Urban poverty: an urgent public health issue.

The World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) has posed a provocative question for public health: “Why do we keep treating people for illnesses only to send them back to the conditions that created illness in the first place?”1 For the WHO Centre for Health Development (WHO Kobe Centre), hub of the Commission’s Knowledge Network on Urban Settings (KNUS), this represents a challenge to the public health sector not only to acknowledge the pervasiveness of urban poverty as a critical pathway to ill health and health inequities, but to address this as an urgent public health issue affecting a billion people living in informal settlements, or “slums.”1

People who live in informal settlements are often systematically excluded from opportunities, decent employment, security, capacity, and empowerment3 that would enable them to gain better control over their health and lives. As noted in the Interim Report by the Millennium Development Goals (MDG) Task Force, which focuses on improving the lives of urban slum dwellers:

Much of urban poverty is not because of distance from infrastructure and services but from exclusion. They are excluded from the attributes of urban life that remain a monopoly of a privileged minority—political voice, secure good-quality housing, safety and the rule of law, good education, health services, decent transport, adequate incomes, access to goods and services, credit—in short, the attributes of full citizenship.4

The issue of urban poverty is not new, but it is often narrowly viewed as an economic issue that is best addressed by economic policies and interventions. Urban poverty today, as driven by globalization and rapid uncontrolled urbanization, also needs to be recognized as a social, political, and cultural process that has profound impacts on public health. Exclusion of the urban poor from the benefits of urban life fosters discontent and political unrest. Within the broader context of health and human development, rapid urbanization of poverty and ill health have been characterized as a new human security threat.5

Rapid uncontrolled urbanization results from the interaction between global and local forces. The interconnectedness of cities through trade, business, industry, tourism, international travel, information technology, and media is reshaping social determinants of health that are manifest at the city level. On the other hand, local and national governance capacity in relation to health systems, housing, transport, property rights, migration, land use policy, working conditions, and employment may be unable to cope with the speed of change brought about by global economic restructuring. Inequity in cities that leads to urban poverty, and poor health, therefore, are also products of global and local forces in the urban setting. Public health can play an important role in ameliorating urban poverty through social processes (participation, social capital, social accountability, and social inclusion) that influence urban governance at multiple nodes6 of power. Addressing urban poverty as an urgent public health issue opens a policy space for fairer health opportunities and healthier and more equitable cities.

IMAGINE THE WORLD AS A GROWING CITY

Today, for the first time in history, half of the world’s population lives in cities. The United Nations estimates that the number of urban residents will increase by more than two billion people by 2030, whereas the rural population will decline by about 20 million.7 Of the many risks to health that are linked to rapid urbanization, none is more compelling than the rise of urban poverty, manifested by the growth of informal settlements. Whereas rising urban poverty is evident in the developed world, this trend is more pronounced in developing countries.

UN-HABITAT states that the global urban slum population is expected to double from one billion (estimated in 2002) to nearly two billion by 2030 (from 32% to 41% of the world’s urban population), and to approximately three billion by 2050.8 Among the one billion people who live in informal settlements today, one-third of households are headed by women. Hundreds of millions of children and youth live and work in depraved conditions in urban areas.9 According to the latest Global Report on Human Settlements, 43% of the urban population in developing regions lives in slums. In the least developed countries, 78% are slum-dwellers.10 The scale and speed of this phenomenon pose serious and compelling risks and challenges to health—in sum, it is a crisis of unprecedented magnitude.

When disaggregated according to the regions of the World Health Organization, as depicted in Figure 1, the largest numbers of impoverished people living in poor conditions in urban settings are found in the Western Pacific Region (around 233 million), followed by the Southeast Asian Region (217 million) and the African Region (156 million).8 Whereas the Western Pacific Region has the highest number of urban slum dwellers, they represent a relatively lower one-third of the total urban population of approximately 700 million, on a par with the developing countries of the Americas Region.2 The rapid expansion of urban areas in South and East Asia is creating megacities of unprecedented size and complexity that present new challenges to providing a decent environment for the poor: the urban slums of the South-East Asia and Eastern Mediterranean Regions account for almost half of urban populations there. Worst affected is the (largely sub-Saharan) African Region, where two-thirds of its urban inhabitants live in informal settlements. It is also experiencing the world’s fastest rates of urbanization. Northern Africa is the only developing region where the quality of urban life is improving: here, the proportion of city dwellers living in slums has decreased by 0.15% annually.10

FIGURE 1

Urban populations and slum dwellers (noted in shaded area) in WHO Regions (as of 2001).8

