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Ill-health and poverty: a literature

review on health in informal


settlements

ALICE SVERDLIK

Alice Sverdlik recently


completed a Masters
degree in Social Policy
at the London School of
Economics and a Masters
degree in Urban Economic
Development at the
Development Planning
Unit, University College
London. She has worked
as an intern with IIED since
January 2009.
Address: IIED, 3 Endsleigh
Street, London WC1H
0DD, UK; e-mail: alice.
sverdlik.09@ucl.ac.uk
Acknowledgment: Profound
thanks to Sheridan Bartlett
for her suggestions for this
review and to the Marshall
Aid Commemoration
Commission for supporting
my studies in the UK.

ABSTRACT This paper reviews the literature on health in the informal settlements
(and slums) that now house a substantial proportion of the urban population
in Africa, Asia and Latin America. Although this highlights some important gaps
in research, available studies do suggest that urban health inequalities usually
begin at birth, are reproduced over a lifetime (often reinforced by undernutrition),
and may be recreated through vulnerabilities to climate change and a double
burden of communicable and non-communicable diseases. The review begins
with a discussion of papers with a life-course perspective on health, poverty and
housing, before considering recent literature on chronic poverty and ill-health
over time. It then discusses the literature on the cost, quality and access to care
among low-income groups, and the under-recognized threat of unintentional
injuries. This includes recent literature that discusses where low-income residents
may suffer an urban penalty rather than benefiting from urban bias although
there are also studies that show the effectiveness of accessible, pro-poor health
care. The concluding section examines emerging risks such as non-communicable
diseases and those associated with climate change. It notes how more gender- and
age-sensitive strategies can help address the large inequalities in health between
those in informal settlements and other urban residents. With greater attention
to the multi-faceted needs of low-income communities, governments can create
interventions to ensure that urban centres fulfil their enormous potential for health.
KEYWORDS climate change / equity / health services / housing / poverty / urban health

I. INTRODUCTION

1. UN Habitat (2006).

2. Hardoy, Cairncross and


Satterthwaite (1990).
3. UNHabitat (2003).

In the informal settlements that now house a significant proportion of the


worlds urban population, residents suffer disproportionately from ill-health
throughout their life-course. These households are more likely to experience
disease, injury and premature death, and ill-health may combine with poverty
to entrench disadvantages over time. An estimated one billion people live in
informal urban settlements or slums.(1) These settlements pose grave threats
to the health of their inhabitants, stemming from poor-quality housing,
lack of infrastructure and minimal access to refuse collection, health care or
other essential services.(2) In 2000, at least 650 million residents of informal
settlements had inadequate water provision and perhaps 850 million lacked
sanitation,(3) and the numbers with inadequate provision are likely to
have risen considerably since then. Residents health may decline in the
face of these profound environmental hazards and ingrained deprivations.

Environment & Urbanization Copyright 2011 International Institute for Environment and Development (IIED).
Vol 23(1): 123155. DOI: 10.1177/0956247811398604
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E N V I R O N M E N T & U R B A N I Z AT I O N

Elevated levels of infant and child mortality often result, but ill-health may
persist at older ages. Due to malnutrition or prior illness, children who reach
adolescence are frequently compromised in health and development.(4) Lowincome adults are at increased risk of occupational injury or disease, which
can quickly curtail their meagre earnings.
Although such negative outcomes may appear inevitable, urban areas
can promote major health improvements even for low-income households
(as has occurred in high-income nations). Medical centres, infrastructure and
health personnel are often concentrated in urban areas, while economies of
scale and proximity can facilitate good quality provision for water, sanitation,
drainage and health care at lower cost.(5) However, many local officials
are unwilling to provide essential services, health-related infrastructure or
recognition to informal settlements.(6) Largely due to unresponsive local
governance, low-income urban residents may enjoy few if any health
advantages over their rural counterparts.(7) Pervasive urban health inequalities
have been uncovered, as reviewed in past issues of this journal.(8) As health
inequalities are recreated over their life-course, low-income urban residents
are consistently denied the chance of improved health.
Informal settlements scale and complexity of health needs are
sometimes misunderstood. The health literature frequently concentrates
upon communicable diseases, yet low-income urban residents also
suffer from non-communicable diseases (NCDs) such as cancer, diabetes
and stroke, which are increasingly creating a double burden in these
households.(9) In low- and middle-income countries, the population
prevalence of chronic conditions climbed from 47 per cent in 1990 to
56 per cent in 2000.(10) Some estimates suggest that by 2030, mortality in
these nations will be dominated by NCDs, road traffic accidents and HIV,
while under-five mortality may fall by 50 per cent.(11) But such advances in
child health require major improvements in services and environmental
conditions, as well as overcoming significant failures in local governance.
Optimistic projections may also overlook climate change, whose health
impacts will be context-specific but often quite negative.(12) Many
informal settlements are at high risk, due to extreme weather events that
may become more frequent and intense as a result of climate change.(13)
Promising trends in health research are also emerging, which could
be extended and could help ensure more equitable interventions. Urban
health researchers have examined how inhabitants are affected by
their physical and social environment, the availability and access
to health/social services, and the interrelationships between these
determinants.(14) A new-found emphasis on vulnerability and social
exclusion has improved understanding of health inequalities.(15) Absolute
poverty lines are increasingly criticized for neglecting cities higher costs
of living and residents need to access health care, infrastructure and
other determinants of health.(16) Replacing these static poverty lines,
dynamic conceptualizations have explored residents vulnerability and
the portfolio of assets critical to overcoming deprivation.(17) Moreover,
health and poverty reduction are enjoying greater prominence in the
international development agenda. The Millennium Development
Goals (MDGs) represent important commitments, even if the MDG
target 11 of achieving significant improvements for only one-tenth
of the worlds billion slum dwellers by 2020 is patently inadequate.(18)
Significant improvements in informal settlements are needed not
only on a wider scale but must be guided by a holistic understanding of

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4. Bartlett (1999), page 65.

5. Hardoy, Mitlin and


Satterthwaite (2001).
6. Satterthwaite (2007).
7. See Section VI for further
discussion and comparisons
with rural areas.
8. Atkinson (1993); also
Stephens (1996); Kjellstrom and
Mercado (2008); and Stephens
(2011) in this volume.

9. As discussed in more detail


in Section VII; also Stephens
(1996); and Moser (2011) in this
volume.
10. Allender et al. (2008).
11. Mathers and Loncar (2006).
12. Confalonieri et al. (2007).
13. See Section VII below; also
IFRC (2010); and Satterthwaite
et al. (2007).
14. Galea and Vlahov (2005).
15. The concept of social
exclusion has long been used
in high-income nations, and
a recent review called for
research on social exclusion,
health and residents of low- and
middle-income cities (Harpham
(2009)). For instance, hazardous
environmental conditions and
minimal services provide a
constant reminder of social
exclusion, perhaps leading
the urban poor to neglect key
health-seeking behaviours
(Montgomery (2009)).
16. Satterthwaite (2004); also
Bapat (2009); and Sabry (2010).
17. Moser (1998).
18. Hasan, Patel and
Satterthwaite (2005); also
see papers in Environment
and Urbanization (2005); and
Satterthwaite (2003).

I L L - H E A LT H A N D P O V E R T Y

19. Unger et al. (2007),


page 1563.

20. See Hardoy, Cairncross


and Satterthwaite (1990)
for a discussion of how
understanding the health
implications of housing has to
go beyond just the structure,
and encompasses the broader
living environment including
provision for water, sanitation,
drainage and the availability
and accessibility of health care
and emergency services.

21. Montgomery et al. (2003).

22. Stephens (1995), page 113.

health. Shelter is often viewed narrowly, and notions of urban health need
to move beyond the absence of disease to encompass well-being. There
remains a pressing need for a new analytic framework to understand health
in slums.(19) At the crux of any urban health framework must be lowincome households, who usually experience cities negative externalities
instead of the benefits. Further research could enhance understanding
of health and its linkages with patterns of low and fluctuating incomes,
urbanization and housing.(20)
To inform future studies and interventions, this paper summarizes
the findings of some recent papers on health in informal settlements
or health among lower-income urban households. Articles from social
sciences and medical databases were selected to capture key urban health
risks across different age groups and regions (by searching for lowincome urban health, slum, favela or related terms). In particular, it
sought community-based research rather than studies using secondary
and hospital-based data (since these may undercount the low-income
groups lacking access to such facilities). Existing literature often focuses
on major cities, giving less detail on small and mid-sized urban centres
even as these are home to a significant proportion of urban dwellers.(21)
Several gaps in the literature are identified, such as studies on ageing,
quality of health care, and occupational health for those working in the
informal economy. Future investigations could analyze how the linkages
between health, poverty, and housing may vary over time, and between
and within households, or under different governance structures. New
insights could help create the corpus of a new health framework, even
transforming approaches to current or emerging concerns.
This review begins with a life-course perspective on health, poverty
and housing, before examining new threats that may exacerbate ill-health
in informal settlements. The sections highlight how health inequalities
begin at birth, are reproduced over a lifetime, and may be recreated
through vulnerabilities to climate change and a double burden of
disease. Drawing on cross-sectional studies, Section II explores key risks
from infancy to adolescence, adulthood and old age, and also sketches
some effects upon other household members. Section III helps uncover the
cumulative effects of ill-health and the discussion considers how illness
may interact with chronic poverty. By examining health expenditures,
access to health services and low-quality care (Section IV), the oftenreinforcing effects of ill-health and poverty come into sharper relief. As
researchers increasingly open the Pandoras box of adult as well as child
health, the effects of inadequate living and working environments and
poverty are shown to compound threats to health.(22) Injuries are rarely
recognized as a major threat, yet Section V notes that they contribute
considerably to premature death and frequently compromise the health of
adults and children. Section VI discusses evidence of an urban penalty
among the poor, and Section VII considers how non-communicable
diseases and climate change may further entrench disadvantages in
informal settlements. However, instances of pro-poor health care are also
highlighted and may set important precedents. With greater attention
to the multi-faceted, changing needs of low-income communities,
governments can create appropriate interventions to ensure that urban
centres fulfil their potential for good health.
But before this review begins, a comment is needed on terminology.
This review discusses the health implications of inadequate housing and

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the ill-health of individuals and households with low incomes, but the
terminology used in many papers is problematic. Areas or settlements
with low-quality housing are often termed slums, erroneously implying
that they have little worth, but residents often value these structures and
improve them by upgrading. The term also conceals the considerable
range of shelter construction, land tenure and ownership arrangements
in such settlements.(23) Many studies nevertheless report their findings in
slums, and the term has been revived with the Millennium Development
Goals that seek to improve the lives and monitor housing conditions for
slum dwellers.(24) Although the term informal settlement is preferred,
it may also be pejorative, and cannot capture all low-quality housing
(for example, legally-constructed tenements). Problems also arise in the
terminology used for residents without the resources to buy, build or rent
reasonable-quality housing. Describing these households as the poor
may wrongly suggest they are poor in other aspects of their lives.(25)

