Introduction Demographic context Urban poor Urban health system Urban burden of disease Conclusion

1. Urban health in low- and
middle-income countries
Department of International
Health, TMDU
Izzeldin F. Adam ; BPEH, MPH.

3. Contents






Introduction
Demographic context
Urban poor
Urban health system
Urban burden of disease
Conclusion

4. Introduction

Over the next 30 years, low- and middle-income
countries will cross an historic threshold, becoming
for the first time more urban than rural.

A number of urban health risks and problems are
likely to increase in low- and middle-income
countries in the coming decades.

Urban health is the health of those who live in the
more densely populated areas with potential of both
public health problems and solutions.

5. The demographic context

In 1950, there were only two
metropolitan areas in the world the
Tokyo and the New York-Newark
agglomerations with populations of
10 million or more.

According to UN projections, in year
2050, cities and towns of poor
countries will account for nearly 90%
of all world population.,

Two thirds of the inhabitants of those
countries will live in urban areas

6. Countries demography

In 1950 there were seven European countries among the
twenty most populous countries of the world, by 2050 there
will be only Russia.

In 2050, India will have become the most populous
country.

By the end of the century ten out of the twenty most
populous countries will be in Africa. Nigeria will be the third
most populous country in the world

7. percentage of urban population
and agglomerations by size class
1960
1980

8. percentage of urban population
and agglomerations by size class
2011
2025

9. Urban and rural population by development regions, 1950,
2011 and 2050 (per cent of total population)

10. urban growth process: How and why dose it
happen?

11. World Population Prospects: Source: UN, Department of
Economic and Social Affairs, Population Division (2011)

12. The urban poor



urban poverty is associated with a lack
of access to piped drinking water and
with inadequate sanitation
The urban poor are seen to exhibit
worse health than other urban children.
poor urban-dwellers are exposed to
substantial risks when their
neighborhoods lack the public health
infrastructure.

14. Urban poor at LIC and MIC

15. Percentages of households with access to services.
piped water in premises
water in neighbourhood
flush toilet
pit toilet
100
90
80
70
60
50
40
30
20
10
0
Rural
Urban
Urban
poor non-poor
North Africa
Rural
Urban
Urban
poor non-poor
Sub-Saharan Africa
Rural
Urban
Urban
poor non-poor
Latin America
Rural
Urban
Urban
poor non-poor
South, Central, West Asia
Rural
Urban
Urban
poor non-poor
Southeast Asia

16. Disability-adjusted years of life lost in Mexico, by cause and
area of residence
Cause
Rural
Rural rank Urban
Urban rank
Rural urban
Diarrhoea
12
1
2.8
9
4.28
Pneumonia
9.3
2
3.9
7
2.39
Homicide and violence
9.2
3
7.4
2
1.23
Motor vehicle-related deaths
7.9
4
8.3
1
0.95
Cirrhosis
7.5
5
6.3
4
1.19
Anaemia and malnutrition
6.8
6
2.4
11
2.86
Road traffic accidents
5.5
7
6.8
3
0.81
Ischaemic heart disease
5.1
8
5.3
6
0.96
Diseases of the digestive system
4.7
9
1.7
15
2.74
Diabetes mellitus
4.1
10
5.7
5
0.72
Cerebrovascular disease
3
11
3
8
1.02
Alcohol dependence
3
11
1.9
13
1.56
Accidents (falls)
2.8
13
2.6
10
1.09
Chronic lung disease
2.6
14
1.9
13
1.39
Nephritis
2.2
15
2.2
12
1.01

17. The urban health system


The urban health system is situated within
larger political-economic frames at the
country level.
the process of decentralization is
reshaping relationships between national,
regional, and local governments, with
important implications for health service
planning, finance, and service delivery

18. Comparison of child mortality rates (5q0) in the Nairobi
slums sample with rates for Nairobi, other cities, rural
areas, and Kenya as a whole.
Source: African Population and Health Research Center,2002

19. Urban health care




the urban poor without cash on hand can find
themselves unable to gain entry to the modern
system of hospitals, clinics, and well-trained
providers.
They are likely to abandon courses of prescribed
medication to save on the costs of purchasing
medicines or buy less than what was prescribed.
They fail to return as requested as follow-up and
assessment for progress.
They are not oriented about their family medical
history

20. Urban sanitation

Water and sanitation have proved time and time again to
be a critical factor in health and economic development.

long-term, reliable funding into urban water and sanitation
infrastructure has a powerful impact on economic
productivity, as well as driving down poverty.

Cities in the developing world are expected to double in
population size every 15 years, and two thirds of the
world's population will live in urban areas by 2030.

The vast majority of these people with little or no access to
fundamental services such as water, sanitation and
electricity.

21. Investment in sanitation

Current investment into water and sanitation in
the slums is inadequate and is failing to reach
the poorest and most vulnerable people.

Only 6% of World Bank sanitation-related
commitments from 2000-2005 went to slums,
with the vast majority going to more
established urban areas.

WaterAid's new manifesto shows that to tackle
urban poverty, the poorest people need to be
at the heart of water and sanitation
investments, planning and implementation.

22. Now from public health point of
view, let’s think about expected
health problems in urban poor.

23. The urban burden of disease










Diarrheal diseases
Mental health
Intimate-partner violence and alcohol abuse
Reproductive health
HIV/AIDS
Tuberculosis
Urban malaria
Traffic-related injuries and deaths
Outdoor air pollution
Future risks from climate change

24. Diarrheal diseases

Water and sanitation are fundamental to
health and development, especially in densely
packed urban areas, where outbreaks of
diseases such as cholera can quickly turn into
epidemics.

