Emerging Disease Burdens and the Poor in Cities of the Developing World

Emerging Disease Burdens and the Poor in Cities of the Developing World
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   Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 84, No. 1doi:10.1007/s11524-007-9181-7 *  2007 The New York Academy of Medicine Emerging Disease Burdens and the Poor in Citiesof the Developing World Tim Campbell and Alana Campbell ABSTRACT  Patterns of future urban growth, combined with advances in the treatment of traditional scourges of communicable diseases, will cause a shift in the burden of disease toward category 2 (noncommunicable) and 3 (injury) conditions over the next 30 years. Communicable diseases, particularly HIV/AIDs, will continue to be the most important killers among the poor. However, new risks will emerge for several reasons.First, the marked sprawl of cities in the developing world will make access to caremore difficult. Second, increasing motor vehicles and the likelihood of inadequateinfrastructure will make air pollution and accidents in road traffic more common thanin the past. Third, impoverished urban populations have already shown a propensitytoward undernourishment, and its obverse, obesity, is already emerging as a major risk.Also, the large projected increase in slums suggests that violence and homicide will become a more important burden of health, and very large hazards will be created byfire-prone, insubstantial dwellings that will house nearly two billion people by 2030. Inaddition, decentralized governance will exacerbate the tensions and discontinuities that have plagued the management of health issues on the urban fringe over the past decade. Accordingly, public health agencies will need to adjust to the regional and country-specific factors to address the changing profile of risk. This analysis suggeststhat four factors – levels of poverty, speed of city growth, sprawl in cities, and degreeof decentralization – will have importance in shaping health strategies. These factorsvary in pace and intensity by region, suggesting that health care strategies for CategoryII and III conditions will need to be differentiated by region of the world. Also,interventions will have to rely increasingly on actors outside the ranks of public healthspecialists. KEYWORDS  Future urban growth, Injury, Noncommunicable disease RISK, HAZARD, AND VULNERABILITY IN CITIES Category 1 conditions, communicable diseases, have been the central focus inpublic health for the past half century. Lopez et al. 1 report that infectious andparasitic diseases account for more than 16% of the more than 50 million deathsand an equal proportion of the 1.54 billion disability-adjusted life years (DALYs)for low- and middle-income countries in 2001. These diseases – respiratory,diarrheal, tuberculosis, and malaria – have the heaviest impact on the poor in low-income settlements around the world. Taken together, infectious and parasitic slumdiseases would rank at the top of all categories of death. Tim Campbell, PhD is Chairman of the Urban Age Institute, San Rafael, CA, USA; Alana Campbell is aconsultant on environmental and public health issues, Washington, DC, USA.Correspondence: Tim Campbell, Urban Age Institute, Chevy Chase, MD, USA. (E-mail: . i54  At the same time, Lopez et al. report a striking drop in deaths in low- andmiddle-income countries due to communicable diseases—on the order of 20% overthe past decade and close to 30% after discounting for the HIV/AIDS pandemic. If the gains in control over communicable diseases were to be consolidated – meaningthat if current strategies of prevention and care continue to decrease the burden of communicable diseases – then it is likely that the public health community wouldneed a shift in focus towards other risks.The hypothesis in this paper is that the features of urbanization in the futurewill help determine which health issues get moved  B up ^  in the list of the top 10.Identifying emerging risks is based on two criteria. First, candidates for the listalready hold important rank in global burden of death or DALYs (Table 1). Second,emerging risks must have some prima facie link to the features of future citygrowth—falling densities, the speed of urbanization, poverty and slum formation,and aging (Table 2).Four issues meet these criteria. Violence and traffic injuries are measureddirectly as burdens of injury, disease, or death. Another two issues – obesity andsettlement in unsafe areas (as well as pollution from increased vehicles) – are riskfactors related to many other problems. All of these issues are already on therespective lists of top 10 burdens or risks. Unsafe settlement concentrates risk of natural hazards and disasters. Second, unlike other top 10 issues, these four aresensitive to physical conditions in growing cities.The patterns of future urban growth will help make these issues emergent forreasons that are related to the mechanics, the geography, and the politicaldimensions of urban growth, as explained in the following section. However, otherfactors will also be at work. First, the strategic elements of the public healthapparatus – the medical technology, training, tools like vaccinations and coldchains, and expertise of public health officials – is not completely  B transferable ^  tothe emerging class of problems. A somewhat different kind of apparatus will beneeded, for