II. POVERTY AND HEALTH OVER THE LIFE-COURSE


a. Infant and childhood conditions
This section discusses recent studies that document health risks for infants
and children in informal settlements, with sections (b) and (c) considering
health risks in adulthood and older age. Infant and childrens health offers
an illuminating entry point into conditions in informal settlements,
since the same health risks facing adult residents often have more serious
impacts on children. Elevated rates of infant and child mortality found
in particular informal settlements were among the first health-related
statistics to suggest a very high burden of disease among low-income
urban dwellers.(26) Children are disproportionately affected by many of the
environmental challenges [in] poor urban settlements, due to youngsters
physiological vulnerability and urge to play even amid hazardous
conditions.(27) Profound risks to children often stem from informal
settlements inadequate sanitation, water and housing, minimal access
to health care, and they may be linked to a high prevalence of extreme
poverty, insecurity and violence.(28) In the city of Vellore in India, nearly 400
babies in three informal settlements were followed for their first year of
life, by which time all except one had fallen ill.(29) Respondents were ill
for one-fifth of their infancy, usually with respiratory and gastrointestinal
conditions. Infants averaged 43 days per year with respiratory illness, far
exceeding the median of eight days of gastrointestinal illness.(30)
Global mortality statistics do not distinguish between rural/urban
areas, but they help reveal the major threats facing disadvantaged children.
Of nearly 8.8 million deaths of under-five children in 2008, 41 per cent
were neonatal (i.e. occurring in the first month of life) for example,
sepsis, pre-term births and other complications.(31) Leading causes of
under-five mortality included pneumonia (18 per cent), diarrhoea (15 per
cent), malaria (eight per cent) and AIDS (two per cent).(32) Although often
preventable or easily treated, these conditions are widespread among most
urban children living in informal settlements but the range of illness and
relative importance of hazards still vary widely between settlements.
Children are highly vulnerable to malaria, which is often fatal
especially at younger ages. A study in two Ghanaian cities examined
several risk factors for children.(33) In the 3,500 children aged six to 60

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23. Hardoy and Satterthwaite


(1989); also Gilbert (2008).

24. UNHabitat (2006).

25. See Appadurai (2001) for


a discussion of low-income
residents who are forging deep
democracy, simultaneously
advancing solutions to
deprivation across local,
national and global scales.

26. See, for instance, Basta


(1977); also Montgomery et al.
(2003).
27. Bartlett (1999).

28. Garenne (2010), page 466.


29. Gladstone et al. (2008).

30. Gladstone et al. (2008).

31. Black et al. (2010).


32. These figures do not include
deaths due to undernutrition,
another major concern in
slums (as discussed below).

33. Klinkenburg et al. (2006).

I L L - H E A LT H A N D P O V E R T Y

34. In 2004, more than onethird of child deaths and


more than 10 per cent of total
global disease burden were
attributable to maternal and
child undernutrition; see Black
et al. (2010).
35. Bartlett (2008).
36. Haque et al. (2003).

37. Childrens low incidence


of persistent diarrhoea in this
survey (just 0.4 per cent of
cases lasted more than three
days) may be attributable to
their relatively higher nutritional
levels; see Haque et al. (2003).
38. Semba et al. (2009).
39. Jakarta, Surabaya,
Semarang, Makassar and
Padang. Respondents were
participating in the Ministry of
Healths nutritional and health
surveillance system.

months who were surveyed, malaria was associated with anaemia,


younger age and lower socioeconomic status. Analysts considered whether
risk of malaria depended upon the city (Kumasi vs. Accra), intra-city
location and migration from rural areas. Overall, prevalence of malaria
was significantly lower in Kumasi than in Accra, although results were
heterogeneous within each city. Accras average malaria prevalence was
14.8 per cent, ranging from six per cent to 22 per cent, while Kumasis
average was just 8.6 per cent, but varied from two per cent to a high
of 33 per cent. Residents in the community with a prevalence of 33 per
cent were usually lower-income, with less education, and children were
significantly more likely to travel to rural areas. These results suggest that
cities health burdens are partly shaped by rural/urban migration, with
mobility having an influence on disease patterns. The study highlights
how malaria may affect young children in markedly different ways,
encouraging interventions that can reflect this complex reality.
Younger children also suffer disproportionately from diarrhoea, although
the risks are mediated by nutritional status, access to good-quality water
and sanitation, and various socioeconomic factors. Poor nutrition heightens
susceptibility to several infectious diseases, indirectly raising child mortality
levels.(34) Under-five children experience more than 80 per cent of the global
burden of diarrhoeal disease, and diarrhoea can promote malnutrition
by impairing food absorption and loss of nutrients.(35) Studies in informal
settlements can help unravel these hidden, intricate relationships. A survey
of more than 250 Dhaka slum dwellers analyzed the incidence and severity
of diarrhoea, as well as age, nutritional status and access to basic services. Just
one-third of households had a municipal source of water and only 26 per cent
of children used improved latrines.(36) Younger children were at greater risk:
respondents aged two to three averaged 2.5 diarrhoeal episodes per year,
but those aged four to five had yearly rates of 1.38. Children who were
malnourished and stunted had elevated rates of diarrhoea, as expected,
averaging more than two episodes per year as against 1.6 episodes in betternourished children. The overall prevalence of malnourished and stunted
children was 39 per cent and 32 per cent, respectively. Although these rates
show the large dietary deficiencies in low-income settlements, they were
actually below those of other Bangladeshi studies in similar age groups.(37)
A study in Indonesia also explored childhood diarrhoea and poor
nutrition, but it considered whether households that purchase cheap
drinking water were at greater risk. As in many low-income communities,
Indonesias urban poor often purchase water from cart vendors, water
tank operators or neighbours.(38) In this study across five cities,(39) almost
140,000 low-income households were purposively surveyed between
1999 and 2003. About 47 per cent purchased cheap drinking water, six
per cent bought more expensive water and another 47 per cent accessed
water from a well, lake or spring. Diarrhoea prevalence in the seven days
before the survey differed between the groups. In households purchasing
more expensive water, 7.7 per cent of children had diarrhoea, rising to
8.1 per cent for households that did not purchase water, and 11.2 per
cent in those buying cheap water. Children in households buying cheap
water were significantly more likely to be undernourished, but nutritional
deficiencies were common in all three groups (prevalence rates ranged
from 2429 per cent underweight, 3035 per cent stunted and 1112
per cent wasted). Surprisingly, no association was found between per
capita weekly expenditure and incidence of diarrhoea. But compared to

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E N V I R O N M E N T & U R B A N I Z AT I O N

the other two groups, families purchasing cheap water were more likely
to have the youngest child suffer from diarrhoea in a multivariate model
(which adjusted for maternal age, education, household expenditure and
other socioeconomic factors). Although water quality was not tested,
these findings suggest a link between buying cheap water and childhood
diarrhoea. Additional investigations could explore the effects of water
vending not only on childrens well-being but also on adult health and
household incomes.
Youngsters are particularly susceptible to pneumonia, a leading
cause of child mortality, as noted above, and young childrens health
burdens may far outstrip those of older residents. In a random survey
of 260 favela (informal settlement) residents in Salvador, Brazil, almost
36 per cent had pneumococcal carriage.(40) But prevalence rates diverged
markedly between age groups, so that the odds of infection for underfive children were eight times that of older subjects. About 16 per cent
of adults aged over 17 were colonized with Streptococcus pneumonia, as
against 45 per cent of children aged 517 and 67 per cent of children
under five. Pneumonia often proves fatal in younger residents in
informal settlements, as underscored by surveillance data in two of
Nairobis informal settlements. Pneumonia was the single leading cause
of premature mortality in young children, comprising 22 per cent of
under-five deaths for 20032005.(41) Contributing factors for pneumonia
were inadequate, overcrowded shelter and indoor air pollution (discussed
below). The premature mortality burden in under-five children was more
than four times that of the rest of the population combined.
Indoor air pollution exemplifies the links between poverty, health and
housing, and also how health impacts are influenced by age and gender.
Low-quality indoor air is often associated with overcrowding, inadequate
ventilation and solid cooking fuels such as wood, crop residues, coal or
charcoal. In 2000, cooking with solid fuels was linked to nearly two million
deaths and 38.5 million disability-adjusted life years, or DALYs.(42) Solid
fuels are widespread in low-income households, while wealthier families
can afford sources higher on the energy ladder, such as kerosene, natural
gas or electricity.(43) Most indoor air pollution studies focus on rural areas,
but low-income urban households may be affected as well.(44) In particular,
low-income women and children are usually most exposed to indoor air
pollution. Children often spend more time indoors as infants, or are strapped
to their mothers backs while they cook.(45) The resultant respiratory problems
include pneumonia, chronic obstructive lung disease (COPD), asthma and
tuberculosis; indoor air pollution is also associated with elevated risk of
cataracts, low birth weight, cancer and cardiovascular failure.(46) Researchers
should still quantify the full range of risks, and longitudinal analyses could
explore lasting impacts on childrens lung function.(47)
Of course, there is also the importance of malnutrition for child illhealth and premature death, as this underlies and interacts with most
other health issues and has some specifically urban dimensions.(48) The
high proportion of children that are underweight and under height in
particular studies has been noted above,(49) and is also discussed in Section
III, within discussions of chronic poverty.
But vulnerability cannot be equated with victimhood, and viewing
children as only a fragile sub-population is inaccurate. Urban residents
under the age of 18 are not a special interest group but a significant part
of the worlds population, comprising 1020 per cent of the citizenry

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40. Reis et al. (2008a).


Pneumococcal carriage is
an initial step in spreading
the pathogen in the
community, which can cause
pneumonia, meningitis and
other respiratory diseases
(particularly in younger
residents).

41. Kyobutungi et al. (2008).


Other leading causes of underfive deaths were diarrhoea
(19.5 per cent) and stillbirths
(16.3 per cent); peri-natal
causes together contributed
28 per cent.

42. Smith, Mehta and


Maeusezahl-Feuz (2004). The
above figures encompass
urban and rural areas.
Disability-adjusted life years
(DALYs) are a measurement
combining years of life lost due
to premature mortality and time
spent in less-than-full health.
43. Barnes, Krutilla and Hyde
(2005).
44. For a comparison of rural
and urban indoor air pollution in
Malawi, see Fullerton et al. (2009).
45. Torres-Duque et al. (2008).
46. Bruce, Perez-Padilla and
Albalak (2000).
47. Fullerton, Bruce and Gordon
(2008).
48. See Fry, Cousins and Olivola
(2002); also Tolossa (2010).
49. See also Agarwal in this
volume; Montgomery et al. (2003);
and Ghosh and Shah (2004).

I L L - H E A LT H A N D P O V E R T Y
50. Bartlett (2008), page 7.
51. Stephens (1995).
52. See discussion in Bartlett
(2002a) for overview; also
Environment and Urbanization
(2002).
53. See Environment and
Urbanization (2010); also
Makau (2011) in this volume;
Mabala (2011) in this volume;
and Fernndez-Castilla, Laski
and Schellekens (2008).

