Cities Transformed Demographic Change and Its Implications in the Developing World (2003) / Chapter Skim
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7. Mortality and Morbidity: Is City Life Good For Your Health?
7. Mortality and Morbidity: Is City Life Good For Your Health?
Pages 259-299
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From page 259... ...
As the transition proceeds, urban populations will experience relatively more chronic disease, including cancers and heart disease; mental health will also be of growing concern. In many and perhaps most cities, however, the health transition is still in its early stages, and these cities will continue to grapple with communicable diseases for the foreseeable future.
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From page 260... ...
Nothing locks this advantage into place. Deteriorating economic conditions, disinvestment by governments in urban public health infrastructure, and newly virulent communicable diseases could conceivably cause the penalties last seen in the nineteenth century to reemerge.
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From page 261... ...
To this end, results from the DHS surveys are compared with findings from spatially focused studies of urban slums and squatter settlements. The chapter then turns to a discussion of treatment-seeking behavior in urban populations and the new configurations of urban health systems.
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From page 262... ...
the significant obstacles that the poorest segments of the population may still face to gain access to public services, such as water, sanitation, and garbage disposal, even when these services are more available than in rural areas; (f) the increased exposure of urban-dwellers to environmental contamination, which increases risk of illness and, especially, infectious disease; and (g)
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From page 263... ...
Limited social support Insecurity of tenure Violence Lack of breastfeeding Accidents Depression Malnutrition Parasitic disease Anxiety Sexually transmitted Malaria Suicide diseases, including Dengue Cancer HIV/AIDS Respiratory infections Heart disease Tuberculosis Injuries Cancer Other infectious diseases (especially diarrhea!
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From page 264... ...
This unevenness can be seen in comparisons of adult and child mortality. In some cities, data registers allow the main causes of death to be identified and permit comparisons of adult and child causes.
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From page 265... ...
MORTALITY AND MORBIDITY TABLE 7-1 Disability-Adjusted Years of Life Lost in Mexico, by Cause and Residence 265 Cause Diarrhea Pneumonia Homicide and violence Motor vehicle-related deaths Cirrhosis Anemia and malnutrition Road traffic accidents Ischemic heart disease Diseases of the digestive system Diabetes mellitus Brain vascular disease Alcoholic dependence Accidents (falls) Chronic lung disease Nephritis Rural Urban Rural Rank Urban Rank Rural/Urban 12.0 9.3 9.2 7.9 7.5 6.8 5.5 5.1 4.7 4.1 3.0 3.0 2.8 2.6 2.2 1 2 3 4 5 6 7 9 10 11 11 13 14 15 2.8 3.9 7.4 8.3 6.3 2.4 6.8 5.3 1.7 5.7 3.0 1.9 2.6 1.9 2.2 11 6 15 13 10 13 12 4.28 2.39 1.23 0.95 1.19 2.86 0.81 0.96 2.74 0.72 1.02 1.56 1.09 1.39 1.01 N(4E: 1991 estimates, expressed per 1000 population.
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From page 266... ...
Urban residents are often thought to be at greater risk of being involved in an accident than rural residents (Odero, Garner, and Zwi, 1997~. This supposition enjoys some empirical support (Mock, Abantanga, Cummings, and Koepsell, 1999)
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From page 267... ...
Anxiety and depression are typically more prevalent among urban women than men and more prevalent in poor than in nonpoor urban neighborhoods. Those suffering from stress may be able to call upon various forms of emotional support, as well as material support in the form of goods, services, and information.
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From page 268... ...
In low-income urban communities, social capital has been found to weaken as households' ability to cope decreases and community trust breaks down, and to be severely eroded by various forms of violence (Moser and McIlwaine, l999~. Chronic "Lifestyle" Diseases As noted above, urban areas have higher risk factors for and rates of diabetes, obesity, cardiovascular disease, cancers, and coronary heart disease.
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From page 269... ...
Unfortunately, the DALYs data available from the Global Burden of Disease studies have not been systematically disaggregated by rural and urban place of residence. Diagnoses of chronic diseases may be better in urban than rural areas, and the studies cited above suggest that urban populations will continue to be at the forefront of health transitions.
