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Urban health in low- and
middle-income countries

Department of International
Health, TMDU
Izzeldin F. Adam ; BPEH, MPH.
Contents







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

Over the next 30 years, low- and middle-income
countries will cross an historic threshold, becoming
for th...
The demographic context


In 1950, there were only two
metropolitan areas in the world the
Tokyo and the New York-Newark
...
Countries demography


In 1950 there were seven European countries among the
twenty most populous countries of the world,...
percentage of urban population
and agglomerations by size class
1960

1980
percentage of urban population
and agglomerations by size class
2011

2025
Urban and rural population by development regions, 1950,
2011 and 2050 (per cent of total population)
urban growth process: How and why dose it
happen?
World Population Prospects: Source: UN, Department of
Economic and Social Affairs, Population Division (2011)
The urban poor






urban poverty is associated with a lack
of access to piped drinking water and
with inadequate sani...
Urban poor at LIC and MIC
Percentages of households with access to services.
piped water in premises

water in neighbourhood

flush toilet

pit toil...
Disability-adjusted years of life lost in Mexico, by cause and
area of residence
Cause

Rural

Rural rank Urban

Urban ran...
The urban health system




The urban health system is situated within
larger political-economic frames at the
country l...
Comparison of child mortality rates (5q0) in the Nairobi
slums sample with rates for Nairobi, other cities, rural
areas, a...
Urban health care








the urban poor without cash on hand can find
themselves unable to gain entry to the modern
s...
Urban sanitation


Water and sanitation have proved time and time again to
be a critical factor in health and economic de...
Investment in sanitation


Current investment into water and sanitation in
the slums is inadequate and is failing to reac...
Now from public health point of
view, let’s think about expected
health problems in urban poor.
The urban burden of disease












Diarrheal diseases
Mental health
Intimate-partner violence and alcohol a...
Diarrheal diseases


Water and sanitation are fundamental to
health and development, especially in densely
packed urban a...
Mental health


mental ill-health accounts for roughly 24% of
all DALYs lost due to non-communicable
diseases in low-inco...
Intimate-partner violence and
alcohol abuse






Review of community-based data for 8 urban areas
in developing world,...
Experience of physical or sexual violence by an intimate
partner since age 15, among ever-partnered urban women.
Source: (...
Reproductive health


Among all urban women, those who are poor
are significantly less likely to use modern
contraception...
HIV/AIDS


In these three cases—Mali, Kenya, and
Zambia—urban prevalence rates are clearly
much higher than rural rates.
...
Estimates of urban and rural prevalence of HIV from the
Demographic and Health Surveys in Mali, 2001; Kenya,
2003; and Zam...
Tuberculosis


Urban crowding increases the risk of
contracting tuberculosis (van Rie et al.
1999), and high-density low-...
Urban malaria




There is clear evidence that malaria vectors
have adapted to urban conditions in subSaharan Africa (Mo...
Urban malaria
Traffic-related injuries




The WHO (2004) estimates that road
traffic injuries lead to 1.2 million deaths
annually and...
Fatality rates for low- and middle-income and
high-income cities and countries.
Outdoor air pollution


The Latin-American literature is
especially rich in scientific
analyses of outdoor urban air
poll...
Climate change


According to current estimates, gradual increases in
sea level are now all but inevitable over the comin...
Urban agglomerations by size class
and inland or coastal location, 2025
Urban agglomerations by size class and potential
risk of multiple natural disasters, 2025.
Let’s imagine our world in
year 2100?

Are you optimistic or
pessimistic…..why?
Conclusion


Public health professionals cannot by themselves
mandate the provision of safe water and adequate
sanitation...
Thank you for attention
We always appreciate your participation
References


Roger Detels , Robert Beaglehole , Mary Ann Lansang , Martin
Gulliford. Oxford Textbook of Public Health, 5t...
Urban health
Urban health
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Urban health

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

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Urban health

  1. 1. Urban health in low- and middle-income countries Department of International Health, TMDU Izzeldin F. Adam ; BPEH, MPH.
  2. 2. Contents       Introduction Demographic context Urban poor Urban health system Urban burden of disease Conclusion
  3. 3. 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.
  4. 4. 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
  5. 5. 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
  6. 6. percentage of urban population and agglomerations by size class 1960 1980
  7. 7. percentage of urban population and agglomerations by size class 2011 2025
  8. 8. Urban and rural population by development regions, 1950, 2011 and 2050 (per cent of total population)
  9. 9. urban growth process: How and why dose it happen?
  10. 10. World Population Prospects: Source: UN, Department of Economic and Social Affairs, Population Division (2011)
  11. 11. 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.
  12. 12. Urban poor at LIC and MIC
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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.
  19. 19. 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.
  20. 20. Now from public health point of view, let’s think about expected health problems in urban poor.
  21. 21. 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
  22. 22. 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.
  23. 23. 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?
  24. 24. 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 .
  25. 25. Experience of physical or sexual violence by an intimate partner since age 15, among ever-partnered urban women. Source: (WHO, 2005)
  26. 26. 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.
  27. 27. 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.
  28. 28. Estimates of urban and rural prevalence of HIV from the Demographic and Health Surveys in Mali, 2001; Kenya, 2003; and Zambia, 2001-2002.
  29. 29. 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.
  30. 30. 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.
  31. 31. Urban malaria
  32. 32. 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
  33. 33. Fatality rates for low- and middle-income and high-income cities and countries.
  34. 34. 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.
  35. 35. 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.
  36. 36. Urban agglomerations by size class and inland or coastal location, 2025
  37. 37. Urban agglomerations by size class and potential risk of multiple natural disasters, 2025.
  38. 38. Let’s imagine our world in year 2100? Are you optimistic or pessimistic…..why?
  39. 39. 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.
  40. 40. Thank you for attention We always appreciate your participation
  41. 41. 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

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