54. Kyobutungi et al. (2008).

55. Patton et al. (2009), page 881.

56. Patton et al. (2009).

57. See the Urban Reproductive


Health Initiative; also Hindin
and Fatusi (2009); Blum and
Mmari (2005); DeJong and ElKhoury (2006); Samandari and
Speizer (2010); Sabin
et al.(2003); and Taffa (2003).
58. Adolescents mental health
is a major concern, and six per
cent of female and male deaths
at this age were due to suicide;
see Patton et al.(2009), page
887; also Patel et al. (2008); and
Harpham et al. (2005).
59. Patton et al. (2009), page 891.
60.The exceptions are subSaharan Africa and southeast
Asia, reflecting the regions
high rates of maternal mortality.
61. Boadi and Kuitunen (2006).

in most low-income nations.(50) Most research has focused on analyzing


infant and under-five morbidity/mortality rates;(51) but with a broader
focus on inclusion, researchers are now exploring how to overcome
childrens marginalization and insecurity.(52) Children are increasingly
recognized as active, rights-bearing agents, and a range of youth-friendly
initiatives have been featured in this journal.(53)

b. Adolescence and adulthood


Although some health risks recede as children reach adolescence, other
risks emerge, and threats remain profound from hazardous shelter,
neighbourhoods or worksites. The study mentioned above, on the causes
of premature mortality in young children in two informal settlements in
Nairobi,(54) also showed how health risks shift over time. Leading causes of
mortality for residents over the age of five were HIV, TB, violent injuries
and road traffic injuries, representing more than two-thirds of this age
groups burdens. Few studies have examined health risks for adolescents,
in part because adolescence is often considered a healthy time of life.(55)
A recent review provides the first analysis of causes of death among
youths aged 1024 years, based on the 2004 Global Burden of Disease
data.(56) Youths were not differentiated by rural/urban location, but
findings are broken down by gender, age group and geographic region.
In low- and middle-income countries, all-cause mortality was 2.4 times
higher in youths aged 2024 than in adolescents aged 1519. Mortality
rates thus escalated from adolescence to young adulthood with the
rise of reproductive health problems,(57) road traffic accidents or mental
illness.(58) But conditions affecting younger children may continue to
threaten adolescents. For youths in sub-Saharan Africa and southeast
Asia, tuberculosis and lower respiratory tract infections actually led to
more deaths than HIV.(59) Gender-related differences may be significant,
with young males usually at greater risk of premature death than their
female counterparts.(60) Young men are often more prone to road traffic
and other injuries (as discussed in Section V).
As noted above, the negative impacts of indoor air pollution are
usually borne by low-income women, infants and young children. Among
950 women and children surveyed in Accra, low-income households
were far more likely to use solid fuels and report respiratory infections.
Poorer women usually cooked with charcoal or wood; meanwhile, richer
households used LPG or electricity.(61) Of the 29 per cent of children
who reported respiratory infections, over 85 per cent were from poor
households. These inequitable health burdens were mirrored among
their mothers. Nearly 30 per cent of poorer women had respiratory
problems in the two weeks preceding the survey, more than twice the rate
reported by women of medium wealth (13.5 per cent) and 10 times that
of wealthy women (3.5 per cent). Predictably, respiratory infections were
most common in households using firewood (67.5 per cent) and charcoal
(31.6 per cent). Infections declined steadily in households cooking with
kerosene (12.9 per cent), LPG (4.8 per cent) and electricity (1.7 per cent).
Although low-quality indoor air is often associated with dirty fuels,
interventions may target better ventilation or behaviours rather than
altering the fuel type. Indoor air pollution also depends upon ventilation,
length of exposure and other modifiable factors. According to a study
of 230 households in Dhaka and Narayanganj, low-income respondents

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E N V I R O N M E N T & U R B A N I Z AT I O N

using dirty fuels sometimes enjoy indoor air quality normally


associated with clean fuels, while others suffer from pollution levels 10 times
the international safe standard.(62) The variation in air quality was largely
explained by household-level practices and structural arrangements.
Respondents differed in their cooking locations, ventilation (opening
windows/doors after cooking) and housing materials (mud walls trapped
more pollutants than bamboo structures). Findings need to be replicated
in other settlements, but the study suggests innovative community-based
approaches to improve indoor air quality.
Outdoor air pollution can be highly inequitable as well, since it
may disproportionately affect low-income communities and workers.
An estimated 800,000 additional deaths annually are attributed to air
pollution, which may generate fatal respiratory illness, affect the central
nervous system and aggravate asthma.(63) Although a common concern
across many cities, air pollution may be particularly burdensome for lowincome residents who work outside or live near industrial sites.(64) Health
impacts are still challenging to isolate, due to possible synergies between
pollutants and confounding factors such as smoking. A study tried to
address these difficulties by comparing exposure data in two Mexican cities
and stratifying participants by city quarter and occupation.(65) Exposure
levels were far higher among outdoor labourers: in Mexico City, outdoor
workers had median occupational exposures to benzene, toluene and
other pollutants that were 1.52.5 times higher than indoor workers.
Levels also diverged by urban quarter, as taxi drivers in Mexico Citys
polluted northeast had significantly higher median exposures than those
in the southeast. Workers in Mexico City had higher exposures than
their counterparts in Puebla. Investigators only collected data over two
days, with a convenience sample of 30 workers per city, so larger-scale,
extended studies are needed. Nevertheless, the study suggests profoundly
unequal burdens falling upon outdoor (poorer) workers in polluted cities.
Low-income adults often face elevated risks of occupational injuries
and fatalities, as a consequence of their hazardous environments or
precarious work arrangements. A high proportion work in the informal
economy, where occupational health and safety standards are violated or
non-existent. Compared to formal labourers, informal workers are more
commonly exposed to poor working environments, low safety and health
standards and environmental hazards.(66) Injury compensation or payment
during illness is highly unlikely because informal labourers are rarely
unionized, employer responsibilities may be unclear, or no employer can
be identified.(67) The resulting injuries or fatalities are often hidden, as
informal employment inherently lacks legal recognition and research
is limited. Given the urban poors overlapping work and home,
many occupational hazards relate to environmental problems at the
household or community level. Still, the linkage between hazardous
living environments and working conditions is largely underexplored.(68) A few
relevant studies are mentioned below, but informal workers health risks
require far greater attention from policy makers and researchers.(69)
Occupational hazards depend upon the particular industry or city.
Informal workers in India frequently report lower back pain, injuries
from heavy lifting or using tools, respiratory disorders (from exposure to
hazardous chemicals or dust) and psychological stress.(70) Risks can be specific
to the occupational group, but are also shaped by the level of formality,
city regulations and gender or age norms (for example, many women and

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62. Dasgupta et al. (2006),


page 439.

63. Cohen et al. (2005).


64. Effects also depend on
exposure times, topography,
weather patterns and
age; younger and elderly
populations are particularly
vulnerable to ambient air
pollution. (Hardoy, Mitlin and
Satterthwaite (2001), pages
9098.)
65. Tovalin-Ahumada and
Whitehead (2007). Outdoor
workers were either vendors
or taxi drivers, with reference
groups of indoor office
workers.

66. ILO (2002), page 65.

67. Giuffrida, Iunes and


Savedoff (2002).

68. Barten et al. (2008), page 227.


69. There is one low-income
urban group that is particularly
neglected when it comes
to health: informal sector
workers. (Harpham (2009),
page 109.)
70. Chattophadyay (2005).

I L L - H E A LT H A N D P O V E R T Y

71. Gutberlet and Baeder


(2008).

72. Quoted in Gutberlet and


Baeder (2008), page 12.

73. Chen, Vanek and Carr


(2004).
74. Pick, Ross and Dada (2002).

75. See also Adedimeji et al.


(2007); Chacham et al. (2007);
and Kalichman et al. (2005).
76. Van Donk (2006), page 157.

77. Collins (2008), page 272.


78. Mabala (2006).
79. Montgomery (2009).
80. Mudege and Ezeh (2009).

81. Quoted in Mudege and


Ezeh (2009), page 250.
82. See Loewenson,
Hadingham and Whiteside
(2009).
83. See, for instance, the high
prevalence of undernutrition
among adolescent girls in a
slum, discussed in Prashant
and Shaw (2009).
84. See, for instance, Sarangi,
Acharya and Panigrahi (2009);
also McIlwaine and Moser
(2004).
85. See, for instance, BanaynalFernandez (1994); also Rodgers
(2004); and other papers in
Environment and Urbanization
(2004).
86. Harpham (2009).

children work from home while construction is frequently male-dominated).


Risks may affect both workers and their families, as revealed by a study among
Brazilian waste collectors. Of the 47 informal recyclers interviewed in So Paulos
metropolitan area, nearly one in five sorted materials at home and thereby
exposed their households to disease vectors or hazardous products.(71) Several
workers had been hit by cars, and musculo-skeletal injuries were common due
to lifting and pushing carts. But social stigma could generate other profound
burdens, with one labourer declaring that more respect would be the most
needed change to improve [recyclers] work.(72)
Informal workers marginality frequently exacerbates their ill-health
and disrupts their livelihoods. For instance, many informal vendors face
official opposition, and are at heightened risk of injury, lost assets and
evictions.(73) In Johannesburg, surveys of 400 female vendors revealed
widespread harassment (verbal and sexual) alongside accidents such as
cuts, burns from preparing food and musculo-skeletal complaints from
heavy lifting.(74) Further studies could explore municipal strategies that
better meet workers needs and unravel the linkages between health
outcomes, occupational hazards and poverty.
No discussion of adolescent and adult health can overlook HIV/AIDS,
and informal settlements may have especially high prevalence rates and
extensive socioeconomic insecurities.(75) Sub-Saharan Africas epidemic
is disproportionately [but not exclusively] an urban phenomenon.(76)
Household-level shocks are profound, but the losses reverberate across the
settlement, city and national scales. HIV depletes the labour force, distorts
the age structure, imperils households...burdens health systems...[and] challenges
the stability of communities.(77) Gender- and age-sensitive interventions
are essential, and organizations must support the participation of girls or
young women, who are often at greater risk.(78) Poverty is sometimes linked
to higher prevalence rates, perhaps reflecting earlier sexual initiation or
forced/traded sex in low-income areas.(79) A study in Nairobis informal
settlement of Korogocho, for instance, found that HIV prevalence was
nearly triple the national average of 6.1 per cent.(80) Other household
members must grapple with profound illness-related losses, which are
at once physical, socioeconomic and emotional. A grandmother caring
for her HIV-orphaned grandson admitted: It has been very difficult for
me...at times we go without food when I dont get any work to do.(81) Childheaded households or poor elderly relatives may struggle to cope with the
anguish, as well as excessive health and economic burdens. These multidimensional challenges may be revealed with a relational understanding
of poverty and health.(82) And as discussed below, studying older residents
health can uncover how risks shift and interlink over the life-course.
There is some discussion of other health risks faced by adolescents
living in informal settlements for instance undernutrition,(83) substance
abuse(84) and violence,(85) and all deserve more attention than this summary
review can provide.

c. Ageing, poverty and urbanization


The elderly poor often face heightened insecurities, ill-health or heavy
family responsibilities. With only scattered studies on ageing in lowand middle-income countries, little is known of older residents health
profiles.(86) However, the overlapping trends of urbanization, ageing and

