Urbanization...A Humanitarian Disaster

GLOBAL HEALTH

New England Journal of Medicine

Volume 361:741-743 August 20, 2009 Number 8


Urbanization — An Emerging Humanitarian Disaster

Ronak B. Patel, M.D., M.P.H., and Thomas F. Burke, M.D.


In 2008, the proportion of the world's population living in urban areas crossed the 50% mark. The current rates of urbanization suggest that in China, 870 million people — more than half the population — will be living in cities within less than a decade, and the capital of Botswana, Gaborone, will grow from 186,000 to 500,000 inhabitants by 2020.1 Most observers believe that essentially all population growth from now on will be in cities: the urban population is projected to grow to 4.9 billion by 2030, increasing by 1.6 billion while the rural population shrinks by 28 million.1

This transition is happening chaotically, resulting in a disorganized urban landscape. Although many expect urbanization to mean an improved quality of life, this rising tide does not lift all boats, and many poor people are rapidly being absorbed into urban slums. Urbanization, in fact, is a health hazard for certain vulnerable populations, and this demographic shift threatens to create a humanitarian disaster. The threat comes both in the form of rising rates of endemic disease and a greater potential for epidemics and even pandemics. To protect global health, governments and international agencies need to make commensurate shifts in planning and programs, basing all changes on solid epidemiologic and operational research.

Although natural disasters and armed conflicts cause migration into urban centers, most people relocate to cities in search of employment. When they arrive, many find only one affordable housing option: illegal and unplanned dense settlements lacking basic public infrastructure, where they must live in lodgings made from tenuous materials, such as used plastic sheets, discarded scrap metal, and mud. The United Nations Human Settlements Program (UN-Habitat) reports that 43% of urban residents in developing countries such as Kenya, Brazil, and India and 78% of those in the least-developed countries such as Bangladesh, Haiti, and Ethiopia live in such slums.2 These slums, which are making up an increasing proportion of growing cities, lack not only most basic government services but also political recognition; as a result, so do their inhabitants. These residents are usually tolerated and their presence tacitly accepted, but the local government generally ignores them, accepting no responsibility for accounting for them in planning or the provision of services.

The current public health paradigm delineates urban health hazards as comprising injuries, pollution, and chronic diseases, such as diabetes and hypertension. Although these hazards are indeed more specific to urban than to rural areas, urbanization also exacerbates long-standing hazards specific to populations that have not undergone the epidemiologic transition from a predominance of infectious diseases. Increasing the population density in cities without proper water supplies and sanitation increases the risk of transmission of communicable diseases. Mortality among children under 5 years of age and among infants is higher in urban slums than in rural settings (see table).3

Though in most countries health care is more limited in rural than in urban areas, the urban environment may lack health support often provided in rural settings while also posing new risks. For example, for women and children, the rural environment provides a community of kinship that often ensures physical safety, food security, and the availability of child care. Without these safeguards, many women's mobility is limited in urban areas. Mobility and child care assistance from more experienced women allow mothers to perform two of the three steps that are theoretically fundamental to health care utilization: identifying illness and seeking care (the third being delivering care). Differential rates of death reflect this effect of urbanization, but we require more data in order to assess the true extent of this problem and other urban health risks. Currently, collected data are rarely disaggregated down to the level of individual city neighborhoods, and slum populations are generally not included when health statistics are reported.

Improved systems for collecting data in slums are urgently needed for the planning of infrastructure construction, programs, and resource allocation. Precise data that distinguish among types of residence, locations, and socioeconomic strata would reveal the varied effects of urbanization on health indicators, allowing for focused interventions.

We believe that the world's wealthier countries need to invest in capturing these data and improving public health systems. Doing so is not purely altruistic; it serves the self-interest of all countries, because poor urban areas can easily become a breeding ground for emerging infections and potential pandemics. The outbreak of severe acute respiratory syndrome (SARS) in Hong Kong in 2002 and 2003, which was believed to have originated in rural China, demonstrated how dense urban living could ignite a global health crisis. In a slum, the lack of surveillance and adequate health care might well result in more rapid spread of undetected diseases; without the necessary resources, it is difficult to implement any kind of preventive, containment, or treatment measures. Developed countries also have a financial stake in the requisite surveillance and health care systems: even conservative estimates of the cost of SARS to the economies of Europe and North America run to billions of dollars.

