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by Dr Anthony J. Marsella and Dr Hugh Freeman respectively Professor of Psychology, University of Hawaii, and Editor, British Journal of Psychiatry, London
uch as the pyramids of Egypt or the medieval cathedrals of Europe symbolized mankind's determination to rise beyond its own limits, so the presentday city symbolizes our impulse to pursue a social and collective exist. ence. How is it then that so many cities have become such a fertile ground for crime, substance abuse, disease, demoralization, human insult and degradation? More than 250 years ago, the Geneva-born Swiss writer JeanJacques Rousseau blamed society for being the cause of illness and disease; he said that, considering the sturdy health of the "savages" of his day, any history of civilized society would be equally the history of human sickness and disease. Nineteenth-century physicians added their voices to this as they claimed that insanity was part of the price we pay for civilization. This helped to popularize romantic notions about the benign nature of rural life and the noxious effects of city life. Yet those who have actually lived in and studied rural societies have seen that they have never been free of stress and strain, and that village life may be 24
cruel, violent, frightening and often degrading for human dignity. Our views on the roles played by "civilization" and the city environment have to be balanced against all the various facets of urban, semi-urban and rural life. It is interesting to note that, among the many studies carried out on mental disorders, not one was able to find a really convincing difference in total rates of psychiatric disorders between urban and rural ar~as.
Mental ill-health Many factors interrelate to create mentally unhealthy communities. In the cities of the developing world, at least 50 per cent of the residents, and in some cases even 80 per cent, live in extreme poverty. These urban poor are at very high risk of infectious diseases, chronic degenerative diseases, and also mental disorders and social pathologies; poverty, rather than city life in itself, is most likely to be the single greatest cause of urban physical and mental morbidity. Some 50 years ago, severe mental disorders were studied in Chicago, USA Conclusions showed that the greatest concentration of schizophrenic disorders appeared to be in the disor-
ganized communities in or near the centre of the city. The authors of this now classic study explained that this was probably due to the social drift of schizophrenics into these areas. . As additional community psychiatric studies were conducted, it became clear that the distribution of mental disorders in cities corresponded to the concentration of poverty in city centres. Other studies indicated that the frequency of severe mental disorders, and in particular schizophrenia, were higher among the lower social classes. More recent research shows that communities which lacked social and cultural cohesion (characterized by family and marital disintegration), and which had no social networks and associations, no community leaders, weak and fragmented communication networks, and high levels of hostility, had an increased risk of mental disorders. All this is more likely to occur in poor communities, whose members come from mixed cultural backgrounds and are often recently arrived migrants, and where social change is The outskirts of New Delhi, India. Such monotonous surroundings leave little room for personal development. W ORLD HEALTH,
March-Apri l 1991
rapid. Such a pattern is not necessarily urban, but is more often found in the cities. I " In an effort to counteract the formation of slum areas, city authorities ~ have tried to resettle people into better > housing. In doing so, however, they have sometimes destroyed long! established communities with a culture ~ of their own and with important social networks, without offering anything to ] replace them. The social support g. .derived from these networks is of ~ fundamental importance in maintaining good mental health and, in most cases, the provision of new houses did not remove the social problems. @
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living on the margin
Many cities of the developed world have seen their centres emptied of their working class inhabitants, and their homes replaced by office space or used for shelter by a mixture of members of minority races and socially marginalized people such as alcoholics, drug addicts or those with marked personality disorders. This has led to the development, in many places, of communities with major social problems, particularly as the change has often coincided with economic decline and "de-industrialization." Some cities have tried to solve the lack of adequate living accommodation by building countless high-rise residential blocks, and by forcing highways through to accelerate communication between different districts. In most cases these residential blocks were created without taking into account the wishes of the people who Bangkok. Thailand, and young were going to live in them, thus skinheads in Germany. Highways creating dissatisfaction and the much cutting through the city risk tearing talked about "inner-city malaise". As apart the human environment, and for the highways, they tore apart contribute to "inner city malaise", a human-scale environments and frag- potential source of juvenile delinquency mented them, giving way to segregated and vandalism. Young people are a cells where movement was difficult, if priority target group for mental health not impossible, for anybody who was promotion. not equipped with a car. Even in cases where planners and i · { builders have made real improve- ~ ~ ments, for instance by reducing the ~ ( population density or making better sanitation facilities, they have not been able to establish or preserve the kinship and mutual-help networks that existed in older communities. Most occupants of the new homes tended to place greater emphasis on their own domestic privacy to the detriment of social interaction. This is partly due to the fact that local building styles and materials, as well as traditions, are abandoned to give way to monotonous streets of identical houses, with their nearby
shopping areas, which are hardly designed to inspire community communication. The effects of reduced supportive ties tend to be greater in individuals such as housewives and the elderly who are not in regular contact with people outside the area. These groups are less likely to find adequate supportive relationships amongst neighbours, especially if they have not' lived there for long. Certainly a greater prevalence of depression has been found in both working-class women and in the elderly. Children and adolescents may also suffer from urban malaise, which is translated into depression, emotional disturbance, educational difficulties and family breakdowns, and often leads to extreme behaviour such as drug addiction or delinquency. What conclusions can be reached that could improve the mental health of those living in cities? The "International hearing on achieving better living conditions in towns," held in Stras-
bourg, France, in October 1988, concluded that a mixed-use policy which combines housing, commerce and business could play a significant role in reducing urban delinquency and vandalism. The meeting condemned housing policies based on demolition and rehousing of the inhabitants elsewhere, which tends to create a climate of tension and insecurity, and to provoke a breakdown of collective life. Architects too were judged to have a responsibility to ·produce a stimulating environment where individuality can be expressed, where there is a sense of belonging, and where places are created in which the residents are proud to live. One proposal is that young people should constitute a priority target group for mental health promotion through the reinforcement of their social networks and the provision of greater psychosocial skills. This might particularly be done through the schools, which could act as focal points for developing a healthier mental life rather than just being institutions for imparting knowledge. The question remains why so many choose to live in great cities and so many still wish to migrate to them in the face of all these problems. Is it the opportunity for wealth, for mobility, for freedom? Is it the appeal of excitement, new possibilities and even risk? The attractions of city life, particularly to the young, are manifold. Yet these attractions often exist alongside crime, substance abuse, hopelessness, exploitation, misery and suffering. Somehow these factors do not seem to matter to many towndwellers. We have therefore to look for ways of reducing the risks of mental and physical ill-health in cities whilst at the same time maintaining their attractiveness.
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W ORLD HEALTH .
M arch-Ap ril 1991