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impoverishment are unmistakable in many nations. The proportion of


the urban population over 60 years of age is increasing,(87) and only a
small proportion of older people receive adequate pensions, insurance
or other forms of social protection. Some elderly residents continue to
work while others are forced to rely upon younger relatives, who must
support their own precarious households. Urbanization is also associated
with changes in diet and exercise that promote non-communicable
conditions, which may particularly affect low-income elderly residents.(88)
These transformations are already well underway, notwithstanding some
marked geographical differences. Sub-Saharan Africa is the only region
whose youth population has not yet peaked.(89) Yet from 2006 to 2050,
the proportion of Africans aged over 60 is likely to double, from five per
cent to 10 per cent of the total population.(90) Life expectancies at birth in
Latin America already average 70 years, most of the population is urban,
and perhaps two-thirds of the elderly live in poverty.(91)
Low-income elderly workers can face greater risk of occupational
injury, and older residents may lack awareness of other problems such
as chronic disease. More than 400 residents aged 65 or older were
surveyed in a peri-urban settlement in Karachi, where more than 80
per cent of men remained economically active but just eight per cent
of women worked.(92) Older men in this context may be at heightened
risk of disability or occupational injury. The study found other genderrelated differences as well as shared vulnerabilities. Diabetes affected 15
per cent of men and 19 per cent of women, but women were more than
twice as likely to report hypertension (22 per cent of men and 45 per
cent of women were hypertensive, respectively). However, this study
noted that these divergent rates by gender may be an artefact of more
regular health screenings among women. The prevalence of diabetes and
of hypertension (a risk factor for cardiovascular illness) already suggests
key areas for intervention. Nearly 40 per cent of those consulted said cost
considerations would deter them from seeking care. Tailored interventions
may be needed to raise awareness of risks and enhance residents healthseeking behaviours, especially regarding unfamiliar chronic diseases.
A survey across eight Nigerian states offers the first large-scale
disability study of older people in sub-Saharan Africa, with respondents
disaggregated by urban/rural location.(93) Among the 2,100 respondents
over the age of 65, nearly one in 10 had a disability that required assistance
(ADL or IADL).(94) Almost 20 per cent of the disabled lacked care givers,
and disability was more common among female and older respondents.
Surprisingly, disability was not associated with economic status (proxied
by asset ownership and house floor quality). Yet older people in cities were
two to three times as likely to be disabled as their rural peers, and further
studies could probe the links between urban poverty, ageing and disability.
By combining qualitative and quantitative data, a Nairobi study
provides a nuanced understanding of elderly peoples burdens. Of 800
residents aged 60 and above in two informal settlements, about 52 per
cent of women and 61 per cent of men remained economically active.(95)
Petty trading and other informal activities were predominant, but no data
are provided about occupational health. Older men frequently struggled
to cope with the psychological burdens of ageing and rarely assumed
caring roles.(96) Although older women adjusted more readily and helped
care for their grandchildren, these responsibilities could be oppressive. As
one woman explained, it was difficult because our children are supposed

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87. Leon (2008).

88. Leon (2008); see Section


VII for further discussion
of chronic or noncommunicable diseases such
as obesity, diabetes, stroke and
cardiovascular disease.
89. Sommers (2010).
90. Mudege and Ezeh (2009).
91. Zunzunegui et al. (2009).

92. Ladha et al. (2009).

93. Gureje et al. (2006), pages


17861787). For disability
among residents at younger
ages, see Saloojee et al. (2007);
also Maulik and Darmstadt
(2007); and Gottlieb et al. (2009).
94. IADL (instrumental activities
of daily living) and ADL (activities
of daily living) are two commonly
used measures of disability
among the elderly. ADL activities
include bathing, dressing and
eating, while IADL measures
respondents ability to manage
money, operate a telephone, use
transportation, etc.
95. Cited in Mudege and Ezeh
(2009).
96. Mudege and Ezeh (2009).

I L L - H E A LT H A N D P O V E R T Y
97. Quoted in Mudege and
Ezeh (2009), page 252.

98. Zunzunegui et al. (2009);


the cities were Buenos Aires
(Argentina), Bridgetown
(Barbados), So Paulo (Brazil),
Santiago de Chile (Chile),
Havana (Cuba), Mexico City
(Mexico) and Montevideo
(Uruguay).
99. For another study on older
residents mental health, see
Guerra et al. (2009).
100. Ramos (2007).

101. For health comparisons


between Mexicos urban and
rural elderly, see Smith and
Goldman (2007).
102. Beydoun and Popkin
(2005).
103. McGranahan, Balk and
Anderson (2007).
104. Solinger (2006).

105. Beydoun and Popkin


(2005), page 2055.

106. Sun and Gu (2008).

to be looking after us.(97) If ageing is accompanied by impoverishment,


care burdens may continue to rise alongside older residents ill-health,
emotional strain and economic vulnerabilities.
Ageing studies in Latin America uncovered striking differences in
disability by gender and city. The Pan-American Health Organization study
in 2000 surveyed more than 10,000 residents aged 60 and over across seven
Latin American and Caribbean cities.(98) Women in all seven cities were
significantly more likely than men to experience disability and lower selfreported health. In every city except Bridgetown, women were also more
likely than men to experience depression.(99) Overall self-reported health
differed by city, with residents in Santiago, Havana and Mexico City reporting
poor outcomes more frequently than in Buenos Aires or Montevideo.
This surveys data were also incorporated in city case studies,
including So Paulo.(100) Education and purchasing power were
significantly associated with some health outcomes. For instance,
purchasing power had an impact on older peoples depression (perhaps
reflecting the high levels of inequality in Brazil). Surprisingly, no
association was found between socioeconomic status and morbidity
due to diabetes, heart disease and other chronic illness. Self-reported
data may offer only a partial understanding, but findings can motivate
further studies and tailored interventions to assist the elderly.(101)
Although there are few studies on Chinas older population, national
surveys and air pollution patterns help uncover some of the risks. The
proportion of citizens over the age of 65 is predicted to triple, from 10
per cent in 2000 to more than 30 per cent in 2050.(102) China is also
urbanizing rapidly, especially in coastal areas.(103) Inequalities are rising
and an urban underclass is emerging; older residents may be particularly
hard-hit following the loss of pensions and lifetime employment.(104)
To date, few studies have examined older residents vulnerabilities and
health concerns. Health and nutrition surveys in 1997 and 2000 suggest
that rural Chinese over the age of 55 were significantly more likely to be
disabled than their urban peers, independently of age and gender as well
as socioeconomic factors.(105) However, national surveys may undercount
the poor and, in turn, struggle to capture inequalities in rural/urban areas.
Another large-scale study of older Chinese found significant links between
health and urban air pollution. Researchers combined city-level pollution
indices with a 2002 longevity survey, which sampled 7,000 residents over
the age of 65 in 171 Chinese cities.(106) Pollution had a negative impact on
self-reported health, levels of disability and other outcomes in the elderly
(even when controlling for individual characteristics and city-level
economic activity). Unlike high-income nations, the elderly in richer
Chinese cities are more affected by air pollution than their peers in poorer
cities. These preliminary findings help link Chinas urbanization, ageing
and economic development to the associated environmental hazards. The
next section considers how illness and deprivation may combine over a
lifetime, using longitudinal data and a focus on chronic poverty.

III. ILLNESS OVER TIME: HEALTH, CHRONIC POVERTY AND


COHORT STUDIES
107. See, for instance, Pryer
(1993).

The trajectories of low-income households are often decisively shaped by


ill-health, injury and premature death.(107) Ill-health is frequently a risk

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factor for poverty, and it may prolong the duration of impoverishment.


Life history research in rural Bangladesh showed how health shocks could
prove critical in the persistence of poverty.(108) Links between ill-health
and poverty may strengthen over time, and the direction of causality can
be difficult to discern. The literature on chronic poverty recognizes the
dynamic, heterogeneous nature of deprivation, and among chronically
poor households, ill-health may be a consequence of poverty as well as a
predictive factor.(109) Researchers could continue to probe illness and chronic
poverty in cities, perhaps identifying mechanisms and pathways in these
monetized economies (for example, the influence of user fees or under-thetable payments). By following the same individuals over time, cohort
or longitudinal studies may offer important insights. Longitudinal
research can reveal cumulative health disadvantages, trace improvements
or uncover other patterns. A few longitudinal studies have traced city
dwellers in low- and middle-income nations,(110) which will be discussed
after considering chronic poverty and health. With further cohort studies
or a chronic poverty lens, analysts may untangle the relations between
entrenched poverty and ill-health. A more nuanced understanding could
emerge and inform policies to promote poverty reduction.
Studies among low-income groups in Dhaka suggest that chronic
poverty is frequently associated with a downward spiral of ill-health, lost
assets and heightened vulnerability. In a survey of more than 400 rickshaw
pullers in 2003, health-related shocks were the single most important factor
in downward mobility.(111) Respondents complained of physical weakness,
gastro-enteric problems or aches and pains, often as a result of occupational
hazards. Financial losses per health crisis typically exceeded their average
monthly household income.(112) Illness heightened workers precariousness,
forcing them to deplete assets or acquire debts. A large-scale survey in 1996
similarly found that after suffering work-disabling illnesses, 22 per cent
of slum dweller households in Dhaka declined in financial status.(113) In
any given month, as many as 3040 per cent of households in Dhakas
informal settlements lost workdays due to illness.(114) Taken together,
these findings suggest several reinforcing pathways between ill-health
and chronic poverty. Illness may promote lasting deprivation, as a result
of lost workdays, depleted savings to cover medical expenditures and/or
insufficient strength to resume working. Chronically poor households thus
experience multiple and overlapping causes of poverty.(115) Illness-related
losses can accelerate a decline into chronic poverty, yet interventions may
prevent this self-reinforcing cycle (particularly if the linkages between illhealth and chronic poverty are better understood).
Ill-health was extremely common among babies in three informal
settlements in Vellore (India) during their first year of life, as noted above
in Section II(a).(116) By tracking the cohort until age three, the investigation
illuminated several trends in childhood illness and malnutrition. By age
two, children averaged just three days and 1.6 episodes of gastrointestinal
illness, but respiratory problems remained quite common;(117) in their
second year, children averaged almost 68 days and seven episodes of
respiratory illness. In their third year, respiratory illness declined only
slightly, to 50 days and 6.6 episodes. The follow-up also exposed chronic
growth problems and inadequate nutrition in older children. A total of
68 per cent of the children were stunted, wasted and/or underweight by
the age of three, although nutritional supplements and interventions
can prevent stunting in later years.(118) Patterns again changed over time:

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108. Hulme (2004).

109. Mitlin (2005a), page 14;


also see papers in Environment
and Urbanization (2005).

110. See also Naicker et al.


(2010); Ye et al. (2009); and
Bhuiyan et al. (2009).

111. Begum and Sen (2005),


page 23.
112. See Section IV below for
further discussion of the cost
of illness.
113. Pryer, Rogers and Rahman
(2005).
114. Cited in Pryer, Rogers and
Rahman (2005).

