The African Centre for Cities’ Healthy Cities CityLab

Understanding Urban Health in the Global South

Like most other cities of the global South, Cape Town’s 3.7 million people live in a juxtaposition of wealth and poverty, of formality and informality. Cape Town’s levels of inequality are amongst the highest in the world, with a Gini coefficient higher than any other non-South African city. Almost 40 per cent of households are classified as poor, which translates into insufficient income and access to basic necessities such as food and shelter. As in other cities of the global South, slums are the most tangible manifestation of poverty and inequality in Cape Town, with an estimated 280,000 households living in informal dwellings. Cape Town’s inequality and poverty is also reflected in its high burden of disease and high levels of health inequity. The most recent age-standardised mortality rate for Cape Town is 1,011 per 100,000 people. This is considerably higher than in most cities in the global North, for example, it is 60 per cent higher than the latest mortality rate for New York City. Health indicators also vary enormously between health districts, for example, the mortality rate for communicable diseases is about five times higher in the Khayelitsha Health District than in the Southern Peninsula Health District (550 deaths per 100,000 people per year versus 112).

The burden of disease in Cape Town and other South African cities is particularly complex and, as such, is known as a ‘quadruple burden of disease’, which consists of:

  • Communicable diseases, closely linked to poverty, such as tuberculosis and diarrhoea (which are both in the top ten causes of premature mortality in Cape Town), continue at high levels. Many of these diseases are linked to overcrowding, inadequate shelter, inadequate access to basic services and inadequate access to affordable and healthy food.
  • HIV/AIDS, which is the leading cause of premature mortality in Cape Town.
  • Chronic diseases of lifestyle, such as diabetes mellitus and ischaemic heart disease (which are both in the top ten causes of premature mortality in Cape Town), are growing rapidly. These are linked to changes in lifestyle associated with rural-urban migration as well as the transition of some households to more affluent lifestyles. These transitions result in more sedentary lifestyles, growing obesity and increased risk of non-communicable diseases.
  • Injuries. Cape Town has particularly high levels of murder and traffic accidents, which are the second and fourth most frequent causes respectively of premature mortality in Cape Town.

Improving the health and well-being of residents of Cape Town is a challenge. The limited health data that is available is out of date and difficult for policy-makers to engage with. The high levels of political contestation in Cape Town have tended towards policy-makers focusing on the short-term and on tangible forms of delivery such as housing and infrastructure.

Cape Town and other South African cities are undergoing large-scale state-driven transformation through national programmes for the provision of low-income housing, infrastructure and the renewal of low-income residential areas. Improving health is not an explicit objective in any of these programmes and evaluations of some interventions suggest that they can sometimes have a negative impact on households. An ongoing illustration is where relocation to the urban periphery results in the disruption of livelihoods strategies and social support networks, with very negative impacts on the health and well-being of residents. For example, the relocation of residents from a well-located informal settlement in Langa, close to central Cape Town, to a relocation area in Delft, about 15 kilometres (9 miles) away, resulted in 20 per cent of households losing a source of income, and up to a five-fold increase in monthly transport costs for those who retained their jobs. While there are exceptions, many new housing projects still tend to provide sterile living environments that are not conducive to mental health or to safe outdoor activity, both in terms of aesthetic appeal and protection from hazards, such as traffic, crime and flooding. It is therefore of crucial importance that we have a better understanding of how the physical urban environment influences health and well-being, so that we can begin to create cities that are more conducive to the health and well-being of all residents.

Literature on the relationship between the physical urban environment and health suggests a number of important linkages, and possible interventions, that can improve health and well-being. These linkages that potentially have implications for interventions in the built environment and the design and layout of new housing areas include:

  • The provision and design of housing and infrastructure. Improving housing conditions and access to services by, for example, slum upgrading programmes can improve health and well-being in multiple ways.
  • The food environment. For example, the nature and location of food outlets can influence diet and nutrition, and the location and nature of spaces for urban agriculture can also be important.
  • Appropriate planning layouts. The design of streets and public spaces can create urban environments that are safer from violent crime and traffic accidents, while access to green space can have a positive impact on mental health.
  • Design and physical activity. Research suggests that certain types of built environments are more conducive to physical activity like walking, cycling and recreation, and can potentially result in improved health outcomes.

