Urban transformation calls for new approach to health services.
Is there really an urban health advantage?
"There's a common belief that urban dwellers are generally healthier than rural residents, in part because there are more health and social services in cities," Montgomery notes. For instance, one analysis of 90 Demographic and Health Surveys found that, on average, the urban populations of poor countries exhibit lower levels of child mortality than their rural counterparts. Similar urban/rural differences surface across a range of health indicators. "However, averages can be a misleading basis on which to set health priorities," Montgomery explains. "Once we break down the data, it is clear that the urban poor often face health risks that are nearly as severe as or even worse than those of rural villagers."
According to Montgomery, who distinguishes between "slum dwellers" and the "urban poor," much more needs to be done to determine the percentage of the urban poor living in slums. For example, one study of urban India found that of all urban households officially classified as poor in 2005, over 80 percent were in nonslum neighborhoods. Also, slums may contain significant percentages of households whose expenditures would put them above the official poverty line. "Without this information, it is not clear whether poverty alleviation programs should target poor places, such as slums, or poor people, who may live in a variety of neighborhoods," Montgomery says.
Montgomery's work attacks another myth: that most urban residents live in huge urban agglomerations, or megacities, with populations of more than 10 million. In fact, of all urban residents in cities of 100,000 and more in the developing world, only about 12 percent, or 1 in 8 urban residents, live in megacities. The majority of urban dwellers live in smaller cities or towns. "The demographic literature tends to overstate the role of very large cities and underemphasize the importance of small- and medium-sized cities," Montgomery concludes.
Natural population growth rate versus migration
When confronted with rapid urbanization, many governments try to expel slum residents and discourage further migration to densely packed urban neighborhoods. This response is likely based on another myth: that migration accounts for most of the urban growth. In developing countries about 60 percent of the urban growth rate is attributable to natural growth--the difference between birth rates and death rates--while the remaining 40 percent is due to migration and spatial expansion. Therefore, a better approach to controlling urban growth might be to promote voluntary family planning programs and work with government health agencies and advocacy groups to improve services to the poorest urban areas, Montgomery suggests.
Urban health risks are often unacknowledged
According to Montgomery, these and other misconceptions have led policymakers to neglect several key areas, especially in the health field. In many countries residents of smaller cities go without adequate supplies of drinking water and minimally acceptable sanitation. Likewise, while rural shortages of health personnel and services have received attention in recent literature, similar shortages also plague smaller cities and towns. Conventional poverty measures also ignore the important factors of crime and violence, risks that threaten many city dwellers. Indoor and outdoor air pollution, as well as injuries and deaths stemming from traffic accidents, also plague the urban poor. In a bulletin published this summer by the Population Reference Bureau, Montgomery enumerates many "under-appreciated" health risks facing the urban poor:
* Calling mental health a "central factor in the health of the urban poor," Montgomery notes that community-based studies of mental health in poor countries suggest that 12 percent to 51 percent of urban adults suffer from some form of depression.
* Violence in urban areas takes a variety of forms, ranging from political and extrajudicial violence to gang violence, local violent crime, and domestic abuse.
* Although as a group urban women are more likely than rural women to use contraception, poor urban women face disadvantages not unlike those facing rural women. The fact that modern contraceptives are often more readily available in urban areas than in rural regions does not imply that poor urban women will be able to use them effectively. Many poor urban women have an unmet need for modern contraception. These women may want to prevent or delay their next birth, yet for various reasons they do not use modern methods to achieve their stated aims, or they use contraception inconsistently or improperly.
* When it comes to HIV/AIDS, there is little evidence of the "urban advantage" that is seen for other health conditions. Community-based studies of HIV prevalence are now available for a number of developing countries. In at least three cases--Kenya, Mali, and Zambia--urban prevalence rates are much higher than rural rates.
* Although malaria has often been regarded as a rural disease, and rural rates of transmission are higher than urban rates, there is evidence that malaria vectors have adapted to urban conditions in sub-Saharan Africa and in some parts of Asia. In urban sub-Saharan Africa, some 200 million city dwellers face appreciable risks of malaria.
* Although data are scarce, it is likely that detection rates of tuberculosis among the urban poor are well below rates for other urban residents.
* Recent estimates suggest that more than 2 billion people worldwide rely on solid fuels, traditional stoves, and open fires for their cooking, lighting, and heating. These fuels--often used by the urban poor--generate harmful gases that are believed to substantially raise the risks of acute respiratory infections and chronic obstructive pulmonary disorders.
New data analysis leads to a better approach
By relying on new databases, such as the Global Rural Urban Mapping Project (GRUMP), part of Columbia University's Earth Institute, Montgomery has uncovered subtle new patterns in urban population projections. GRUMP is one of the first efforts to combine satellite mapping data with population census information. This combination has led to new insights into the distribution of human populations across ecosystems, as well as into changes in patterns of rural and urban development.
"Perhaps the greatest need on the demographic front is to ensure that the censuses in developing countries are analyzed at the level of small geographic units and the results placed in the hands of the local and municipal governments," Montgomery suggests. "The data can be an effective tool in planning the pace and spatial distribution of future growth." Remote-sensing methods, such as satellite mapping, can serve as a valuable supplementary tool.
While geographic targeting may be an effective health strategy for reaching slum dwellers, other approaches will need to be devised to meet the needs of the poor who live outside slums, Montgomery suggests. "The public health sector needs to work in tandem with other government agencies," he says. "Municipal, regional, and national governments need to join forces and form partnerships with private for-profit and nonprofit groups."
As an example of successful partnerships, Montgomery points to grassroots savings groups, which in some cases have collaborated with nongovernmental organizations to improve local sanitation and water supply systems, providing public toilets in Mumbai and extensions of water and sewer lines in Karachi. According to Montgomery, the changes need not be big to make a difference. In Mexico, for example, a program that replaced dirt with cement floors significantly improved the health of young children, leading to reductions in rates of parasitic infection, diarrhea, and anemia.
"Among all the misconceptions that have hindered work on urban health, perhaps the most pernicious is the view that in contrast to rural villages, urban neighborhoods somehow lack the social cohesion needed to sustain community participation," Montgomery concludes. "In an urbanizing era, there is every reason to design health programs for the urban poor that take full advantage of the social resources and resourcefulness of their communities."
Balk, Deborah, Mark R. Montgomery, Gordon McGranahan, Donghwan Kim, Valentina Mara, Megan Todd, Thomas Buettner, and Audrey Dorelien. 2009. "Mapping urban settlements and the risks of climate change in Africa, Asia and South America," Chapter 5 in Jose Miguel Guzman, George Martine, Gordon McGranahan, Daniel Schensul, and Cecilia Tacoli (eds.), Population Dynamics and Climate Change. New York: United Nations Population Fund and International Institute for Environment and Development, pp. 80-103. Montgomery, Mark R. 2008. "The urban transformation of the developing world," Science 319 (5864): 761-764.
Montgomery, Mark R. 2009. "Urban poverty and health in developing countries," Population Bulletin 64 (2): 1-16.
The William and Flora Hewlett Foundation
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|Title Annotation:||URBAN POVERTY AND HEALTH|
|Date:||Dec 1, 2009|
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