115. Mitlin (2005b), page 8.

116. Gladstone et al. (2008).

117. Rehman et al. (2009).

118. Using WHO child growth


standards, wasting is defined
as low weight-for-height and
stunting is low height-for-age.

I L L - H E A LT H A N D P O V E R T Y

119. Menezes et al. (2005),


page 444, emphasis added.

120. Horta et al. (2008).

121. See also Moser (2004);


Ferri et al. (2007); and ScheperHughes (2004).
122. Menezes et al. (2005).

infants were more likely to be wasted and underweight in their first year,
but stunting was increasingly common by the age of two or three. Only
cohort studies can offer such detailed insights into chronic malnutrition
and shifting burdens of childhood illness.
Child mortality rates have declined in Pelotas, Brazil, but cohort
studies still found enduring income-related health inequalities. In this
city of 300,000 people, researchers followed two cohorts of babies born
in 1982 and 1993. Income remained paramount in explaining child
mortality rates: for both cohorts, the poorest groups infant mortality
ratio was more than six times as large as among children born to the
wealthiest families.(119)
Another study in Pelotas analyzed the causes of death from 1982 to
2006, again uncovering stark disparities. Low-income children had higher
mortality rates in all age brackets, with a relative risk of 2.89 between the
lowest and highest tertiles when holding race and gender constant.(120)
In discussing the cohorts 288 deaths by 2006, the study helps uncover
the shifting nature of risk over the life-course. More than 40 per cent of
deaths occurred in the peri-natal period, due to infectious and parasitic
diseases. Among under-five children, parasitic and infectious diseases
remained the leading cause of death (31 per cent of cases) and another 24
per cent died from respiratory diseases. Few deaths occurred between the
ages of five and 14, with no leading cause. External causes led to nearly
two out of three deaths among youths aged 15 to 24-years old, reflecting
the widespread risk of urban violence.(121) More positively, however, the
overall infant mortality rate did decline from 36 to 21 per 1,000 between
1982 and 1993.(122) As discussed below, these reductions seem partly
attributable to Brazils subsidized health care. Amid troubling inequalities
at all age levels, reductions in infant mortality help affirm the potential of
accessible, high-quality health care.

IV. HEALTH EXPENDITURE, QUALITY AND ACCESS TO CARE

123. Selvaraja, from the poorest


income quartile in Colombo, Sri
Lanka, quoted in Russell and
Gilson (2006), page 1738.

124. McIntyre et al. (2006),


page 862.
125. Moser (1998).
126. Moser (1998).
127. Whitehead, Dahlgren and
Evans (2001), pages 833834.
128. Whitehead, Dahlgren and
Evans (2001).

Illness is something we are all scared of here. How can we live without
working? If my husband is ill, we have to get money from somewhere
for food and for the medicine, we have to borrow. (Selvaraja)(123)
Selvaraja, who comes from poorest income quartile in Colombo, admits that
sickness is widely feared, and her household may be forced into debt during
a breadwinners illness (We have to borrow). While direct expenditure
on drugs or hospitalization can be highly burdensome, the indirect costs
of missed workdays may be even more unmanageable (How can we live
without working?). Health expenditures often comprise a larger proportion
of low-income households incomes, as compared to wealthier households,
so that costs of illness inflict a far greater burden on poor families.(124)
Low-income households may adopt various coping strategies during healthrelated crises, and they manage a portfolio of assets including social networks,
productive capital and labour.(125) Yet if savings are exhausted, or children
have to work rather than attend school, long-standing vulnerabilities may be
magnified.(126)Patients may encounter a medical poverty trap, with limited
options that only exacerbate their deprivation and ill-health.(127) The poor
may endure untreated morbidity or reduced access to care, minimizing
their expenditure but inviting future complications.(128) Alternatively, they

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may purchase medications or undergo procedures whose cost makes them


increasingly vulnerable to chronic poverty. Competent medical personnel
are rarely available in poor communities, and low-quality care may further
compromise health outcomes.
Without appropriate interventions, poverty and ill-health can
become entrenched through limited access to services, high levels of
expenditure and inadequate care. However, as discussed below, some
governments have helped break the medical poverty trap by extending
access to affordable, high-quality care. Other cities face the multipronged challenge of enhancing access, improving quality and reducing
costs. Improving immunization rates remains crucial, since vaccination
coverage in informal settlements is usually far below that in wealthier
areas.(129) Expenditure studies can provide several policy insights by
exploring how medical treatment is mediated by (direct/indirect) costs
under various health systems.(130) For many households, indirect costs of
illness are at least two to three times greater than the direct costs, and
spending more than 10 per cent of household income on health care and
treatment is usually deemed catastrophic, although lower levels may
be ruinous in the poorest households.(131) Some expenditure studies are
discussed below, including quality and access considerations, if possible.
Further studies could examine quality and its relation to cost, access and
strategies to assist low-income households, as existing research pays too
little attention to urban health care quality.(132) Integrating health care
quality, access and affordability may identify the key steps needed to
reduce medical poverty traps.
Researchers in India found stark inequalities in the cost burdens and
quality of care, which suggests several pathways towards entrenched
ill-health. Nearly 500 babies born in Lucknows public hospitals were
followed for six weeks, and analysts compared their health outcomes,
provider types and frequency of care seeking.(133) Although mortality rates
did not differ by income strata, morbidity was higher in the poorest three
quintiles compared to wealthier groups.(134) Moreover, these inequitable
outcomes were mirrored in expenditure levels and quality of care. With
poor newborns less likely to be seen by doctors, 40 per cent were treated
by private providers who often lack recognized degrees. The poorest
two quintiles spent 10.3 per cent and 6.9 per cent, respectively, of their
monthly incomes on health, while the richest two quintiles spent less
than four per cent. Notwithstanding their higher spending levels, poorer
residents were far less likely than wealthier groups to seek medical care.
In sum, multiple overlapping and regressive features of health care
were uncovered in Lucknow. Low-income households pay higher costs
relative to their earnings, but are less likely to seek treatment and usually
access lower-quality care. When combined with greater exposure to
environmental hazards, these disparities may explain poor newborns
elevated morbidity rates. Disadvantages could be recreated later in life,
since neonatal health may shape adults outcomes (although this must
be verified by following the cohort). A study in Delhi found that lowincome households were more likely to seek care than wealthier families,
yet were less likely to access high-quality providers.(135) These findings
only underscore the need for improving access to affordable, high-quality
care in disadvantaged communities.
Pregnant women in Nairobis informal settlements frequently lack
access to emergency transport or affordable, adequate maternal care.

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129. Unger et al. (2007);


also Agarwal (2011) in this
volume. Several interventions
have sought to improve
immunization rates; Ghei et al.
(2010); also Uddin et al. (2010).
130. For health expenditure
comparisons in rural and urban
areas of coastal Kenya, see
Chuma, Gilson and Molyneux
(2007).
131. McIntyre et al. (2006).
132. Montgomery (2009),
page 15.

133. Srivastava, Awasthi and


Agarwal (2009).
134. Morbidity causes
were not disaggregated
by income quintile, but the
most common were upper
respiratory infection (9.5 per
cent), diarrhoea (7 per cent),
septicaemia (6.2 per cent) and
pneumonia (5.2 per cent).

135. Das and Hammer (2007).

I L L - H E A LT H A N D P O V E R T Y

136. Ziraba et al. (2009).

137. Ziraba et al. (2009), page 7.


138. Fotso et al. (2009).

139. Barros et al. (2008).

140. The poorest two quintiles


spent an average of Rs 16.14
(US$ 5.50) and Rs 37.14 (US$
12.68), respectively, while the
richest quintile averaged Rs
123.07 (US$ 42).

141. For further discussion of


access to reproductive health
services, see Ezeh, Kodzi and
Emina (2010); also Hazarika
(2010).

142. Russell and Gilson (2006).


143. Russell and Gilson (2006),
page 1736.
144. Studies of universal, free
TB screening programmes have
similarly highlighted heavy
indirect costs for the poor;
see Kemp et al. (2007); also
Lambert et al. (2005).
145. Russell and Gilson (2006),
page 1743.

Even normal delivery costs may be excessive for those living in informal
settlements. Normal delivery fees average KSh 1,700 (US$ 23), while
caesarean deliveries range from KSh 3,000 (US$ 42) in a public district
hospital to 10 times that in a mission hospital.(136) Moreover, mothers in
two of Nairobis informal settlements often lacked access to transport,
qualified staff or emergency services. Women used 25 health facilities
altogether, but just two had comprehensive emergency obstetric care.
Of the 14 unlicensed private clinics in these settlements, none was
considered adequate and few staff could perform basic emergency
obstetric procedures. Just five facilities provided on-site transport, so
that women usually walk even in emergencies and mothers resort to
using facilities near to them irrespective of their quality.(137) Another study
underscored the low-quality care and uncovered inequalities within the
two settlements.(138) Although 70 per cent of mothers in the settlements
delivered in a health facility, just 48 per cent had a skilled attendant. But
compared to the poorest mothers, the wealthiest women were more than
twice as likely to deliver at a health facility and 45 per cent more likely to
deliver at appropriate health facilities.
However, Brazils experience indicates that high-quality maternal
services can be accessible to low-income groups. The Pelotas birth cohort
again provides insights, by exploring womens utilization of the Unified
Health System (SUS). Begun in 1988, this provides full maternal care from
antenatal to post-delivery through a decentralized mix of providers.(139)
Data on expenditure and providers were collected from nearly 4,000
mothers in Pelotas, who were interviewed three months after giving
birth. Expenditures were progressive, since the richest mothers spent
nearly eight times as much as the poorest.(140) The unified health system
financed 80 per cent of the deliveries, although utilization peaked in the
poorest households (it was used by 98 per cent of mothers in the first
income quintile, 95 per cent in the second and 90 per cent in the third).
The proportion dropped to 75 per cent in the fourth quintile and onethird in the richest quintile, but findings suggest that the programme was
still widely utilized and well-regarded. Appealing to mothers across the
income spectrum, the programme also sets a notable precedent in highquality public care.(141)
Access to health care is widespread in Sri Lanka, services are wellregarded and levels of direct expenditure are low in deprived communities.
Under Sri Lankas public health care provision, the state provides access
to tertiary hospitals and local municipal dispensaries (where GPs offer
free consultations). Of 400 households surveyed in two low-income
Colombo settlements, 77 per cent spent less than five per cent of their
monthly income on health, and mean costs did not vary significantly
between income quartiles.(142) Even for patients with chronic disease,
just three per cent had monthly burdens that exceeded 10 per cent of
household income. These encouraging findings were complemented by
life histories, which explored how illness and poverty may interact even
under progressive health systems. For patients in the poorest quartile,
expenses usually triggered coping strategies that pushed them deeper into
poverty.(143) Transport costs, missed workdays and other indirect costs
often resulted in a downward spiral.(144) Yet there were several factors
in households declines, such as drink and other drug problems, earlier
shocks, the loss of land [or] broken relationships.(145) Findings suggest a
need to address indirect costs, overcome past shocks and bolster assets.

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E N V I R O N M E N T & U R B A N I Z AT I O N

Vol 23 No 1 April 2011

Nevertheless, Sri Lanka has demonstrated that governments can reduce


direct costs by extending access to high-quality services. The next section
considers unintentional injuries, which may trigger major expenditures
or indirect losses if a breadwinner cannot work.