Understanding health-related behavior and the logistics of the health care environment of urban areas can also aid in the design of appropriate interventions. All three factors necessary to the effective utilization of health care — illness identification, care seeking, and care delivery — vary within urban settings. Although slum residents often live close to many health care providers, they generally have little access to high-quality care. Care-seeking patterns show that although less expensive, higher-quality government clinics are often available, slum residents who do seek care tend to choose more expensive private providers — for a multitude of reasons, from perceived quality to ease of access.4 Studies show that the care received by the urban poor is often of low quality. One study examining the care provided by 100 private practitioners in an urban slum in Mumbai, India, found 80 different treatment regimens being used for tuberculosis, only 4 of which met the guidelines of the World Health Organization.5

In some cases, new interventions are required for this population, but in others, interventions that are known to be effective simply need to be translated into effective programs. Fundamental public health services, such as vaccination, a safe water supply and sanitation, and oral rehydration therapy, remain important, and operational research is required in order to implement them effectively. Adapting interventions for implementation by community health workers or trained midwives has shown benefit, and we believe that a cadre of health care workers practicing in slums must be trained in order to reach this population.

Our knowledge base also needs to be supplemented through dedicated research. Epidemiologists must develop methods for collecting precise and accurate data and surveillance on the health of urban populations. Research must be conducted on the design of interventions and approaches to using proven public health tools that exploit the advantages conferred by urban settings, such as the concentration of target populations and better communication and transportation infrastructures for delivery of care and health education. And governments, nongovernmental organizations, and private providers must commit themselves to implementing new policies and programs. Many projects and field research efforts fall by the wayside when no governing or implementing agency "scales up" initial results. Governments need to determine the structure of health care provision, administration, and regulation, and nongovernmental organizations should aid in promoting good governance, increasing capacity, and ensuring access to care.

As the world becomes increasingly urban, the health of the urban poor may suffer. Decades of progress in public health could be erased, and the stage could be set for devastating pandemics of infectious disease. Action is needed now to avert such a disaster.



No potential conflict of interest relevant to this article was reported.


Source Information

From the Harvard Affiliated Emergency Medicine Residency based at Brigham and Women's Hospital and Massachusetts General Hospital (R.B.P.), and the Division of Global Health and Human Rights, Department of Emergency Medicine, and the Department of Pediatrics, Massachusetts General Hospital, and Harvard Medical School (T.F.B.) — all in Boston.

Makes Sense to Me....

From: Bob Corbett
Date: Thu, Aug 13, 2009 at 1:58 PM
Subject: 35006: Morse (comment) Rules of Engagement (fwd)
To: Bob Corbett's Haiti list

Photo by John Carroll

I'm trying to get a better understanding of why the United Nations could keep so silent about the fraud during Haiti's April Senatorial elections and the June runoffs and my mind keeps drifting back to Rwanda and the genocide which saw the killing of 1,000,000 people, all under the watchful eye of the UN. That's right the UN witnessed the killing of one million people and yet, did nothing. Why? It's a standard phrase that comes up during interventions and occupations: "Rules of Engagement". The UN is invited by a host country and the "rules of engagement" are determined with the host country. In Rwanda the genocide was seen as an "internal political conflict" and under the "Rules Of Engagement", the UN was not permitted to "Engage". One million people died and the UN did nothing. I can't stress this enough.


I don't want to put the deaths of one million people on the same scale as senatorial election fraud but perhaps these failures by the UN have similar starting points. Perhaps there is an intrinsic weakness in the UN intervention process that leads to failure.

In Haiti there are a couple of things to consider:

1) The UN is here at the "invitation" of the Haitian government, so the UN doesn't want to embarrass "the hand that invites them".

A successful UN mission may mean
Brazil's becoming a part of the UN Security Council. The Brazilians may not want to open a can of worms by criticizing the hand that is so tied to their future; the "hand" that could potentially get them membership to the UN Security Council.

A conflict with the Haitian government could mean the end of the UN mission. If the invitation to the UN is withdrawn, a lot of UN jobs and careers will be sidetracked; the UN mission will be seen as a failure. What will happen to all those resumes (curriculum viteas)? What will happen to Brazil's standing with the UN Security Council and with the international community?

2) If things are perceived as "moving along nicely", then the UN, the UN Special Envoy along with all UN employees will be seen as having had a successful diplomatic intervention; more jobs for all. A "cover up" or "spin" is not the same as making things better but some at the UN may see spin and cover up as necessary evils; an alternate political truth or reality at the expense of the Haitian people.

