THREATS TO URBAN HEALTH

CAROLYN STEPHENS

Carolyn Stephens ([email protected]) is a senior lecturer in environment and health policy at the London School of Hygiene and Tropical Medicine and visiting professor in environment and health policy at the National University of Tucum Argentina.

The future looks more urban than ever. As urban demographer Ellen Brennan has observed, “In a few years, roughly around 2006, a crossroads will be reached in human history, when half of the world’s population will be residing in urban areas.” By 2030, three-fifths of the world’s population will live in urban areas.

Evidence indicates, though, that this future may be more unequal than ever. The majority of urban people will live in Asia, Africa, and Latin America - in countries that are getting relatively poorer, not richer. The latest World Bank data show the ratio of income per capita in the richest countries over that in the poorest countries has increased from 11 to 1 in 1870, to 38 to 1 in 1960, and to 52 to 1 in 1985. And poverty in the poorest countries appears to have become more urbanized. An urban world with growing inequality bodes ill for the health of urban dwellers.

In addition, globalization - the rapid global movement of capital, ideas, skills, and employment connected to the concentration of power in the private sector - is changing the urban physical and social environment. Consequent changes in diet and physical activity are affecting the health of all urban people. Accompanying these changes is the fact that the poor rely increasingly on the wealthy. The United Nations Environment Programme (UNEP) reports that private foreign investment controlled by corporations was worth US$250 billion in 1996, in contrast with less than US$50 billion in official development assistance. In the same year, foreign exchange trading by big investors amounted to US$350 trillion - more than 10 times the world’s gross domestic product. The wealth of the world is now in the hands of a tiny minority of people. The ratio of the average income of the world’s wealthiest 5 percent to the world’s poorest 5 percent increased from. 78 to 1 in 1988 to 123 to 1 in 1993.

This shift of financial and political power influences development opportunities for urban areas. Cities compete against each other for foreign and private investment on the basis of their population and resources. Urban development relies on low-cost urban labor in one city or country competing with low-cost urban labor in another. As a result the well-being and health of the world’s urban people can become precarious.

URBAN HEALTH AND PRIORITIES FOR ACTION

Urban areas could be healthy places for people to grow, live, and work. Health depends on equitable availability of a simple set of good physical conditions, such as clean and plentiful water, clean air, uncontaminated and adequate food, access to sanitary home and work environments, protective shelter, sate and remunerative employment, and safe environments in which to move around. At first, the urban health picture looks quite simple. Urban development, based on industrial or manufacturing processes, provides employment, which leads to a wealthier society. A richer society, in turn, can pay for better delivery of water, sanitation, health services, and education. Ultimately this translates into better health. Witness the mortality rate of children under five of 5 per 1,000 in highly urbanized industrialized countries, as opposed to about 170 per 1,000 in 30 percent urbanized Sub-Saharan Africa and about 120 per 1,000 in 27 percent urbanized South Asia.

But this simple view conceals the impact on health of inequalities between and within urban centers. Urbanization in developing countries has not taken place in a context that enables good physical conditions for health to be easily realized. Historically, the industrialized countries of the northern hemisphere built their economies by transforming and trading the natural-resource bases of Asia, Latin America, and Africa. These northern countries went on to control the trade system, limiting the ability of the so-called “developing” countries to follow the same route toward urbanization and development.

Developing countries have three significant urban health agendas, each linked to the issue of inequity between and within cities: the resolution of health problems stemming from (1) urban poverty, such as infectious diseases and poor nutrition, (2) the current “dirty” industrialization process, and (3) the social and political environment within cities.