V. UNINTENTIONAL INJURIES OVER THE LIFE-COURSE


Injuries have been termed a neglected epidemic, resulting in more
than five million deaths globally every year and equalling the combined
fatalities from HIV, malaria and TB.(146) Road traffic injuries (RTIs) are
already a major cause of morbidity and mortality in low- and middleincome nations, where their burden may only increase.(147) In addition
to traffic accidents, other unintentional injuries are common in informal
settlements, mainly due to the physical hazards concentrated there. For
instance, residents can be easily injured as a result of open fires...flimsy
construction, lack of safe storage for chemicals and poisons, [and] piles of
debris...(148) With inadequate access to emergency care, injured residents
are likely to suffer serious complications. The word accident may
connote unpredictability or inevitability, but accidents are actually highly
patterned and injury prevention can be extremely effective.
Yet even in low-income communities, injury patterns are complex
and heterogeneous. The type and severity of injury are influenced by age,
gender, road safety and other household- or city-level factors. A life-course
perspective can help uncover some of these regularities. Among youths
under the age of 18, there are 830,000 injury-related fatalities each year.(149)
Later in life, the elderly are prone to falls and other injuries. Mainstreaming
injury prevention can still combat this neglected epidemic, while
community-based research can illuminate the diverse patterns.(150)
Faulty assumptions and data gaps have obscured the impact of
injuries in informal settlements. Injuries have often been a neglected
public health concern, with accidents being perceived as unavoidable
or a chance occurrence.(151) Multi-sectoral prevention campaigns were
belatedly launched in high-income nations, yet impressive gains were
quickly recorded. In the past 30 years, child injury deaths have been
reduced by up to 50 per cent.(152) But in low- and middle-income nations,
prevention programmes are rare, and funding is limited (partly because
donors prioritize other health threats(153)). Few countries have surveillance
programmes, and data on hospital admissions or fatalities may undercount
low-income households who cannot access such facilities. Moreover,
for every injury-related fatality, 1050 times as many may survive with
permanent disability.(154) Consequences are frequently more severe in lowincome households, much as direct and indirect costs of illness weigh
more heavily on these groups. Injuries may similarly promote lasting
impoverishment, and disability can be devastating in settlements without
adequate trauma care, welfare provision and rehabilitative services.(155) Yet
many urban policy makers ignore injury-related fatalities and morbidity,
because of under-reporting, competing health priorities and viewing
accidents as unavoidable.
A large community-based study in Lima helps explore the range and
prevalence of risks, although only childrens injuries were recorded. In
the peripheral settlement of San Juan de Miraflores, households reported
lifetime injuries for 10,210 children up to the age of 18.(156) Findings

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146. Gosselin et al. (2009),


page 246.
147. Mathers and Loncar (2006).

148. Bartlett (2002b), page 1.

149. Harvey et al. (2009).


150. See Section VII for further
discussion of RTI trends, and
see Section II on occupational
health and injuries. This section
does not consider violent
injuries; see Environment and
Urbanization (2004); also Moser
and McIlwaine (2004); and
Seedat et al. (2009).
151. Bartlett (2002b).
152. Harvey et al. (2009).
153. For a critique of the
meagre budgetary allocations
for injuries by the PanAmerican Health Organization,
see Fraade-Blanar, ConchaEastman and Baker (2007).
154. Gosselin et al. (2009).

155. Gosselin et al. (2009).

156. Donroe et al. (2009).

I L L - H E A LT H A N D P O V E R T Y

157. Hyder et al. (2008).

158. Poudel-Tandukar et al.


(2006).

159. Burrows et al. (2010).

included 1,046 falls, 135 poisonings, 286 burns and 401 RTIs, with more
than 70 per cent of the 1,868 injuries considered serious. Excluding the
111 victims with multiple injuries, as many as 1,757 out of the 10,210
children (17 per cent) had a lifetime injury. Boys were more likely than girls
to be injured (odds-ratio of 1.6), in keeping with past studies. Households
with one injured child were at increased risk, suggesting the need for an
integrated approach to prevention. About 55 per cent of the households
lived in poverty, and injuries displayed some interesting differences by
socioeconomic status. In this study, poorer children were at greater risk
of burns, pedestrian RTIs and multiple injuries, yet poverty was not a risk
factor in falls or poisonings. Children in larger households were actually less
likely to fall, perhaps because watchful older siblings helped prevent these
accidents. Moreover, patterns of risk shifted over the life-course, as RTIs
were increasingly common after the age of five. In sum, childrens injuries
were a widespread problem influenced not only by poverty but also by
gender, household characteristics, settlement hazards and life-course stage.
Children in South Asia seem prone to other accidents, such as
drowning and cuts, and the regions injury burden may far exceed
some previous estimates. In Bangladesh, perhaps 2025 per cent of all
childhood deaths are from drowning.(157) This systematic review examined
South Asias unintentional injuries in under-five children, but findings
diverged widely. Studies from 1980 to 2007, mostly in Bangladesh and
India, suggested that injuries annually cause between 161,000 and
586,000 childhood deaths. The review found that the weighted mean was
284,000 deaths, or triple the estimated 94,000 fatalities in the 2002 Global
Burden of Disease study. Figures do not distinguish between rural/urban
populations, yet injuries are clearly a major concern in South Asian cities.
In Kathmandu, more than 200 deprived youths aged 1017 were
asked what their most serious injuries had been over the past year.(158)
Responses indicated the widespread occurrence of injury, as well as
the range of risks. The most common injuries were falls (59 per cent),
transport-related accidents (50 per cent), cuts (44 per cent) and burns
(16 per cent). Adolescents aged 1417 years were slightly more likely to
experience cuts and burns than children aged 1013. Transport accidents
usually involved pedestrians, as in other low-income settings, and victims
were more likely to be male (65 per cent of boys vs. 38 per cent of girls
reported traffic injuries). Further studies could clarify the regional burden
of injury and identify cities particular risks.
A study in South Africa found that injury patterns not only differed
according to a childs gender, race or age, but also by city. Based on six
cities surveillance data between 2001 and 2003, there were 2,923 fatal
injuries in children aged 014.(159) The three leading causes of death
were pedestrian injuries, drowning and burns, in all cities except Cape
Town. Although income data were not recorded, race can offer a proxy
for socioeconomic status, and highlight major inequalities. Black Africans
represented 65 per cent of the population in the 2001 census, but black
African children comprised 77 per cent of the victims of fatal injuries. For
some causes of injury, racial differences were especially profound. The
rate of fatal burns for black African and coloured children reached 4.5 and
2.7 per 100,000, respectively, but just 0.3 and 1.2 for whites and Asians.
For pedestrian road injuries, the mortality rate was 0.7 per 100,000 white
children as against 7.9 for coloured and 9.4 for black African children. Boys
had significantly higher rates of drowning and pedestrian RTIs (although

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E N V I R O N M E N T & U R B A N I Z AT I O N

gender was not a risk factor for passenger RTIs). The broader urban setting
also influenced injury patterns, and cities ranged widely in road safety.
Pedestrian fatalities in Tshwane (Pretoria) were far less common than in
eThekwini (Durban) or Nelson Mandela (Port Elizabeth).(160) Given the
influence of urban context and socioeconomic factors, injury prevention
campaigns must be informed by disaggregated micro- and meso-level data.
Older peoples falls are a major cause of morbidity and mortality as
well as a significant economic burden, but research is scarce in low-income
settings. Worldwide, injury is the fifth-leading cause of death in elderly
people and these fatalities are usually due to falls.(161) Falls also result in
extensive disability and functional impairment, comprising more than
80 per cent of injury-related hospital admissions in people over 65. This
review on preventing elderly peoples falls, while helpful, largely utilizes
data from high-income nations.
In Beijing, a survey of 1,500 residents over the age of 60 yielded
findings about falls and their steep costs. A total of 379 falls occurred in 272
individuals over the previous year, or a frequency of 18 per cent.(162) Women
and older respondents were at greater risk but it seems that most falls were
not severe. Just 143 resulted in injuries (38 per cent) and there were only
16 hospitalizations. Nevertheless, the economic burden of hospitalization
was very high; hip fractures cost more than twice the average annual
income in Beijing. Even for falls without fractures, households must make
heavy expenditure on drugs, hospitalization, etc. A 2001 study suggests
that 25 million falls occur annually among 20 million elderly people in
China, and the direct medical costs reach five billion Yuan.(163)

Vol 23 No 1 April 2011

160. Tshwanes rate of fatal


pedestrian RTIs was 2.5 per
100,000 children, but rates
climbed to 9.4 in eThekwini and
10.0 in Nelson Mandela.

161. Kannus et al. (2005).

162. Yu et al. (2009).

163. Cited in Yu et al. (2009).

VI. URBAN PENALTY


It is widely believed that urban dwellers in low- and middle-income nations
benefit from urban bias in the policies of governments and international
agencies, but the evidence is limited.(164) Low-income urban households
may enjoy few benefits if governments are unable or unwilling to provide
infrastructure and services, or fail to promote environmental health and
access to health care. On average, urban areas have lower child mortality
rates, better access to care and better nutrition compared to rural areas.(165)
But health averages are misleading, since wealthier residents outcomes
inevitably boost average figures for urban populations or particular cities.
In many nations, affluence is often the dominant factor in shaping rural
and urban health outcomes.(166) In nineteenth-century European and
American cities, infant and child mortality rates often exceeded those
of rural areas (creating a so-called urban penalty). Infant and child
mortality subsequently declined as a result of improved housing as well
as immunization campaigns, sanitary interventions and reductions in
malnutrition.(167) Yet achieving this urban advantage in health depends
strongly upon essential services and health-related infrastructure which
unaccountable or incapable governments rarely provide in informal
settlements.(168)
Research increasingly suggests that a high proportion of low-income
urban households have little or no advantage over their rural counterparts,
sometimes even suffering an urban penalty. Over the past 30 years,
studies have uncovered informal settlements elevated levels of infant
and child mortality, or the high prevalence of underweight or stunted

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164. Hardoy and Satterthwaite


(1989); also Wratten (1995); and
Satterthwaite (2007).

165. Harpham (2009).

166. McGranahan (2007).


167. See Garenne (2010),
page 465 for further historical
discussion and comparisons
of past and present-day urban
child mortality rates.
168. It is therefore critical to
distinguish between availability,
proximity and accessibility of
health services in urban areas.
Low-income communities are
frequently denied access to
high-quality health care, even
if it is nearby; see
Satterthwaite (2007).

I L L - H E A LT H A N D P O V E R T Y

169. Dye (2008), page 768.


170. Dye (2008).

171. See also Ronsmans et al.


(2009); and Gupta, Thakur and
Kumar (2008).

172. APHRC (2002).

173. van de Poel, ODonnell and


Van Doorslaer (2007).
174. van de Poel, ODonnell and
Van Doorslaer (2007), page 2000.

175. Matthews et al. (2010).

176. Matthews et al. (2010),


page 6.