instance in community peace making, planning of traffic and humansettlements, and public education in nutrition. THE URBAN TRANSFORMATION—RISING CITIESIN CROSS-CURRENTS Many studies 2–4 have shown not only that the planet is nearly urban but also thatthe urban population, on the average, is older and remains poor, that virtually allof the next two billion more people living in cities will occur in the developing partof the world, and that rural populations will remain essentially flat. Although termslike  B population explosion ^  and  B massive urbanization ^  are used often and ratherloosely in the popular and even academic literature to describe the current picture,in reality, the fastest phases of urbanization have already passed. Pace of Growth Asia and Africa have the most impressive urban futures. The two Asian giants,India and China, account for most of the urban population on the planet. Both areless than 40% urban and both will produce the largest urban systems, coupled withthe fastest economic growth in the world. Less appreciated is that the Africancontinent has the fastest-growing cities. This is problematical because, unlike LatinAmerica before it, and Asian countries at present, urban growth is taking place inadvance of an industrial basis for growth. Unless national economies enjoy a EMERGING HEALTH RISKS IN CITIES  i55       T     A     B     L     E     1     E    m    e    r    g     i    n    g     b    u    r     d    e    n    s    a    n     d    r     i    s     k    s    :    s    e     l    e    c     t    e     d     h    e    a     l     t     h     i    s    s    u    e    s      P    r    o     b     l    e    m     t    y    p    e     G     l    o     b    a     l    r    a    n     k      i    n    g     d    e    a     t     h    s     D    e    a     t     h    s      (    m      i     l     l      i    o    n    s      )     G     l    o     b    a     l    r    a    n     k      i    n    g     D     A     L     Y    s     A     t     t    r      i     b    u     t    a     b     l    e     D     A     L     Y     S    o    r     Y     L     L      (     %    o     f     t    o     t    a     l    g     l    o     b    a     l      )     C     l    a    s    s    o     f    w     h      i    c     h    r    e    p    r    e    s    e    n     t    a     t      i    v    e     O     t     h    e    r    m    e    m     b    e    r    s    o     f    c     l    a    s    s     I    n     f    e    c     t      i    o    u    s     d      i    s    e    a    s    e    s    o     f     t     h    e    s     l    u    m     C    o    m    m    u    n      i    c    a     b     l    e     N     A     8 .     5     N     A     2     0     3      (     1     5 .     7      )     C    o    m    m    u    n      i    c    a     b     l    e     H     I     V     /     A     I     D    s ,    w    a     t    e    r   -     b    o    r    n ,    r    e    s    p      i    r    a     t    o    r    y ,    m    a     l    a    r      i    a     E    m    e    r    g      i    n    g     b    u    r     d    e    n    s     T    r    a     f      fi    c      i    n      j    u    r      i    e    s     1     0     õ      1     1     0       9      2     C      i     t    y     /    u    r     b    a    n     P    e     d    e    s     t    r      i    a    n     f    a     t    a     l      i     t      i    e    s    ;    c    o     l     l      i    s      i    o    n    s     V      i    o     l    e    n    c    e     6      (    a    g    e     1     5  –     4     4      )       9      2     5  –       G      1     2     5     /     1     0     0 ,     0     0     0     N     A     N     A     S    o    c      i    a     l     D    r    u    g    s ,    g    a    n    g    s ,     h    a    n     d    g    u    n    s     E    m    e    r    g      i    n    g    r      i    s     k    s     O     b    e    s      i     t    y     7     õ      3     8     õ      3     P    e    r    s    o    n    a     l    r      i    s     k     S    m    o     k      i    n    g ,     d    r    u    g    s     U    n    s    a     f    e    s    e     t     t     l    e    m    e    n     t     N     A     N     A     N     A     N     A     S    o    c      i    a     l    r      i    s     k    e    n    c    r    o    a    c     h    m    e    n     t     b    y     b    u      i     l     t    e    n    v      i    r    o    n    m    e    n     t     F     l    o    o     d ,      fi    r    e ,     l    a    n     d    s     l      i     d    e    s      S    o    u    r    c    e    :    a    u     t     h    o    r    s     b    a    s    e     d    o    n     B    o    s    s    e    r     t    a    n     d     B    e    a    u    v    a      i    s ,        1       1      W    o    r     l     d     H    e    a     l     t     h     O    r    g    a    n      i    z    a     t      i    o    n ,        1       2     a    n     d     K    r    u    g    e     t    a     l .        