The urban setting in a globalized world is increasing exposure to unhealthy environments, disasters, climate change, violence and injuries, tobacco and other drugs, and epidemics including HIV-AIDS. Without access to adequate shelter, health care, and resources, the urban poor face the greatest threat. Given current demographic trends, the majority of all urban inhabitants in years to come will suffer disproportionate exposure to the triple burden of ill health: injuries, communicable diseases, and noncommunicable diseases.19

UNDERSTANDING THE ROLE OF PUBLIC HEALTH IN AN URBANIZING WORLD

Over the past 12 months, the Knowledge Network on Urban Settings has worked with researchers, local communities, academia, development organizations, donors, and practitioners from local, national, regional, and global organizations to distill what is known about social determinants,3 health and health inequities in urban settings.

While KNUS research is ongoing, the following findings are of particular relevance to public health:

The urban poor do not “wait” for governments or organizations to act on their behalf. They have the desire and resourcefulness to find ways to improve their shelters, access running water, produce food, organize child care, educate themselves and their children, and protect each other amid extreme poverty.20

While poor communities are severely affected by violence, it is important to recognize the wealth of untapped social resources within informal settlements. One case study from the favelas of Brazil notes the presence of “social networks, trust, solidarity and mutual support, celebration, cultural life, local businesses, informal activities on education, recreation, sports, religion, politics, and much more.”21

Uncontrolled, rapid urbanization and the unraveling of the traditional social fabric deepen inequity and give rise to alternative governance structures such as gangs (which target impoverished youth) and paramilitary organizations (known to recruit children for warfare).22 People who live in informal settlements are at higher risk of exposure to crime and violence.11

Since 2000, the world’s fastest growing urban areas are also those where there are increasing concentrations of informal settlements. This has profound consequences for public health strategies to control communicable (HIV-AIDS, TB, H5N1 virus, dengue, and other vector-borne diseases), as well as noncommunicable (obesity, diabetes, cancer, chronic heart disease, stroke, hypertension) diseases,23 mental health and conditions that are associated with urban life (road traffic injuries, urban violence, obesity, and unsafe settlements).

Urban poverty has been narrowly framed as an economic development issue. Unless a broader development perspective is used, policies, programs, measurements, evaluations, and strategies—as well as the “actors” and “stakeholders” who are expected to take action—will fail to fully engage the social, cultural, environmental, and health dimensions of urbanization and urban poverty.

Improving local urban governance as a strategy for alleviating urban poverty (as exemplified by the work of UN-HABITAT24) has created a new policy space for linking development to health and vice-versa, but this space has not been effectively used by the public health sector as a means of shaping healthier public policy in the majority of cities.

Given the high concentration of national resources in cities, it is often assumed that city dwellers have better access to services including health care, and that poor people in urban settings are therefore better off than their rural counterparts.25 This is where the issue of equity emerges as crucial for the urban poor, who, in fact, grapple with complex and debilitating challenges: inability to pay for goods and services, lack of social support systems,26 unhealthy and unsafe living and working conditions,27 exposure to crime and violence,28 limited food choices,29 discrimination, isolation26 and powerlessness.6

Despite the obvious linkage between urban poverty and ill health and the potential impact on the rest of the population, the health sector in many countries continues to narrowly define its role as that of finding ways to improve access to services and improve the financing of health care services for the poor. Although important, this is far from sufficient.30

PUBLIC HEALTH: A RALLYING POINT FOR EQUITY IN CITIES

The need for intersectoral action and policy to address social determinants of health is not a new concept. The challenges and difficulties of mobilizing intersectoral support for policy and resources are known. In its review of 80 case studies, KNUS has discovered that “health” can unite individuals, communities, institutions, leaders, donors, and politicians from divergent sectors, even in complex and hostile contexts where structural determinants of health are deep and divisive. Some of the case studies are highlighted below.

Whether it is getting a local community to design a health plan for themselves (Dar es Salaam, Tanzania’s Healthy City Programme31), or enabling citizens to vote for priorities in local resource allocations for health (participatory budgeting in Porto Alegre, Brazil32), decreasing dengue incidence (Marikina Healthy Cities Programme, Philippines33), or involving the entire community in designing shared spaces that encourage walking and cycling (Healthy by Design, Victoria, Australia34), public health is an effective rallying point for achieving greater health equity in the urban setting.