177. Kennedy, Nantel, Brouwer


and Kok (2006).

178. Kennedy, Nantel, Brouwer


and Kok (2006), page 187.

children in urban areas of low- and middle-income nations. Indeed,


no investigation has yet shown that the health benefits of urban living generally
outweigh the health risks,(169) and comparisons should not obscure the
broader aim of improved well-being, regardless of citizens income or
location.(170) Examining rural/urban outcomes can highlight the urban
poors particular needs but should not detract attention from the rural
poors specific concerns. Careful comparisons may spur more appropriate
policies, thereby advancing health equity in cities and rural areas alike. The
studies reviewed in this section highlight the importance of disaggregated
socioeconomic data, which reveal intra-urban health differentials and the
heterogeneous outcomes even within informal settlements.(171)
A study in 1998 by the African Population and Health Research Centre
found that child health outcomes in Nairobis informal settlements were
far worse than Kenyas rural and urban averages. Infant mortality rates in
informal settlements averaged 91 per 1,000, as against 74 nationwide, 76 in
rural areas and 39 in Nairobi overall.(172) The average under-five mortality
rate in informal settlements was 150 per 1,000, while Nairobis average
was just 62 per 1,000 and the national and rural rates were 113 per 1,000.
Child health also differed widely between Nairobis informal settlements,
and under-five mortality rates peaked in Embakasi and Westlands, at
254 per 1,000 and 195 per 1,000, births, respectively. Moreover, child
mortality rates in informal settlements are rising due to HIV, insanitary
conditions, deepening income insecurity and poor governance (itself a key
factor in inadequate sanitation or health outcomes). Studies in informal
settlements subsequently uncovered residents lower access to maternal
care, as discussed earlier. These findings exposed sharp inequities in
maternal and child health, which aggregate urban statistics would miss.
Demographic and Health Surveys (DHS) examine health burdens in
low- and middle-income nations, and studies utilizing DHS data have
found little urban advantage in health. Drawing on DHS data from 47
low- and middle-income countries, urban areas lower child mortality
rates and improved nutrition largely vanished after researchers controlled
for wealth, education and other socioeconomic factors.(173) An urban
child health advantage was only identified in a little more than onethird of the countries studied.(174) In 30 out of 47 countries, under-five
mortality rates did not differ significantly between the poor in rural and
urban areas. In a true urban penalty, the urban poor in nine countries
had higher mortality rates than the rural poor. Another study used DHS
data on maternal-newborn services in 30 nations and identified several
typologies of care.(175) Low-income urban mothers were usually profoundly
disadvantaged compared to wealthier households. A few nations have
universal access to maternal care, benefiting low-income households and,
given political will, this can be done in countries with low GDP.(176) But
when political will is lacking, poor households in rural and urban areas
frequently suffer comparable levels of health disadvantage.
A study of disparities in childhood nutritional status in Angola,
Central African Republic and Senegal found that when using a simple
urban/rural comparison, the prevalence of stunting was significantly
higher in rural areas.(177) But when the urban and rural populations were
stratified using a measure of wealth, the differences in prevalence of
stunting and underweight in urban and rural areas disappeared. Poor
children in these urban areas were just as likely to be stunted or underweight as
poor children living in rural areas.(178)

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E N V I R O N M E N T & U R B A N I Z AT I O N

Regional analyses of DHS data confirm the overwhelming importance of


socioeconomic factors, though puzzling results may require more extensive
data collection and analysis. A study in Latin America found that some
countries experience an urban health penalty or record minimal differences
between low-income rural and urban households.(179) Although Bolivias rural
poor had higher child mortality rates than the urban poor, the prevalence
of chronic malnutrition was nearly identical. In Brazil, Colombia, the
Dominican Republic and Paraguay, rates of infant and child mortality
were higher among the urban poor than among the rural poor. DHS data
on childhood stunting in 15 sub-Saharan African nations underscore the
role of socioeconomic factors. The urban advantage in child health
evaporates in all countries except Malawi once the SES [socioeconomic status]
of families and communities are accounted for.(180) Thus, levels of affluence
have overwhelmingly explained the rural/urban variation in DHS data.
But sample sizes are too small to allow much disaggregation within urban
populations, and it remains unclear why some countries exhibit an urban
penalty and other countries do not.(181) Patterns may be heterogeneous
between informal settlements, as noted above in Nairobi.(182) Indeed, a
nations urban advantage may vary between different urban centres and
between districts within cities.(183) Addressing ill-health in poor urban (and
rural) communities needs a more detailed information base than that
provided by the DHS and other surveys with nationally-representative
samples.

Vol 23 No 1 April 2011

179. Bitrn et al. (2005). The


urban and rural poor were
defined as the bottom 40 per
cent on an asset index.

180. Fotso (2007), page 221.

181. Bitrn et al. (2005)


page 186.
182. APHRC (2002).
183. Satterthwaite (2007),
page 53.

VII. EMERGING URBAN HEALTH RISKS AND INEQUALITIES


Due to emerging risks, urban health inequalities may assume new forms while
being reproduced on a larger scale. Outcomes are difficult to predict, but climate
change and conditions often given inadequate attention will likely exacerbate
ill-health in disadvantaged communities. For instance, low-income households
are increasingly at risk of non-communicable diseases (NCDs), which were once
assumed to be associated with affluence.(184) Road traffic injuries (RTIs) are
another escalating cause of morbidity and mortality in many nations and
pose particular risks to young city dwellers, as noted above.(185) Yet a high
proportion of low-income urban households remain at heightened risk of
communicable diseases and the resulting double burden may further
entrench inequalities. In perhaps the gravest emerging threat, climate
change is likely to have a range of negative impacts, and high-density
urban informal settlements with inadequate housing have been identified
as being particularly at risk.(186) Within these settlements, climate-related
risks may disproportionately affect vulnerable groups such as children
and the elderly.(187) The following part (a) will discuss NCDs and other
emerging issues, while part (b) will focus on climate change; however,
both sections urge cross-cutting, integrated interventions that may reduce
new risks.(188)

a. Urbanization, NCDs, injuries and ageing


Crossing geographic, age and class boundaries, NCDs display a marked
temporal and socioeconomic patterning. They are frequently associated with
sedentary lifestyles and diets high in fat, sugars or processed foods.(189) Many

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184. Chronic or noncommunicable disease is


a root term that includes
specific diseases such as
cardiovascular disease, obesity
and diabetes (Allender et al.
(2008), page 940).
185. Mathers and Loncar (2006).
186. Confalonieri et al. (2007);
also Satterthwaite et al. (2007).
187. Bartlett (2008).

188. Due to space constraints


this section cannot consider
mental health interventions,
in detail, which are only
beginning to be studied
in low-income settings
(Montgomery (2009), page 10).
189. Popkin (1999).

I L L - H E A LT H A N D P O V E R T Y

190. Prentice (2006), page 93.


191. Allender et al. (2008),
page 939.

192. Groeneveld, Solomons and


Doak (2007).

193. Fleischer et al. (2008).


194. Hill et al. (2007).

195. Studying ruralurban


migration can also probe
dietary changes, new activity
patterns and emerging NCDs;
see Torun et al. (2002); also
Ebrahim et al. (2010).
196. McGranahan (2007),
page 7.
197. The Chris Hani
Baragwanath Hospital is the
only provider of specialist
cardiac services for Soweto,
and its caseload represents
a barometer of the underlying
spectrum of cardiovascular
disease (Stewart et al.
(2008), page 2361).
198. Stewart et al. (2008).
199. Das et al. (2007).

200. Das et al. (2007).

urban residents are less physically active than rural households but more
likely to consume such foods, in turn suffering higher rates of hypertension,
stroke, obesity, etc. Thus, NCDs initially occur among urban middle-aged
adults, but increasingly [affect] semi-urban and rural areas and younger age
groups.(190) One estimate suggests that by 2020, NCDs may comprise 69
per cent of all deaths in low- and middle-income countries, and most
victims will be relatively young [and] of lower socioeconomic status.(191)
Quality of life is often impaired, and in impoverished households the
long-term costs of chronic disease may prove particularly burdensome.
Yet changes are still incipient in many cities, so that outreach and other
interventions could help to minimize the impacts of NCD. With careful
planning and age-sensitive strategies, policy makers may also curtail the
projected increase in RTIs and vulnerabilities among the elderly.
Since NCDs arise gradually and unevenly at the household and city
levels, studies may not find clear associations between urbanization,
poverty and NCDs. In Quetzaltenango, a Guatemalan city of 100,000
people, wealthier children are still at higher risk of obesity.(192) This survey
of 600 children aged from eight to 10 compared outcomes by public and
private school attendance, as a proxy for socioeconomic status (SES).
Nearly one-third of wealthier students were overweight or obese, as against
just 12.9 per cent of their low SES peers. Better-off children were thus more
than twice as likely to be overweight, while stunting was nearly four times
more common among poorer students (27 per cent of low SES children
vs. 7.3 per cent of high SES children were stunted). Nor were NCDs in
Buenos Aires consistently linked with socioeconomic status according to
a risk survey of 1,500 residents. Low-income respondents were more likely
to report hypertension, but not diabetes.(193) In a community-based survey
of 1,300 women in Accra, chronic and communicable conditions were
widespread, but low-income respondents were not at greater risk.(194) By
continuing to explore the dynamic relations between NCDs and urban
poverty, research may pinpoint priorities for intervention in low-income
settlements.(195)
However, data shortfalls and limited awareness of NCDs may
conceal the magnitude of todays problems, underscoring the need for
enhanced surveillance and outreach. Chronic conditions in low-income
households are often neglected, as the formal health system records only
the complications or outcomes that require their intervention.(196) Prospective
surveys have already yielded sobering results. In Soweto, Johannesburg,
risks of heart disease were widespread among 850 individuals seeking
care in a local hospitals cardiology unit.(197) As many as 60 per cent of
respondents had hypertension, 47 per cent smoked and 34 per cent were
obese.(198) Long-term residents, particularly black African women (52 per
cent of the cohort), were at elevated risk of cardiovascular disease. Another
prospective study followed 50,000 Kolkata residents between 2003 and
2005 to assess stroke outcomes. Comparable to wealthier regions, the agestandardized incidence was 145 strokes per 100,000 persons per year.(199)
The overall 30-day stroke fatality rate was 41 per cent, exceeding highincome nations average rates of 1733 per cent. In informal settlements, the
stroke fatality rate was 31 per cent as against 44 per cent in non-slum areas.
But lower fatalities in informal settlements are highly unlikely, and these
findings suggest improper reporting procedures or mis-attribution.(200) Better
surveillance and reporting are crucial to ascertain the risks and, in turn, to
forge an appropriate response in these communities.

