Raising living standards : Health

I’m Srinath Reddy,President, Public Health Foundation of India speaking to you from New Delhi. Today we will discuss Urban Health. You may ask ‘Why is urban health important all of a sudden?’ It is because many people are now currently living in urban areas, and more will be living in cities and towns as the years roll by. And this is not happening only in high-income countries, it is also true of low and middle-income countries. Indeed in some of the low and middle-income countries close to 80% are now living in  cities and towns in urban areas whereas in others, it’s around 30% now but it is increasing year by year. With the majority of the world’s population going to be living in the cities or in towns, urban health becomes an important consideration because that is where they’re going to be spending all or most of their lives.

Urban health becomes a particularly important problem because of the special characteristics of cities where people live not only in large numbers but highly crowded communities. And we find that some of the health problems arise because of the configuration of cities, the nature of services available or not available and some of the living conditions that are created by urban lifestyles.

So, if we are really trying to keep people healthy over a life course and are trying to provide them essential health services whenever they need, health planning has to become an important part and parcel of city planning or urban planning.

Unfortunately that’s not happening now and that’s why we find a very large number of health problems in our cities. One would intuitively think, and it’s to some extent is true, that people in cities are healthier than people living in rural areas – at least in the low and middle income countries where there is a fair amount of poverty, deprivation in the rural areas compared to cities. And one would think that a higher life expectancy in people who live in cities or in urban areas compared to people living in rural areas is an indicator that in general they’re living healthier lives.

That’s not really true. Firstly, the very high level of what we call morbidity or disease-related disability because of a number of diseases which may not kill early but certainly occupy a very large part of one’s life. Secondly, the urban poor are particularly disadvantaged and those living in slums or low-income communities and cities and towns experience not only poor health but also a fair amount of early mortality which cuts down their life expectancy and they become prey to a very large number of diseases. Even the urban middle class and urban rich are not spared from diseases and disability which accrue from the kind of lives they lead. Therefore there is a wide variety of diseases and disorders that now we find in urban population. Quite often its a mix of the problems of under development, which are particularly seen in rural and poor populations and diseases of maladapted modernity. For example, infectious diseases: one would think that people dwelling in cities would not have much of infection but access to clean drinking water, proper sanitation and unpolluted air are not available in most urban environments particularly in low and middle-income countries. And when you have poor sanitary conditions with huge garbage heaps or open defecation there are bound to be infectious diseases like diarrhoea, respiratory infections which are particularly problematic in children, Kill them early or disable them significantly and childhood under nutrition is often a problem that occurs by itself in poor communities and sets the stage for infection, and infections also create undernutrition and therefore this is a vicious cycle affecting child health.

Similarly, poor communities also have problems in young women going in for pregnancies in a state of poor nutrition and having higher Maternal Mortality Rate and indeed when we take urban health indicators as single aggregate, we mask huge inequities that exist between the urban rich and  urban poor. The urban poor, in some cases are worse off than the rural population when it comes to those indicators – whether they’re living in slums, or whether they are recent rural migrants from rural areas, who will now have the double jeopardy of the diseases they have carried and the risk they’ve carried from rural areas to the risk they have acquired, and the diseases now they manifest because of their urban living. When it comes to infections, there are also other problems in urban areas. We now find a large number of vector-borne diseases coming in because mosquitoes are breeding in fresh water pools that are occurring in stagnant water collections. These stagnant freshwater pools in cities tend to breed mosquitoes which spread dengue, chikungunya and other forms of vector-borne diseases which are particularly prone to occur in urban areas now. Even urban malaria is now becoming an increasing problem. The crowded communities in urban areas make them extremely vulnerable for a very rapid spread of infection. If you get a virus like H1N1 or H5N1 and if it enters the urban community it is likely to spread very rapidly through the respiratory route because people are crowded together. And while tuberculosis does occur everywhere, again, lack of adequate access to healthcare and living in crowded communities makes multidrug – resistant tuberculosis, a nightmare in urban areas. So infectious diseases are still a reality in urban areas. Even if you trace the history of public health, if you take what happened in London in the 19th century where John Snow discovered that the Broad Street epidemic of cholera was because of contamination of sewage into a water pump and by removing the handle of the water pump, they could control the cholera epidemic. Importance of having clean drinking water and sanitation and not having putrid garbage or unclean rivers as your environment, was clearly recognised by Europe and therefore the whole sanitarian movement transformed the living conditions and raised life expectancy and well-being in Europe. Now many of the low and middle income countries have not had the level of civic planning in cities that is required to ensure regular availability and access to clean drinking water, good hygiene and sanitation, as well as a relatively unpolluted air.

In addition, we find that there are a whole host of diseases, we call ‘non-communicable diseases’ like cardiovascular or heart diseases like diabetes, cancers, chronic respiratory diseases many of which are related to the urban living or the patterns of our lifestyle.

For example, poor diets which are rich in unhealthy fats, sugar and salt, a high consumption of ultra processed foods which are easier to obtain in a busy working day creates conditions for all of these diseases.

Over and above that, there is the big problem of physical inactivity partly because of the working conditions and partly because of the way cities are configured without adequate space or time, for pleasurable and safe physical activity. So physical inactivity and diet actually create most of the conditions for these chronic diseases and then you have problems of air pollution which again compound respiratory problems, create the conditions not only for cancers but also for heart attacks and stroke.

