Why focus on the health of the urban poor?
Urban growth is transforming population health, especially for the urban poor. One in three urban dwellers – 828 million people – lives in a slum, producing slum cities within cities. More than 90 per cent of slums are found in developing countries. Slum dwellers are not the only poor residents of cities, but they do represent a clustering of living conditions within a city. As urbanisation continues, even if the relative levels of urban poor remain constant, the absolute number of people living in poverty in cities will rise. Poverty is set to become an increasingly urban phenomenon.
Urban poor populations, and the places where they live, are diverse. Neighbourhoods are not uniformly poor, and being poor does not necessarily mean suffering ill-health. Health is determined by many diverse factors, including income, gender, age, access to health services and infrastructure. Yet we know little about the health of the urban poor.
How can we get data on the health of the urban poor?
Rapid urban growth places increased demands on already overstretched agencies to collect data from and about the urban poor. Even aggregate ‘headcount’ data can fail to keep up with rapidly changing urban populations. We know that slum residents tend to be less likely to be included in censuses and surveys (they might want to remain hidden if their residence is illegal), that slums are difficult places for interviewers to work in, and that slum households tend to be less likely to be included in routine mapping of neighbourhoods. Many urban poor are hard to reach from the perspectives of the people that run censuses and surveys.
The data that do exist tend to be aggregated at a level which ignores and masks differentials within cities and between neighbourhoods. We need disaggregated data if we are to really understand, and improve, the health of the urban poor. Not only do we need more distinction within cities, we need more distinction between cities. Continuing to compare ‘rural’ and ‘urban’ populations within countries (the dominant approach of demography and health surveys) doesn’t make sense when we know that the boundaries between urban and rural are fuzzy and continually evolving in planned and unplanned ways. It also masks differences between cities of different sizes and wealth. We know very little about the health of poor people in the world’s 500 smaller cities (between one million and ten million inhabitants), because research has tended to focus on megacities with more than ten million inhabitants.
Urban advantage or urban penalty?
How we measure urban health affects whether we find an urban advantage, disadvantage or even a ‘double-burden’ in health. An urban advantage in health tends to be found when analyses just focus on crude urban vs. rural comparisons, ignoring whether people are poor or not. When we compare the chances of survival of young children between urban and rural areas, the chances of dying by their first birthday tend to be higher in rural areas.
But these sorts of comparisons ignore the heterogeneity of urban areas and populations. Averages at the rural and urban level can disguise significant variations, not just in terms of health outcomes, but also in terms of health systems and services and living conditions. In our opinion, such crude urban-rural comparisons mask the real health implications of being urban and poor in many low-income countries. Instead, we need to better understand the poor–rich gaps in health within urban areas. Where the evidence exists, it suggests that many urban poor, in particular children before they reach their fifth birthday, are in fact paying an urban penalty with their health.
This urban penalty might be related to a double burden of disease facing the urban poor. There is rising prevalence of both infectious and chronic diseases in slum communities, interacting in ways that increase the chances of ill-health and premature death. It is not the case, then, that chronic diseases affect only the rich: the urban poor are also affected by these ‘diseases of affluence’. Overcrowding and poor sanitation can increase the risk of respiratory, viral and skin diseases. Lifestyle and everyday responses to difficult social environments can increase population risk of the major chronic diseases. People might not have access to nutritious food, increasing the risk of cardiovascular diseases, diabetes and major cancers. Where early sexual activity occurs, perhaps due to peer pressure or as a survival strategy, and there is an increased risk of sexually transmitted infections, the risk of developing an HIV-related cancer can also increase. In conditions of extreme poverty, adults and young people may be more likely to drink alcohol, smoke and use drugs to ease everyday psycho-social stresses. Yet each is a major risk factor for cancers, cardiovascular disease and diabetes. Livelihood strategies can increase infectious and chronic health risks. For example, young people who make a living from ‘e-waste’ (electronic devices dumped as waste, often in poor urban neighbourhoods) are exposed to toxic materials that can cause serious conditions such as cancer of the lymph system, central nervous system damage and asthma.
Why is access to health services so bad for the urban poor?
Urban populations are often assumed to have better access to health care than those living in rural areas. However, urban health systems in many poorer countries have a weak to non-existent public health structure and lack implementation and infrastructures. Rapid urban growth in many settings has exceeded the capacity of health systems to serve rapidly growing urban populations. Just because health services are located in an urban area does not mean that they are easily accessible by the urban poor. Health workers find it difficult or are reluctant to serve extremely poor urban areas. A female slum resident who is pregnant might live a short distance from emergency obstetric services, but if she needs help in the middle of the night, it might be too dangerous for her to leave her home to seek help.
Additionally, the cost of health care represents a significant barrier for the urban poor. Poor populations spend a significant part of their income on health care: it is estimated that more than 100 million people are pushed into poverty every year due to health care expenses. As the presence of multiple ill-health conditions increase in urban settings, health care costs can push poor people further into poverty.
What do we need to know?
We need to know what works to improve the health of the urban poor. The existing evidence base is tiny compared to the rapidly growing and large urban poor population, with almost no qualitative evidence to complement the limited quantitative data. We need high-quality evidence on effective and sustainable interventions that specifically target the urban poor. The starting point must be disaggregated data which makes visible the significant differences between areas and populations within cities.