However, the existing bodies of knowledge on the relationship between human health and the physical urban environment are overwhelmingly based on empirical work undertaken in the global North, and the concepts of ‘health’ and ‘the urban’ that underpin this body of knowledge are also derived largely from the particular historical and cultural contexts of the global North. The many manuals on how to create healthy urban environments are therefore of limited use in cities such as Cape Town, where contextual realities are often very different to those in the global North, and where many of the underlying assumptions do not necessarily apply.

In response to this partial disjuncture between our contextual realities and the bodies of knowledge on the relationship between human health and the physical urban environment, the African Centre for Cities at the University of Cape Town established its Healthy Cities CityLab programme to bring researchers from different disciplines at the University of Cape Town together in a long-term interdisciplinary applied research programme on the relationship between the physical urban environment and health and well-being in Cape Town. The Healthy Cities CityLab is one of a number of the African Centre for Cities’ CityLabs, which stimulate policy-relevant research, and researcher-practitioner engagement, on various key challenges facing Cape Town.

The key components of the first phase of the research programme include:

  • Undertaking body-mapping workshops in different types of neighbourhoods, such as informal settlements and new housing projects, to determine grassroots perceptions of health and well-being.
  • Undertaking an analysis of current key institutional structures, policies and practices that relate to urban health in Cape Town, using interviews and documentation.
  • Engaging with policy-makers and practitioners in order to explore ways of incorporating explicit health and well-being objectives into policy and implementation processes.

This research programme is ongoing, but there are a number of key issues which have emerged thus far.

First, many of the implicit assumptions about what an ‘urban environment’ is are integrally rooted in the Western modernist conception of cities. For example, instruments for measuring ‘walkability’ assume that there are clearly defined streets, plots or dwelling units and land uses, and that there are clear separations between urban and rural, residential and commercial, and public and private. African urbanism, on the other hand, is characterised by informality and complexity and the lack of neat separations. In the informal settlements found in African cities, for example, there are no clearly defined streets and no clear separations between vehicle space and pedestrian space, between public and private space, and between land uses; residential dwellings are often also the site of home-based enterprises. Similarly, plots and dwelling units are not clearly defined and even the idea of the ‘household’ can be fairly fluid, with extended families spread across urban and rural homes and with frequent movement between them. All of this can make the relationship between residents and their neighbourhood environment far more complex than in the conventional conception of the Western modern city. The main implication of this is that some of the tools relied on to create healthier urban environments in cities of the global North, such as land-use zoning schemes, will have only a limited effect in cities of the global South, where large segments of cities fall outside the ambit of formal regulations. In Cape Town and other cities of the global South there needs to be more emphasis on guiding the physical creation and management of the urban environment through participatory processes that involve both formal and informal structures.

Second, much of the body of knowledge on the relationship between the urban environment and health rests on an underlying implicit assumption about choice and the availability of alternative options. In contexts such as Cape Town, with high levels of poverty and inequality, and with entrenched socio-spatial segregation and distorted property markets that do not function in most of the city, these assumptions about choice in terms of where to live and choice of lifestyle do not necessarily hold. The implication of this is that the health care promotion programmes that try to change the lifestyles of residents (for example, physical activity and diet) that have been implemented in many cities of the global North may be less effective in cities of the global South. Given the constraints on freedom of choice in many cities of the global South, physical interventions, such as creating safer streets and public spaces and creating healthier food markets and suitable spaces for urban agriculture, would seem to be essential preconditions for health promotion programmes.

Third, as is the case with most other cities of the global South, available health data on Cape Town is fragmented, out of date and often cannot be disaggregated down to fine-grained scales. This makes it difficult for policy-makers to recognise urban health issues as a priority, and makes it difficult to monitor the health impact of interventions in the urban environment. Cheap and effective methodologies for the collection, analysis and monitoring of relevant urban health data need to be explored.

Creating healthier urban environments is primarily about governance, politics and decision-making. It is crucial to ensure that policy-makers are aware of key health issues, such as health inequity levels, and how the physical urban environment contributes to this, and how interventions that would not necessarily involve more expenditure, just differently distributed, can contribute to improving health and well-being for all.

Warren Smit is a Researcher at the African Centre for Cities (ACC) at the University of Cape Town. He co-ordinates the ACC’s Healthy Cities CityLab research programme on health and the urban environment in Cape Town.

Vanessa Watson is Professor in the School of Architecture, Planning and Geomatics and Executive Committee Member of the African Centre for Cities at the University of Cape Town. She is also an Editor of the journal Planning Theory (UK).