Unfortunately, the UN seems to have become blinded by some of it's earlier successes. Overseeing the 2006 Presidential elections and the ensuing political calm has given the UN in Haiti the false impression that they can do no wrong in this impoverished nation. The impression that the UN is "so smart, they can get away with anything" is not the impression
to have when dealing with a country like Haiti. Haiti's population is so politically astute that in the long run, they'll make the UN pay for it's miscalculations.

The very thing wanted by ruling authorities in Haiti (factory investment), will be the very thing they're not going to get. Who wants to invest in a volatile country where workers are demonstrating in front of factories; where factory owners are going to embassies for protection; where the very family visited by the US Secretary of State was seen going to the Spanish embassy for protection after a particularly aggressive demonstration? A US embassy car was even attacked last week.

This isn't an investment climate. It could be an investment climate, but the current decision making process is leading us away from political calm.

Issues that have to be addressed and investigated for Haiti to get on track:

1) The election fraud of April and June. When I say the election fraud has to be addressed, I mean those implicated in the execution of the fraud as well as those involved in the cover up. Haitian Presidential elections are coming up next year and if this election process isn't put back on track immediately, we're all in for a long bumpy ride.

2) Economic development for the rural sector has to be initiated rather than si
mply bringing more factories to Port au Prince. Haiti's cities cannot support an influx of people coming in from the provinces looking for work. The infrastructure in Haiti's cities cannot absorb the people already living there; why attract tens of thousands more people now?

3) Why do St Mark and Gonaives still have sub human living conditions? What happened to all the money that has been allocated to these regions since 2004? Since 2004 at least five hurricanes (four in one month) have decimated the region.
We have to find out what's happening to the aid and why the intended recipients aren't getting it. Is it "local politics" or is it "corruption" that keeps these cities in their current states.

I've recently been to Gonaives and St Mark and I don't see how the UN can keep quiet about the current living conditions.

In conclusion, I have to say that things are deteriorating in Haiti right now and the signs tell us that they're going to get worse before they get better and the reason for this is not the Haitian people but the collective leadership of local decision makers along with the international community. It's time to make some significant changes; now.

Richard Morse

Port-au-Prince, Haiti

Minimum Wage Increased in Haiti

Haiti lawmakers OK minimum wage hike after clashes

By JONATHAN M. KATZ (AP) – Tuesday, August 4

PORT-AU-PRINCE, Haiti — Lawmakers voted to more than double Haiti's minimum wage Tuesday night after long hours of debate and clashes between police and protesters, who complained they can't feed and shelter their families on the current pay of about $1.75 a day.

The plan adopted fell short of the $5 wage demanded by the demonstrators, although it would more than double the minimum pay to about $3.75 a day.

The raise would include workers at factories producing clothes for export, an idea that President Rene Preval opposed. After refusing to publish into law a plan passed by Parliament in May to nearly triple the minimum wage, Preval proposed giving the garment factory workers an increase to about $3.

Given the lateness of Parliament's 55-6 vote to adopt the new raise, there was no immediate reaction from the president or from the protesters.

Earlier in the day, police fired tear gas at some 2,000 protesters who gathered outside Parliament to demand a big increase in the minimum wage. As legislators prepared to meet on the issue, some of the protesters threw rocks at police and began ripping down flags of U.N. member countries near the building.

Most of the crowd dispersed before the Parliament session began, with no arrests and only two reported injuries, including a cameraman who was hit in the head with a rock.

Many of the protesters were minimum-wage factory workers, such as Banel Jeune, a 29-year-old father who sews sleeves on shirts.

"Seventy gourdes, that doesn't do anything for me," he said, referring to his current minimum wage. "I can't feed my kids, and I can't send them to school."

The issue has been inflammatory in Haiti, which is the Western Hemisphere's poorest nation. But despite the heated debate and occasional violence, few people would be affected by the wage increase.

Most of Haiti's 9 million Haitians who are employed work on small farms or sell basic goods on the street. Only some 250,000 people have jobs covered by the minimum salary law, said lawmaker Steven Benoit, who sponsored the bill.

Still, some development experts argue that a pay increase would hurt plans for fighting Haiti's widespread unemployment by creating more jobs in the factories that produce clothing for export to the United States.

With new trade advantages that allow for duty-free exports of clothing to the U.S., such factories could provide "several hundred thousand jobs to Haitians ... over a period of just a few years," according to a report submitted to the U.N. in January. But it said that plan requires costs be kept down.

The report had been requested by Secretary-General Ban Ki-Moon and prepared by Oxford University professor Paul Collier. It is now being promoted by former U.S. President Bill Clinton, the new U.N. envoy for Haiti.