Urban health threatened by inequities
Dr Margaret Chan
Director-General of the World Health Organization
Ladies and gentlemen,
On this World Health Day, we are looking at why urban health matters. Some trends help answer that question.
First, urban health matters for more and more people. For the first time in history, more people are now living in cities than in rural areas. Worldwide, virtually all population growth over the next 30 years will be in urban areas, with the most explosive growth taking place in Asia and Africa. By mid-century, seven out of every ten people will live in a city.
This trend is not inherently bad for health. In general, urban populations are better off than their rural counterparts. They tend to have greater access to social and health services, literacy rates are higher, and life expectancy is longer. When cities are planned, managed, and governed well, life flourishes for most residents and health outcomes surpass those seen in rural areas.
However, average figures hide some major discrepancies, and these discrepancies are growing. Cities concentrate opportunities, jobs, and services, but they also concentrate risks and hazards for health.
When large numbers of people are linked together in space and connected by shared services, the consequences of adverse events are vastly amplified. Examples range from contamination of the food or water supply, to high levels of air or noise pollution, a chemical accident, a disease outbreak or a natural disaster.
This is part of the problem. In many countries, urban growth has outpaced the ability of governments to build essential infrastructures and enact and enforce the legislation needed to make life in cities safe, rewarding, and healthy.
For a growing number of people in a growing number of cities, the essential services needed for healthy living are extended to only the wealthier neighbourhoods or simply do not exist at all. For example, most cities in low- and middle-income countries do not have sewers.
Cities also tend to promote unhealthy lifestyles, like cheap and convenient diets that depend on processed foods rich in fats and sugar, yet low in essential nutrients. Like sedentary behaviour, smoking, and the harmful use of alcohol and other substances.
These lifestyle changes are directly linked to obesity and the rise of chronic conditions like heart disease, stroke, some cancers, and diabetes. These conditions are costly to treat, for households and societies, and they are increasingly concentrated in the urban poor.
This is the second worldwide trend that makes urban health matter, especially for the urban poor. The growth of urban centres in the 21st century is being accompanied by a shift in the burden of poverty. In previous centuries, poverty was greatest in scattered rural areas. Today, poverty has become heavily concentrated in cities.
Today, around one third of urban dwellers, amounting to nearly one billion people, live in urban slums, informal settings, or pavement tents. More than 90% of slums are located in cities of the developing world. In many of these cities, slums have become the dominant type of human settlement.
The threats to health are multiple: from inadequate sanitation and refuse collection to pollution and accidents from congested traffic, from children playing barefoot in soil or water contaminated by untreated waste, to outbreaks of infectious diseases that thrive on filth and crowded conditions.
Such diseases are likewise numerous. Slums are productive breeding grounds for tuberculosis, hepatitis, dengue, pneumonia, cholera, and diarrhoeal diseases that spread easily in highly concentrated populations.
People do not really live in such squalid conditions. They are stranded there.
These are the worst examples of the negative effects on health of poorly managed urbanization. But they are not the only examples.
Nearly every city everywhere has pockets of extreme deprivation together with extreme wealth. They have people who over-consume health care, and pay too much for it, together with people who forego the most basic and essential care for financial and other reasons.
In every corner of the world, certain city dwellers suffer disproportionately from poor health, and these inequities can be traced back to differences in their social and living conditions.
Ladies and gentlemen,
Cities are growing larger and larger, and their populations of the poor are growing larger even faster. The consequences for health are immense.
In fact, one of the best ways to measure urban harm is to look at the gaps in health outcomes seen when affluent and deprived groups, living in the same city, sometimes just a few blocks away, are compared.
On this World Health Day, WHO is asking municipal authorities, concerned citizens, nongovernmental organizations, and advocates for healthy living to take a close look at health inequities in cities and take action.
Why should inequities in urban health and living standards matter? Most obviously, the health consequences of poverty and squalid living conditions are contagious in a city setting. They are detrimental to all city dwellers.
Societies with big differences in opportunities, income levels, and health outcomes tend to have less social cohesion and more violent crime. Social unrest, violence, and outbreaks of disease can easily spread beyond a single neighbourhood or district to endanger all citizens and taint a city’s reputation.
Municipal authorities know what this means in terms of attracting tourists and new businesses and winning the next election. City dwellers know what this means in terms of social cohesion, safety, security, and the quality of life.
Poor health, including mental health, is one of the most visible and measurable expressions of urban harm. Health inequities can also be a rallying point for public demands for change that compel political leaders to take action.
This is my final point. When municipal authorities think about the future of the cities they govern, they need to think about health, and plan for health.
In developing countries, the best urban governance can help produce 75 years or more of life expectancy. With poor urban governance, life expectancy can be as low as 35 years.