Health in a city environment

24 World Health • 47th Yeor, No. 3, May-June 1994 Health in a city environment Fran~oise Barten Rapid urbanization creates marginalized communities who live in desperate poverty and may represent up to half the population of some developing countries. R apid urbanization and the increase in urban population are recognized as being among the major challenges for health development in the 1990s and in the decades to come. Between 1950 and 1980 the world's urban population increased from 701 million to 1983 million, or from 25% to 41 % of the total world population; by the year 2000 this proportion will be 50%. Change has been particularly rapid in the South, where the scale of urban growth is unprecedented in human history and cities have experienced growth rates two to three times higher than those of industrialized countries in the past. Between 1990 and 2025, the total urban population in "develop- ing countries" is projected to increase threefold, to 4000 million or 61 % of the population. Urbanization is .taking place in a context of increasing poverty. As much as half of the population of cities in the South live in conditions of extreme poverty associated with enormous deficiencies in such basic services as water supply, sanitation, sewage systems, drainage and basic health care. A key-feature- and one of the most important reasons for concern - is the existence of gross inequalities in health and environ- ment between cities and between richer and poorer areas within the same city. In Guatemala City, for instance, the poor who live in the slums on tht< slopes of La Limonada - a ravine which crosses the city centre - have no water supply while just opposite, in the graveyards of the rich, fountains spray water all day. Health problems are complex and poorly defined. Apart from the diseases of poverty (infectious diseases, malnutrition), the poor are exposed to the health risks of modernization (traffic, pollution, etc.) and suffer the consequences of social and psychological instability as the traditional support structures of the rural area steadily disappear. Most people in the Third World cities struggle to survive by partici- pating in the informal or hidden economic sector where exposure to occupational hazards is of very little concern. Recent emphasis on this sector as a strategic approach to urban development tends to neglect the fact that small-scale industries may also constitute important Partners from North and South are working together on a variety of urban projects. The aim is to contribute to improvements in city living standards well into the next century. environmental health hazards for communities living nearby. While the environmental prob- lems are wider in scope and far more serious in terms of impact on human health than those in cities in the North, the capacity to respond to such problems is also more limited. The absence of effective local governance certainly aggravates them. Health authorities have to cope simultaneously with three distinct disease profiles- infectious diseases, degenerative diseases and problems caused by environmental, occupational and social conditions - whereas it took industrialized countries more than a century to confront these three. Focus on the vulnerable If the health sector is to focus on so- called "vulnerable groups", it should be recognized that this refers to 50% of the population! It is clear that many problems cannot be addressed without fundamental changes in the distribution of incomes, both nationally and internationally. However, the cities also offer many opportunities for change; and an integrated approach to health and urban development involving all actors at city or district level (local World Health • 47th Yeor, No.3, Moy-June 1994 Children in slum areas are subiect to environmental hazards that may threaten their health and even their lives . government, community organiza- tions, nongovernmental organiza- tions (NGOs), professional groups) appears to be the most promising line. In Manila, the recently ac- cepted Local Government Act allows NGOs and community-based organizations to participate in district and subdistrict planning, including health. During the past decades, NGOs of various back- grounds had already acquired extensive experience in bottom-up approaches. Community-based organizations were developed in some cities in the 1970s, with land tenure as the main issue. However, health also proved to be important in the efforts to mobilize and raise awareness among the people. In due course, universities and other training and research institutions played an important role in support- ing local urban health systems and in addressing policy questions. North-South collaboration The need for new models to resolve the problems of the urban poor recently led to the formation of an innovative network programme, involving institutes in both the South and the North, and including the Nijmegen Institute of Interna- tional Health which is acting as temporary secretariat (on a rotating basis). The programme, Health and Environment in the Cities, or HEC, is meant to be a continuous working platform where partners from North and South collaborate on various projects. The "urban environment" is defined as the social, political, economic and physical environment, since all these factors interrelate and determine health in the city. The broad aim is to achieve equity in health, putting the key features of inequalities right up front. Because of the emphasis on inequity and the commitment to locally defined solutions and social participation, the prime focus is on the improve- ment of interventions not only in terms of design but also in terms of the processes of intervention. Distinctive features are the multidisciplinary approach and the emphasis laid on information/ communication to raise awareness and strengthen community-based organizations in the negotiation and planning process with local govern- ments. This drives the network approach along a very different path from that of more conventional operational research and interven- tion studies. Projects include those on the environmental and occupational health hazards of small-scale industries (Dar es Salaam, Tanza- nia), living and working conditions of scavengers (Jakarta, Indonesia), designing women-friendly health care (Managua, Nicaragua), deter- minants of violence (Kingston, Jamaica), urban health manage- ment and so forth. Besides these countries, HEC includes member institutes from India, Netherlands, Switzerland and the United Kingdom. 25 The initiatives, formulation, execution and evaluation of research projects, accompanied by opera- tional research, come from a local level. The medium-term goal is to build the capacity within each society to identify, analyse and act on their own environment-related health problems; considerable emphasis is therefore given to participatory network methods and approaches. In this way, the HEC group hopes that its joint North- South programme will contribute to sustainable health and urban devel- opment- including the alleviation of poverty and inequalities- in selected cities well into the next century. • Dr Franr;:oise Barten is Coordinator of the Niimegen Urban Health Group, the Health and Environment in the Cities Programme of Niimegen University, Geert Groote Plein Nrd 9, 6525 EZ Niimegen, Netherlands. Small-scale informal industries offer the only means of survival for many people in periods of serious unemployment