Urbanization and Health in Developing World Cities

After fading from the agenda over the past fifteen to twenty years, urban health is recapturing the attention of policy makers and international health advocates worldwide. With rapid rates of urbanization, cities are struggling to provide a host of services and infrastructure for old and new populations alike.

On December 2, 2005, the Comparative Urban Studies Project (CUSP) hosted a seminar to discuss the ways in which health is inextricably tied up to the urban agenda, particularly in the developing world. In addition, the seminar examined how local governments are responding to increased responsibilities for the provision of basic services including water, sanitation, and health care. Allison Garland, CUSP Program Associate, provided introductory remarks for the session, stressing that urban populations are particularly vulnerable to infectious disease. Decentralization has made local government a crucial player in the fight against infectious diseases such as HIV/AIDS. To better address these challenges, health programs, services and policies must be linked to the urban environment and incorporated into the broader development agenda.

Trudy Harpham, Professor of Urban Development and Policy at London South Bank University provided a brief history of urban health policies and initiatives. The early 1980's and the late 1990's marked a period of time where urban health professionals, specifically World Health Organization (WHO) officials, began to move away from highly centralized debates over urban health to a decentralized state of affairs, typified by the Healthy Cities movement. The objective of the Healthy Cities movement was to get health on the agenda of relevant sectors at the city level. This brought attention away from the Ministries of Health down to the local governments. What remained was to engage the health services sector with the environmental health sector. After the 1980's, cities began to decentralize even further and city authorities no longer had the leverage to decide how cities would be developed. Finally the local government comes to the forefront of urban health issues.

In the broad spectrum of urban health, health practioners have to look at what NGOs are doing, both internationally and nationally. In some countries, Harpham argued, NGOs are letting local municipalities off the hook by assuming the responsibility of delivering effective urban health strategies themselves.

In particular Harpham mentioned three NGOs that have been working in low-income communities for about 20 years: The Orangi Pilot Project in Karachi, Pakistan; the Pekin Environmental and Health Project in Dakar, Senegal; and SPARK in Mumbai, India. These NGOs have been successful because they have found local solutions to local problems, gaining support from municipalities over time. In addition, all three projects have successfully used maps as powerful tools to disaggregate data and communicate intraurban inequalities.

At the community level, there can be tremendous value added to urban poverty and governance programming, for example, by attaching health initiatives. A failure to communicate across sectors has inhibited the incorporation of urban health into the broader development agenda. Harpham made the case for integrated planning but independent implementation.

Harpham also discussed the importance of "looking both ways", a plea to look down towards the community and NGOs and also towards the national level, reengaging with powerful line ministries. Further engagement of local government with central line ministries can put urban health back onto the development agenda. By "looking both ways" best practices can be translated into best policies.

Victor Barbiero, former Chief of the Implementation Support Division at USAID Office of HIV/AIDS began his talk with the metaphor of the "urban crucible" to describe how urban conditions have given rise to the spread of both chronic and infectious disease.

Barbiero discussed various transitions (urban, demographic, and epidemic) to illustrate the importance of urban health in a world with a growing urban population, particularly in developing countries. With the urban transition, there needs to be a paradigm shift to deal with health development in the future. He explained that 60% of the world's population will live in cities within the next 30 years and it's imperative that cities and are prepared for the changes and effects this will bring. Through various statistics, Barbiero explained that smaller cities are growing the most and within these urban areas, middle and low-income populations will increase. Where are the services and policies, he asked. The development community must face global urbanization and implement programming that reflects these trends.

Barbiero cited several strategies to meet the challenges of urbanization and health, including greater involvement of the private sector to maximize its efforts to provide urban services. Furthermore, the mass media can help educate people about different types of diseases and other at risk issues. Finally, Barbiero agreed with Harpham that wraparound programming could make the best use of resources by linking an urban health dimension to existing activities. There is a need to engage decision makers on the ground to take the urban imperative into account and incorporate urban health into mainstream programming, he concluded.