URBAN POVERTY

An estimated 600 million or more people live in low-income settlements in African, Asian, and Latin American cities and towns. This urban poverty is generally accompanied by limited and poor-quality water, food, and housing, as well as limited education and low-paid hazardous work. Urban poverty is the most direct result of constricted urban development opportunities, which are driven by inequalities between countries and cities. Undernutrition, malnutrition, and infectious diseases are widespread in African and Asian urban centers because of poverty. Malnutrition increases the risk of infectious disease. Death rates for infectious diseases - such as diarrhea, measles, and tuberculosis - and for infant mortality among urban poor children in developing countries can be up to 100 times higher than those for urban children in industrialized countries. The World Bank calculated that in 1998 acute respiratory diseases (about 111 million years of life lost) and diarrheal diseases (about 94 million years of life lost) were the world’s major health problems, and they were concentrated in urban areas of developing countries. In one poor part of Calcutta that contains 4 million people, about one out of every fifth child under 5 and adult over 65 dies due to diarrheal and respiratory diseases. Malaria and dengue fever represent significant health problems in urban areas of Africa and Asia. Thus the first challenge is to provide a solution to the disease-causing environments propagated by poverty.

“DIRTY” INDUSTRIALIZATION

Pollution from dirty industrial development adds to health risks. Metropolitan areas in developing countries often rely on attracting investment for rapid, environmentally dirty industrial development. Transportation also contributes significantly to local air pollution and global warming. UNEP reports that 1 billion urban residents are exposed to health-threatening levels of air pollution, creating the double health burden city dwellers face of poverty and environmental degradation.

This type of double health burden is linked to the dilemma of developing-country cities being forced to compete against each other in dirty development: attracting investment on the basis of extremely low environmental standards and extremely poor labor conditions. This kind of development is hazardous for the current generation but also toxic for the future, It raises the challenge of providing a form of urban development that eliminates urban poverty without introducing the effects of dirty, unsustainable industrialization.

INTRA-URBANSOCIAL AND POLITICAL INEQUALITY

Good urban health also depends on the urban social and political environment. The shift toward inequality within countries is evident in almost every city and town internationally, regardless of its wealth, and has been linked to social and health impacts such as increases in violence and poor mental health. Evidence shows that urban violence stems from political disempowerment, unequal access of some people to opportunity and justice, frustrated aspirations, and perpetual confrontation with lack of change. Death rates from urban violence in the low-income areas of cities are high. More than twice as many poor in SPaulo, for example, die a violent death compared with the rich. Poor urban children, particularly boys, are greatly affected by the trauma of urban violence. All these issues raise the third challenge for urban health: developing urban areas in a way that provides equal opportunity and benefits to all.

SUSTAINABLE AND EQUITABLE DEVELOPMENT

Many now believe that the three urban health challenges outlined above could be met if urban policymakers focused more on environmental and social sustainability. Sustainability could help reverse trends in inequality because it emphasizes equity in consumption and resource distribution.

If equitable, sustainable development is to be achieved, a first step may be to emphasize the use of health as a means of identifying priorities in urban policy. This would enable the urban development agenda to be guided by the long-term goal of human well-being rather than the short-term goal of economic well-being. Governmental, nongovernmental, and international organizations are developing urban initiatives - such as the highly participatory Local Agenda 21 plans. Healthy Cities, and Sustainable City Networks - that emphasize healthy and sustainable development. These initiatives incorporate intersectoral collaboration; the participation, particularly of the poor, in setting priorities; equity in distribution of services; and sustainability in decisions about investment.

The forces of globalization must also be turned toward environmental and social justice, and thus to the advantage of the urban majority and the urban future. Against the attempts to shift toward equity and intersectoral collaboration, urban services have become part of the globalized economy, with large-scale privatization of urban services, including education, water, waste disposal, energy, housing, sanitation, and health. Privatization policies were intended to improve efficiency and extend delivery, but urban services appear to be moving into the hands of major multinational corporations, who then control many aspects of urban policy that were formerly in the hands of local government. The result often has been a narrowing of delivery.

Macropolitical and macroeconomic processes influence the ability of decisionmakers to improve the conditions that affect the health and well-being of urban citizens. Many specialists argue that only when local governments gain control of the destiny of their cities will sustainable urban development become a reality and will we be able to achieve health security for all.

For further reading see United Nations Environment Programme, Global Environmental Outlook 2000 (London: Earthscan, 1999); and Carolyn Stephens and Simon Stevenson, “From Insecurity to Sustainability: The Need for Health and Equity in the World’s Urban Future,” Woodrow Wilson Working Paper (Washington, D.C.: Woodrow Wilson Center, 2000).