At present diarrheal diseases caused by a lack
of safe water and sanitation is the biggest killer
of children under five in Africa, claiming more
children's lives than HIV/AIDS, malaria and
measles combined.

In South Asia it is the second biggest killer.

25. Mental health

mental ill-health accounts for roughly 24% of
all DALYs lost due to non-communicable
diseases in low-income and middle-income
countries.

Anxiety and depression are typically found to
be more prevalent among urban women than
men and are believed to be more prevalent in
poor than in non-poor urban neighborhoods
(Almeida-Filho et al. 2004).

Mental ill-health might affect other dimensions
of health …How?

26. Intimate-partner violence and
alcohol abuse



Review of community-based data for 8 urban areas
in developing world, showed that mental and
physical abuse of women by their partners was
common.
Alcohol use directly affects cognitive and physical
functions, reducing self-control, and leaving
individuals less capable to negotiate non-violent
solution (WHO,2003.
Effective partnerships against crime and violence
involve the formulation of community-driven
violence-prevention strategies .

27. Experience of physical or sexual violence by an intimate
partner since age 15, among ever-partnered urban women.
Source: (WHO, 2005)

28. Reproductive health

Among all urban women, those who are poor
are significantly less likely to use modern
contraception to achieve control over their
family-building.

Maternal mortality risks, because of lifethreatening problems in the course of a
woman's pregnancy, delivery, and the
emergency care.

Delays in initiating the search for care are
compounded by the tendency for poor
families to pursue local care first, before
reaching the modern health.

29. HIV/AIDS

In these three cases—Mali, Kenya, and
Zambia—urban prevalence rates are clearly
much higher than rural rates.

HIV prevalence is higher among the betteroff families that were more likely to live in
urban areas.

other risk factors (including sexual risktaking, use of condoms, and male
circumcision) tended to mask the
association between living standards and
prevalence.

30. Estimates of urban and rural prevalence of HIV from the
Demographic and Health Surveys in Mali, 2001; Kenya,
2003; and Zambia, 2001-2002.

31. Tuberculosis

Urban crowding increases the risk of
contracting tuberculosis (van Rie et al.
1999), and high-density low-income
urban communities may face elevated
levels of risk.

The interactions between HIV/AIDS
and tuberculosis, and the spread of
multi-drug-resistant strains of the
disease, have caused WHO to expand
its programme beyond DOTS.

32. Urban malaria


There is clear evidence that malaria vectors
have adapted to urban conditions in subSaharan Africa (Modiano et al. 1999), and
some evidence suggestive of urban risks has
emerged for parts of Asia as well.
Keiser et al. (2004) calculate that in urban
sub-Saharan Africa, some 200 million citydwellers face appreciable risks of malaria,
and they estimate that 25-100 million clinical
episodes of the disease occur annually.

33. Urban malaria

34. Traffic-related injuries


The WHO (2004) estimates that road
traffic injuries lead to 1.2 million deaths
annually and an additional 20-50 million
non-fatal injuries, the majority of which
occur in low- and middle-income
countries.
Bartlett (2002) draws on hospital- and
community-based studies to show how
poverty and gender affect the risks, and
how the time pressures on urban parents
limit the effort they can devote to closely
supervising their children

35. Fatality rates for low- and middle-income and
high-income cities and countries.

36. Outdoor air pollution

The Latin-American literature is
especially rich in scientific
analyses of outdoor urban air
pollution and its effects on
respiratory illness via the intake
of airborne particulates and
other pollutants emitted by
industry and vehicles.

Traffic and vehicular regulation
are also key factors in outdoor
air pollution.

37. Climate change

According to current estimates, gradual increases in
sea level are now all but inevitable over the coming
decades, and this will place large coastal urban
populations under threat.

Alley et al. (2007) forecast rises in sea level of
between 0.2 m and 0.6 m by 2100, which will be
accompanied by periods of exceptionally high
precipitation, more intense typhoons and hurricanes,
and episodes of severe thermal stress.

38. Urban agglomerations by size class
and inland or coastal location, 2025

39. Urban agglomerations by size class and potential
risk of multiple natural disasters, 2025.

40. Let’s imagine our world in
year 2100?
Are you optimistic or
pessimistic…..why?

41. Conclusion

Public health professionals cannot by themselves
mandate the provision of safe water and adequate
sanitation, nor can they, acting alone, rise to meet
the challenges of mitigating urban air pollution,
reorganizing traffic injuries, and readying cities to
adapt to the threats that will be posed by climate
change.

‘joined-up government’, whereby public health
agencies join with concerned actors in other sectors
of municipal, regional, and national governments, is
needed.

42. Thank you for attention
We always appreciate your participation

43. References

Roger Detels , Robert Beaglehole , Mary Ann Lansang , Martin
Gulliford. Oxford Textbook of Public Health, 5th edition 2011

WaterAid America Inc., 315 Madison Avenue, Suite 2301, New
York, NY 10017, USA. Tel: (212) 683 – 0430

United Nations,Department of Economic and Social Affairs.
WORLD POPULATION TO 2300, 2004 new York

Water aid sanitation UK, water and sanitation