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From page 270... ...
The Urban Penalty The prospect of- communicable diseases proliferating in countries with weak governmental and public health capacities has raised concerns about new forms of urban penalties. The phrase "urban penalty" arose from analyses of English mortality data from the industrial revolution of the nineteenth century, which revealed that urban mortality rates (particularly from tuberculosis)
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From page 271... ...
In view of the many factors involved in reducing mortality and the natural disadvantages faced by spatially concentrated urban populations, it would not be surprising to find evidence of slippage in the urban health advantage, nor would it be surprising to see instances in which rural populations have regained their earlier
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From page 272... ...
RECENT EVIDENCE ON CHILDREN'S HEALTH AND SURVIVAL What empirical evidence is there of an emerging urban penalty for children in developing countries? For an overview, we turn first to data from the DHS on children's height and weight, and then consider child survival.
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From page 273... ...
, the urban/rural difference is statistically significant. Among urban children, do these measures of health vary according to city population size?
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From page 275... ...
With regard to height for age, almost all surveys suggest that poor urban children fare at least as well as rural children, and generally fare better. Comparisons of weight for height are less definitive.
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From page 276... ...
276 o cat Cal Cal V: so o Cal Cal so ¢ so ' - o.
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From page 277... ...
That an urban advantage is found is not especially surprising, although it would have been thought an anomaly a century ago. The more revealing comparisons involve urban children in poor households, those in nonpoor households, and rural children.
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From page 278... ...
It is likely that poverty-related differences in children's health are due, at least in part, to such differences in access to services.8 If poor households have worse access to sanitation and clean water, for example, children in those households may be at greater risk of exposure to communicable diseases, in particular diarrhea! diseases.
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From page 279... ...
shown in this table place urban poor children at a point midway on the risk spectrum, falling between the urban nonpoor and rural children. In comparing urban poor and rural children, we find that in some 57 of 87 surveys, the mortality risks facing the urban children are significantly lower.
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From page 281... ...
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From page 282... ...
or rural areas. In light of these contradictory findings, as well as other case studies suggesting deteriorating health conditions among slum dwellers, we cannot draw strong conclusions about trends in the urban health advantage.
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From page 283... ...
, where women have regained the survival rates characteristic of the late Soviet era. Indeed, for Almaty women under 40 and above 65 years of age, 1999 mortality rates were already below those recorded in 1991.
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From page 284... ...
Bradley, Stephens, Harpham, and Cairncross (1992: viii) advance the view that "urban poor households sometimes have worse nutritional status than rural households, contributing to ill-health related to nutrition." The panel's review of DHS data uncovered no systematic tendency for poor urban children to fare worse than rural children, but identified a number of exceptions to the general rule.
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From page 285... ...
Several recent empirical studies have highlighted urban neighborhood and contextual effects on health outcomes and mortality, indicating that the urban poor, especially those living in majority-poor communities, suffer from urban penalties based on their geographic location and its interrelationship with poverty, segregation, and other forms of deprivation. Infant mortality rates in the municipalities that make up Greater Sao Paulo varied in 1992 from 18 per 1,000 (in Sao Caetano do Sol)
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From page 286... ...
During the 1990s, infant mortality rates declined in urban Kenya and in Nairobi overall, increased in rural areas, but appear to have increased even more sharply in the Nairobi slums. Figure 7-2 compares the infant mortality rate (0-1 year)
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From page 287... ...
Finally, it is understandable that much research on urban health is focused on absolute poverty rather than on measures of relative poverty. There are enormous intraurban differences in housing, income, sanitation, drainage, piped water,
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From page 288... ...
The impact of relative poverty is powerfully described (Wilkinson, 1996: 215, cited in Blue, 1999:214: From the point of view of the experience of people involved, if health is being damaged as a result of psychosocial processes, this matters much more than it would if the damage resulted from the immediate physical effects of damp housing and poor quality diets.... To feel depressed, cheated, bitter, desperate, vulnerable, frightened, angry, worried about debts or job and housing insecurity; to feel devalued, useless, helpless, uncared for, hopeless, isolated, anxious and a failure: these feelings can dominate people's whole experience of life, coloring their experience of everything else.
