to flood inundation, the
household waste is often mixed with the water. Improper household waste management, which is
generated from low environmental health, is one of the main sources for the diseases.
Based on how the diseases are transmitted, the source can be classified to water borne
diseases and vector borne diseases. Water borne diseases is especially emerging due to poor
sanitation condition. Water borne diseases not only spread when the water is high, but also when
it gets lower. When the water elevation decreases, it left mud and residual on the ground surface.
The most disease emerging due to the combination of the inundation and poor sanitation is
Diarrhea (Table 3.5), in which it is mostly emerging due to unavailability of clean water and
exposed feces (Ahmad 2003). In addition to diarrhea, dysentery also emerging due to
contaminated groundwater.
Table 3.5. Water borne diseases in the inundated villages
Source: Soedarsono 2011






Vector borne disease is mainly transmitted by animals, especially by mosquito and

mouse. Malaria and dengue fever, as the main diseases transmitted by mosquito, is the most
suffering the local community. 90 cases of malaria and dengue fever have been identified by
Soedarsono (2011). Leptospirosis, as transmitted by mouse, only occurred on one cases.
Unfortunately, due to the massive impact to the environment, it cannot be underestimated. Vector
borne diseases in the inundated villages are shown in Table 3.6.

Table 3.6. Vector borne diseases in the inundated villages



Source: Soedarsono 2011









Health Impact Assessment in Indonesia is rarely implemented especially for disaster
management. Nevertheless, in matter of fact Indonesia experiences natural disasters for the
geographic condition. Natural disaster could bring primary effect such as death and secondary
effect of diseases caused by the natural disaster. Health Impact Assessment could help to reduce
the risk of natural disaster impact in Indonesia. It is necessary to made socialization,
dissemination, and policies as an implementation of Health Impact Assessment in Indonesia for
future. As a mitigation act of natural disaster, Health Impact Assessment can be implemented to
reduce the health impact of the disaster occurs in Indonesia.
The primary reason of why the Health Impact Assessment is necessary needed in
Indonesia is because natural disaster frequently happens in this country. Flood, earthquake,
landslide, volcano eruption, and tsunami occur as the short period disaster and to be worst
climate change has added as the long period disaster. Health Impact Assessment will be as a tool

to help community to reduce the health impact of the natural disaster damaged such as injury,
respiratory infection, infectious disease, and even death. Health Impact Assessment will arrange
regulation to reduce the risk because policies can have a considerable influence on health and the
production or prevention of illness, disability or death. A high level of human health protection is
necessary to be ensured in the definition and implementation of all community policies and
activities. HIA will also can measure the possibility of disease happens in a natural disaster
Health Impact Assessment should also be able to comprehensively reflect the real
conditions and real environmental problems, so it is necessary discussion of cross-sectoral
coordination. Organization partnerships take key action to develop Health Impact Assessment in
one community. In this case, Indonesia Government including the regional government could
work together with private sector and local community to be participated together in develop the
policies and to make sure the health impact assessment is implemented.


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