Then you have addictions to tobacco, whether it smoked or oral tobacco, substance abuse, alcohol; all of these are particularly prevalent in cities especially in slum areas and therefore, we find many of the low-income communities now vulnerable to chronic diseases despite their relative poverty.

In addition, we have other problems like mental illness because the poor with their subsistence living and struggle for reeking out an existence out of meagre incomes are also subjected to a lot of stress compounded by migration and the problems of migrant living.

At the same time the middle class and the rich also have the stresses of daily living and being caught in crowded traffic jams: all of that of course creates stress a chronic condition. And all of these can lead to mental illness and whether it’s depression or violence, including domestic violence- all of these are major problems that we encounter in urban environments.

We also have the problem of traffic accidents – quite often young people die or are severely disabled because of poor traffic regulation and road traffic injuries occurring in urban areas. About 52% of all deaths that occur in the age group of 15-29 are because of road traffic injuries and about 90% of them occur in low and middle income countries. Therefore, again poor urban planning leads to many avoidable health problems.

We are now seeing new challenges coming up. Climate change, for example, is raising temperatures all over the world and in many cities the temperatures are rising to such an extent that people are suffering the consequences in terms of heat strokes, heat deaths and of course a variety of other problems which are also fostered – like mosquitoes grow faster in warm environments and therefore again vector-borne diseases increase.

As cities grow, we must also recognise that they need to become much more resilient, they need to be resilient to Climate Change, they need to be resilient to natural disasters, we have seen floods hitting so many cities. Cities seem to even crumble with heavy rainfall and that has its own health consequences.

Diseases can spread rapidly in terms of natural disasters, mental health can get disturbed during natural disasters and services breakdown including access to health services breaks down when hospitals are disabled or healthcare providers are stranded during natural disasters.

resilient and climate resilient cities?” – is going to be one of the future challenges that we have to address.

One of the problems of course, is, that health ervices too are not appropriately distributed or are accessible in urban areas. Many times we feel that urban areas are going to have more of health professionals, more doctors, more nurses etc, so, ‘why on earth our health services not going to be adequately available?’ but there was the huge maldistribution in urban areas. The poor are unable to access good quality health services because of differential concentration of health professionals as well as financial barriers to access of good health services. Quite often they depend upon informal healthcare providers who are not qualified ranging from quacks to poorly trained healthcare providers and many times their health suffers as a result of poor management of their health problems and the contrary is also true that they do seek treatment for minor ailments too in large hospitals which makes the hospitals overcrowded that’s because primary care services are not well organised in health services. And if they do seek healthcare, they often get impoverished in the absence of universal health coverage. So one of the things that’s missing in many of the low and middle income countries is financial protection apart from quality of health care. If they actually are going to become poorer, or get crushed into poverty further because of unaffordable healthcare then that itself is a cause of huge health inequity. And organising urban health services to provide assured access, quality as well as affordability especially in the slum and low-income communities is absolutely critical but at the same time we ought to ensure that there is greater coordination between city planning and health planning.

Whether it is housing for everybody including low-income housing, whether it is safe cycling lanes, safe pedestrian pathways, well-lit streets where people can walk without fear of crime or falling, the risk of falling into potholes, clean and green community spaces where they can exercise, public transportation which are likely to be available and promote active living – all of these are going to be important elements of city planning. Unless you have a good land-use mix, street connectivity, look at residential density as an element of promoting active living, prevention of crime so that people can actually exercise safely; all of these are going to be coming into in city planning and if this is not paid attention to, then health will suffer.

Therefore what we need now, is a much greater coordination between urban planning which is traditionally in other sectors outside of health, and health planning. Then we also need a greater integration of health services, unless that happens we’ll have vertical programs functioning in silo, then we need  to promote greater access to disadvantaged communities both in terms of physical access as well as financial affordability and also provide greater education so that they know what kind of services need to be accessed to increase the demand generation from the poorer sections of the people who need those health services. We also need to bring in urban health-related awareness into health professional training. A large number of healthcare providers and public health professionals are still not familiar with some of the special features of urban health planning, they’re still rooted in terms of looking at traditional health care models and traditional public health systems. So even professional education of health professionals and healthcare providers needs to be transformed but most important, we also need to make sure that urban local bodies and administrators, municipal authorities- all of them become much more alive to the need of protecting urban health whether it is food safety or whether it is clean water and sanitation or whether it is ensuring urban primary care services.

Unless urban local governance becomes more responsible, as well as more accountable we are not going to see urban health in a good shape for years to come. But cities also provide the solution – because the sheer size of the cities and there are urban aggregation as well as their access to technologies including information technology makes it easier to do things on scale. We can actually build water and sanitation services to scale, we can build health services to scale and integrate all of them in a manner that we can actually ensure both healthy living as well as appropriate and affordable healthcare. So with Smart City Planning we can actually build-in much better health and make sure that urban health becomes a living reality for every person living in a city or a town, at every stage of his or her life. But that’s the way to go and that’s the way we must ensure that as an enlightened community, we make sure that things happen at different levels, but in an integrated way to make that a concrete reality.

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