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From page 289... ...
The conceptual distinctions we have mentioned between the public and private sectors, for-profit and not-for-profit providers, the formal and informal sectors, and modern and traditional providers can be difficult to detect (see Giusti, Criel, and Bethune, 1997; Londono and Frenk, 1997; Ferrinho, van Lerberghe, and Gomes, l999~. The urban health sector presents many arrangements that defy easy categorization dual public and private practices by government-employed physicians, the introduction of private wards in public hospitals, the self-referral of patients between healers and Western doctors and between public and private facilities, and the introduction of user fees into government services.
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From page 290... ...
Many urban residents are eclectic, using healers even while they are attending modern health facilities, and healers often assume an important role when modern services fail to effect a cure or are perceived to fail (Molyneux, Mung'Ala-Odera, Harpham, and Snow, 1999~. Private providers Private facilities are an important urban treatment source for STDs, malaria, tuberculosis, and diarrhea (Brugha, Chandramohan, and Zwi, 1999; Brugha and Zwi,
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From page 291... ...
Selected Issues in Health Service Provision and Use Aspects of urban health service use that have attracted research attention include the Malfunctioning of the referral system, the impact of user fees on rates and patterns of use, quality of care as a key influence on treatment seeking, and urban/rural linkages. These are addressed in turn below.
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From page 292... ...
The principal weakness identified in urban health systems is at the second tier of services, these being the units that should manage referrals, supervise primary care and first-contact services, and provide basic care for patients with obstetric difficulties and trauma (Lorenz and Garner, 1995~. A World Health Organization strategy to strengthen this tier is to promote the development of urban intermediate-level health services or "reference centers," either by upgrading health centers or by giving referral hospitals authorization to provide different levels of care in the same institution (Sanders, Kravitz, Lewin, and McKee, 1998)
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From page 293... ...
primary and secondary level care is available." Quality of care is now mentioned frequently, and, as just noted, its importance is underscored by studies exploring how user fees affect utilization. The aspects of quality found to be associated with use include drug availability, prescribing and dispensing practices, the physical condition of health facilities, service availability, number of personnel, crowding and length of waiting time, attitudes displayed by health workers toward clients, and the degree of confidentiality (Hotchkiss, 1998; Brugha and Zwi, 1999; Bassett, Bijlmakers, and Sanders, 1997~.
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From page 294... ...
Urban/rural linkages At a time when thinking on urban health is broadening to include social aspects of the environment and recognizing the multiple factors that operate at different levels, attention must also be paid to the sociodemographic linkages between rural and urban areas. The importance of urban/rural links in health is most frequently illustrated in the transmission patterns of HIV (and other infectious diseases)
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From page 295... ...
These findings, based on a comprehensive literature review and analysis of the DHS-United Nations urban database, serve as the basis for the conclusions and recommendations presented below. Conclusions Child survival and child health Infant and child mortality rates are higher on average in rural than in urban areas.
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From page 296... ...
However, poor urban children are much less healthy than nonpoor urban children, and they are sometimes not as healthy as their rural counterparts. Although there are few countries for which changes over time can be examined, it appears that the urban health advantage for children has not changed during the past two decades.
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From page 297... ...
Considering weight for height, poor urban children are generally heavier than rural children, but in 16 countries the reverse obtains. The urban health penalty In summary, there is no clear and compelling evidence of an emerging urban health penalty that puts urban children at greater risk than rural children.
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From page 298... ...
Service delivery The deficient health status of poor urban children in comparison with their nonpoor urban counterparts and sometimes in comparison with rural children leaves no doubt as to the importance of a focus on urban poverty in nutrition and health programs. Urban policy makers in Africa in particular should focus on improving environmental conditions and access to health services, as well as curbing the spread of AIDS, to reduce infant and child mortality among the urban poor.
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From page 299... ...
MORTALITY AND MORBIDITY 299 comparative research on inter- and intraurban differentials in health and treatment seeking, the quality of urban health services, and perceptions of quality. Although the urban advantage would appear to have persisted over time, research on urban penalties is urgently needed in sub-Saharan Africa, where there are credible accounts of stagnation and even declines in child health in some countries.
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