While debate and discourse inevitably arise on methods, terminology, resources, and priorities for achieving better health, invoking health as a social goal and the imperative for “fairer health opportunities for all” has been a powerful lever for addressing social determinants of health in urban settings. The research and analysis also point to the critical importance of social processes in achieving more equitable health outcomes. Preliminary findings from the thematic papers of KNUS4 suggest that:

Integrated interventions that support community action through participation and empowerment (urban primary health care,35 Healthy Cities,36 Community-Based Initiatives,37 Sustainable Cities,38 Local Agenda 21 sites,39 Cities Without Slums40 and many other integrated approaches) have been shown to reduce health risks, improve health outcomes, and promote better quality of life;

Where integrated interventions are further linked to better urban governance (local government accountability, local capacity building in support of decentralization, land use policy, participatory budgeting, urban planning and design, sustainable food systems), a healthier social environment is possible;

Where “change agents,” “catalysts,” and “facilitators” have stepped in to mobilize communities toward public health action and ultimately to influence intersectoral policy and mobilize resources for health equity (national urban renewal programs, agricultural policy, national housing policy linked to urban development), bringing interventions to scale is more likely; and

Networked governance,6 where urban poor communities and other organized groups (e.g., Shack Dwellers International41) work with local or national government agencies such as the Community Organizations Development Institute of Thailand42 and the Committee of Resource Organizations of Mumbai, India43 and international alliances or organizations like the Alliance of Healthy Cities, 44 European Healthy Cities Network,36 Network of Healthy Municipalities,45 Cities Alliance,40 UN-HABITAT and WHO, demonstrates the power of harnessing social processes created by the interconnectedness of cities. Taking the principles of empowerment and participation a step further through city-to-city learning28 is a means of transforming global power relations and overcoming the structures that perpetuate urban poverty.

SHARPENING THE FOCUS ON SOCIAL PROCESSES

Primary health care and its emphasis on community action and social process in the urban setting is a key strategy in achieving better health equity for the urban poor.46 Sharpening the focus on social processes throughout the entire public health arena paves the way for scaling up interventions that work.

The case studies of KNUS describe a range of actions that contribute to strengthening and supporting the role of public health:

Engaging in political processes (budget hearings, elections, lobbying, campaigns) that impact on social determinants such as violence prevention, employment, child development, and gender equity;

Strengthening “bonding” and “bridging” social capital by facilitating dialogue among stakeholders across sectors and within hierarchies;

Using a “healthy settings approach”47;

Engaging communities through participation and use of empowering processes;

Engaging in intersectoral policy debates on nonhealth equity drivers (e.g., transportation, land use policy, land tenure, human rights);

Using existing networks to advance policy issues (local, national, regional, international);

Advocating for social and financial accountability at all levels;

Recognizing the links between mental health and well-being and public places, community spaces, parks, and gardens where social cohesion and the expression of diversity are simultaneously nurtured through cultural activities, art, recreation, sports and play;

Using local data (intra-urban health differentials) and local situations to articulate the links between health and other sectors such as transportation, housing, and public services that impact social determinants;

Supporting regulations that protect people, especially vulnerable or exposed groups, from threats and hazards (in workplaces, communities, schools).

USING SOCIAL CAPITAL TO INFLUENCE URBAN GOVERNANCE

How can we do a better job of linking disadvantaged people living in cities to the human and financial resources, policies, programs, and actions that would enable them to gain control over their health and their lives? How can we mobilize the resources to enable this process to happen at a scale that will make a difference for the world’s urban poor? What is the link between social processes and urban governance?

Social capital, as part of social processes, is a critical means of changing power relations in cities. Public health can provide the “glue” to link, network, and bind the growing groups of poor and marginalized populations to nodes of power.

The urban setting is a social determinant of health in itself. Public health gains in disease prevention and control in our cities can easily unravel with the growth of physical and social environments of extreme deprivation. In an interconnected world, our cities can continue to be “engines of economic growth”48 and “centres of culture.”49 The question is whether public health can use the interconnectedness of cities as a positive pathway to enhancing equity in health between and among cities and nations.

Exposed populations in the urban setting:

•There are 150 million street children worldwide. Forty percent of them are homeless.11

•A study in Zambia shows that 2/3 of urban households have lost their breadwinner to HIV-AIDS.12

•At least once every 5 years, 60% of those living in cities of 100,000 inhabitants or more are victims of one form of crime or another.13 Violent crime is particularly prevalent in Latin America’s large cities, disproportionately affecting men in low-income neighborhoods,14 with relative risk of 5.1 in lowest versus highest measure of living standards.15

•In Nairobi, where 60% of the city’s population lives in slums, child mortality in the slums is 2.5 times greater than in other areas of the city.16

•In Manila’s slums, up to 39% of children aged between 5 and 9 are already infected with TB—this is twice the national average.17

•In Latin America, the average urban woman’s employment income is only 58–77% of men’s.18