1       6      N     A    =    n    o     t    a    v    a      i     l    a     b     l    e     Y     L     L    =     Y    e    a    r    s    o     f     L      i     f    e     L    o    s     t CAMPBELL AND CAMPBELL i56  reversal of fortune – as they have, for instance, in China and India – the result willcontinue to concentrate poverty in cities. B Flattening  ^  of Cities Perhaps the most notable finding in recent urban research is the discovery by Angelet al. 5 based on satellite imagery that virtually all of the 120 cities sampled aroundthe globe are beginning to sprawl outward. Although the degree of sprawl varies byregion, the data form a consistent pattern globally. Average densities are falling incities around the globe, and particularly in the developing regions. These observations are corroborated by data from East Asia. 6,7 Webster 6 observes thatsettlements are taking place in administrative and jurisdictional  B no man _ s land, ^ the periurban areas conventionally defined as starting just beyond the contiguousbuilt-up urban area and extending as far as 150 km from the core city center. Often,these areas lie in environmentally fragile zones, i.e., river banks, canal edges, andfloodplains or worse, marginal land that is unstable and unsuitable for occupation.The significance of these findings is in the implications this growth patternholds for reduction in coverage of social and physical infrastructure, includingfacilities for primary and secondary health care, roads, and other services. Althoughmany variations and exceptions to the pattern can be found, the overall trend isgrowth toward the periphery with lower coverage of physical infrastructure andsocial services. City Populations Older and Poorer Two other important socioeconomic features of growing cities – aging and poverty –will have decisive effects on health care in the future. Although half the developingworld population is under 25, the youth segment of the population will move intoolder age brackets without being replaced at the rates of the past. Since the 1970s,fertility declines in virtually all regions, and particularly the least developed, haveresulted in fewer people in the younger cohorts in rough proportion to the numbersof persons entering older age. The result is a drop by more than one-third in theproportion of people from 0–14 years of age, a distinct aging of the urbanpopulation. 8 Poverty will continue to be a signal feature of many of the cities in thedeveloping world, but with marked variations by region. The World Bank estimatesthat, on the whole, roughly 30% of urban populations live in poverty. 9 However,the prospects for poverty vary strongly by region, as measured imperfectly by slumgrowth rate (Table 3, first column). TABLE 2 Emerging health issues: notional variation with urban development Problem typeVaries withurban growthChanges with spreadin city growthPresents risk for the poorVaries with ageand genderCommunicable diseases High Somewhat High SomewhatTraffic injuries High Somewhat High HighViolence Somewhat Somewhat High HighObesity Somewhat Low High HighUnsafe settlements High High High Somewhat Source: The table summarizes from the literature covered earlier in the article the direction and strength ofrelationship (high, somewhat, low) between each of the categories of burden (rows) and the key features offuture urban growth (columns).EMERGING HEALTH RISKS IN CITIES  i57  Decentralization The most important cities on the planet are subject to many conflicting forcespulling policy attention in many directions. Political forces of decentralizedgovernance push city leaders to attend to local needs of constituents and wishesof civil society often in opposition to national authorities, who aim to achievedifferent priorities. More than 70 countries around the globe are currentlydecentralizing, meaning they are passing on decision-making and spending powersto local governments. Nearly 25 republics in Latin America accomplished thischange during the 1990s. 10 Popular elections subject city decision-makers to aclamor f or participation with which they have limited or no experience. Bossert andBeauvais 11 illustrate these competing forces in public health as city and communityleadership – mayors, elected officials, health sector professionals, and administra-tors – play more important roles in health care of many countries. EMERGING RISKS IN URBAN PLACES The results of these territorial, social, and political forces will have relatively greatereffects on some burdens than others. Four issues are singled out as likely candidatesof increasing burden. Road Traffic Injuries: Neglected Epidemic World Health Organization 12 data reveal that, worldwide, the number of peoplekilled in road traffic accidents is around 1.2 million, whereas the number of injuredcould be as high as 50 million, and these numbers are forecast to increasesignificantly in the coming decades. Road traffic injuries, urban and rural, rankedwithin the top 10 causes of death in 2001. 11 Developing countries account for morethan 85% of all the fatalities and over 90% of DALYs lost due to road trafficinjuries. For these reasons, the problems of road injuries and deaths are referredsometimes to the  B neglected epidemic. ^ 13 TABLE 3 Gross domestic product growth not sufficient to reach millennium developmentgoals RegionSlum growthrate 2 Average GDPper capita 2000–2015(percent increase per year)Percent population living onless than one US$/day 32 Target percentProjectionto 2015 bygrowth alonepercentEast Asia 2.28 5.4 14 1Europe and C. Asia NA 3.6 1 1Latin America andCaribbean1.28 1.8 8 8Middle East andNorth Africa _ 0.15 1.4 1 1South Asia 2.20 3.8 22 15Africa 4.53 1.2 24 35 Adapted from World Bank. 32 NA = not availableCAMPBELL AND CAMPBELL i58
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