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E N V I R O N M E N T & U R B A N I Z AT I O N

NCDs often result in heavy expenditure and difficult trade-offs


in low-income households, as these extended illnesses may become
unsupportable. Diabetes is already on the rise among poorer groups, and
by 2030, 75 per cent of the worlds 330 million diabetics will live in lowerincome nations.(201) Qualitative research explored the precariousness of
low-income diabetics in Dar es Salaam, where high costs, a double burden
of disease and conflicting priorities often disrupted treatment regimens.
For instance, a middle-aged diabetic would forego insulin so that she could
purchase her daughters TB medicine.(202) A survey of diabetics in Chennai
(formerly Madras) again uncovered extreme measures to cope with
heavy costs. Diabetics annual median treatment costs reached Rs 25,391
(US$ 525), with 51 per cent on hospital admissions and 34 per cent devoted
to drugs and monitoring.(203) Although 28 per cent of diabetics in the lowestincome tertile drew upon their savings, 60 per cent needed loans or sold/
mortgaged their properties to pay for care.(204) Debts, hospitalization fees
or ongoing treatment costs may only entrench households disadvantages,
especially in the context of a double burden. Affordable treatment, vigorous
prevention campaigns and lifestyle changes are critical to avoid escalating
NCD rates in low-income settlements.
With increased congestion on unsafe and poorly-maintained roads,
injuries and deaths from road traffic may escalate. Worldwide, about 1.2
million people die annually in traffic accidents and another 50 million
are injured, usually in poorer regions.(205) The significance of road traffic
injuries in informal settlements has been mentioned above (such as in
Lima and Nairobi). By 2030, the annual fatalities from road accidents
could nearly double and may rank in the top 10 causes of mortality and
morbidity in lower-income nations.(206) Emergency centres and trauma
programmes must be improved, since existing facilities already struggle
to cope.(207) The most vulnerable groups in these countries include young
residents and pedestrians, cyclists and motorcyclists, rather than motor
vehicle passengers or drivers. In 2004, 14 per cent of male adolescent and
five per cent of female adolescent deaths were due to RTIs.(208)
Enhanced road safety and other injury prevention strategies are crucial
in informal settlements, which could complement several interventions.
Reducing the risk of burns from fire, for instance, may simultaneously
enhance indoor air quality, and injury prevention and programmes to
improve environmental quality could be natural partners.(209) Although
high-income nations have pioneered measures to reduce vehicle speeds
and require seat-belts, these may not be directly transferable to informal
settlements. New approaches are needed, such as supporting safe play
spaces or adequate child care.(210) Mainstreaming injury prevention is vital
not only for child health but also for adolescents at heightened risk of
RTIs, adults exposed to occupational hazards, and elderly residents prone
to falls. Campaigns to prevent injuries could thereby promote safety at all
ages, enhance environmental quality and catalyze change across several
domains of life in informal settlements.
Mental health issues in informal settlements or associated with
inadequate incomes have also received too little attention.(211) Although their
importance has been highlighted for a number of years,(212) needed health
interventions are only beginning to be studied in low-income settings.(213)
More generally, age-sensitive research and interventions are needed to
respond to cities unfolding demographic changes. Urbanizing areas will
be home to ever-larger numbers of older people, with policy ramifications

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Vol 23 No 1 April 2011

201. Boutayeb (2006).

202. Kolling, Winkley and von


Deden (2010).

203. Tharkar et al. (2010).


204. By contrast, more than
80 per cent of high-income
diabetics used savings and just
6 per cent needed a loan or
sold/mortgaged assets (Tharkar
et al. (2010)).

205. Peden et al. (2004).

206. Mathers and Loncar


(2006).
207. Gosselin et al. (2009).

208. Patton et al. (2009).

209. Harvey et al. (2009),


page 394.

210. Bartlett (2002b).


211. See Izutsu et al. (2006).
212. See, for instance, Harpham
and Blue (1995); also Blue (1996);
and Montgomery et al. (2003).

213. Montgomery (2009). For


some discussion of relevant
issues, see WHO (2008); also
De Silva, Huttly, Harpham and
Kenward (2007); Lund et al.
(2010); Prince et al. (2007); Patel
and Kleinman (2003); and Parkar,
Fernandes and Weiss (2003).

I L L - H E A LT H A N D P O V E R T Y
214. Guzman and Saad (2008),
page 261.
215. Montgomery et al. (2003).

216. Bartlett (1999), page 72.


217. For further
recommendations, see
Guzman and Saad (2008).

that cannot be overstated.(214) Transitions in age structures will be


accelerated by declining fertility levels in urban areas.(215) Health and
other policy implications must be analyzed on a regional and city-level
basis, including the effects on working-age populations and children.
Childrens needs have to be mainstreamed into the processes that affect
community change, much as gender has been incorporated into
settlement planning.(216) So, too, should elderly peoples needs be granted
thoroughgoing consideration in health planning.(217) As discussed below,
climate change may exacerbate several health risks to which younger and
older people are especially vulnerable. Analyzing age-specific needs, as
well as commonalities and links between household members, may help
to advance more appropriate strategies.

b. Climate change, informal settlements, cities and health


218. Costello et al. (2009),
pages 1693 and 1709.

219. Kovats and Akhtar (2008).


220 Satterthwaite et al. (2007);
also Satterthwaite (2009).

221. Huq et al. (2007), page 8.

222. ONeill et al. (2009).

223. Costello et al. (2009).

224. Hajat et al. (2005).

225. Confalonieri et al. (2007).

226. WHO (2009).

Called the twenty-first centurys biggest global health threat, climate


change may affect an unusually wide range of health outcomes.(218) Possible
impacts include heightened vulnerabilities to disaster, altered communicable
disease patterns, or water and food insecurity. Health impacts are often
overlooked in sectoral climate change assessments, and additional research
is needed to inform responses and promote resilience.(219) Moreover, these
threats are extremely inequitable, since the most at-risk populations
generated only minimal emissions.(220) Low- and middle-income nations
will likely bear the brunt of climate-related impacts; within these
countries, residents of informal settlements may be among those who
are particularly at risk as they have far less scope to reduce the risks, and
many live in the areas most at risk.(221)
Heatwave fatalities show the risks of rising temperatures, and
vulnerable and low-income groups within low- and middle-income
nations may suffer disproportionately. The urban heat island (UHI)
effect can increase temperatures by 15 C above nearby rural areas and/or
raise night-time temperatures by several degrees above surrounding rural
areas.(222) Risks will increase as climate change amplifies the UHI effect,
and vulnerable groups include the elderly, pregnant women and children.
Mortality rates have risen sharply in European heatwaves, including
perhaps 70,000 excess deaths in the summer of 2003.(223) Although data
are sparse in lower-income regions, one study compared heatwave deaths
in Delhi, So Paulo and London between 1991 and 1994. The cities
diverged in age structures and severity of risk, with Delhi recording higher
mortality rates and children overwhelmingly affected.(224) Almost half of
Delhis fatalities occurred among children under the age of 15, usually as
a result of waterborne or other communicable diseases. But in So Paulo
and London, residents over the age of 65 comprised 48 per cent and 80 per
cent of deaths, respectively, and more than 50 per cent of all fatalities were
due to cardio-respiratory causes. Adapting to heatwaves requires several
strategies, ranging from modifying the built environment to improving
housing and building standards.(225) And during heatwaves, children, the
elderly and other vulnerable populations will need particular attention.
Climate change may also promote morbidity and mortality due to NCDs,
by affecting pre-existing conditions, air quality, mental health and occupational
safety. A recent report explores effects on mental health, such as increased stress
or emotional trauma due to heat, extreme events, etc.(226) Chronic conditions

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E N V I R O N M E N T & U R B A N I Z AT I O N

may be aggravated by other climate-related effects. For example, air


pollution and higher temperatures frequently interact to exacerbate
chronic respiratory and cardiovascular problems, and heatwaves
may trigger hospitalizations for acute renal failure and other kidney
disease.(227) In addition, heatstroke and heat stress are occupational
hazards that can lead to fatalities or chronic ill-health in both outdoor
and indoor workers.(228) Further research is needed to clarify the
effects and pathways between climate change, NCDs and low-income
communities.
Residents of informal settlements may face particular challenges in
coping with floods or other extreme events. Climate change is likely to
exacerbate the risk of flooding due to higher-intensity or more frequent
storms, rising sea levels and more intense precipitation.(229) Low Elevation
Coastal Zones (LECZs) often concentrate large urban populations, and
with informal settlements often in low-lying or hazardous areas they
are especially susceptible to floods, landslides, and other climate-related
disasters.(230) For instance, a Mumbai cyclone caused 94 centimetres of rain
in a single day in July 2005 and killed more than 1,000 people, most of
whom resided in informal settlements.(231) Rising sea levels heighten the risk
of floods, stronger storms compound the risk, and precarious settlements
on floodplains are highly vulnerable.(232) As extreme events become
more frequent and intense, households resilience could steadily decline
from the combined effects of repeated losses, injuries, mental distress or
communicable disease.
Urban policy makers must also respond to a broad spectrum of negative
synergies between climate change, poverty and health. Mechanisms are
complicated and contextually specific, while the impacts of climate
change may range from the quite direct [for example, ill-health from heat
exposure] to the extremely indirect...(233) Climate change will likely increase
food and water insecurity, and the urban poor may be disproportionately
affected given their sensitivity to rising prices of essential goods. Rainfall
may increase in some regions but decrease elsewhere, and even gradual
changes in water availability may be linked to thresholds at which
the resilience of human systems switches from adequate to inadequate.(234)
Heightened water insecurity will have serious ramifications upon health
and on already strained urban water supply systems.(235) Food insecurity
and childhood malnutrition may be exacerbated by reduced rainfall,
other climate-related impacts on agriculture or interrupted supplies
during extreme events.(236) WHO estimates suggest that due to climate
change, the burden of diarrhoeal disease may rise 25 per cent by 2020
in low-income nations.(237)
Infectious disease may be promoted by warmer temperatures, increased
humidity, changing rainfall or extreme weather events.(238) For instance,
dengue fever is a mosquito-borne virus often associated with climate
change and urbanization.(239) It results in 50100 million cases annually,
including 500,000 hospitalizations and 22,000 fatalities in children.(240)
Poor urban communities are especially vulnerable, as dengue thrives in
areas lacking provision for water, solid waste or vector control. Climate
change may promote less well-known conditions such as leptospirosis, a
potentially fatal rodent-borne illness associated with poor environments,
urbanization and flooding.(241) Malarias geographical reach may increase,
and transmission seasons in affected areas may lengthen due to climate
change.(242)

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Vol 23 No 1 April 2011

227. Kjellstrom et al. (2010).


228. Confalonieri et al. (2007),
page 405.

229. IFRC (2010); also Wilbanks


et al. (2007).
230. Confalonieri et al. (2007),
page 372.
231. De Sherbinin, Schiller and
Pulsipher (2007). Although
climate change cannot be
linked to particular events, the
scale of recent devastation
indicates cities vulnerability to
extreme weather events
(Huq et al. (2007)).
232. McGranahan, Balk and
Anderson (2007).
233. McGranahan (2007), page 25.
234. Wilbanks et al. (2007),
page 365.
235. Kovats and Akhtar (2008);
also Muller (2007).
236. Bartlett (2008).
237. Confalonieri et al. (2007).
238. Confalonieri et al. (2007).
239. Barclay (2008).
240. Morens and Fauci (2008).
241. In Brazilian cities, the
incidence of leptospirosis is
10,000 severe cases per year
(Reis et al. (2008b), page 2). A
study in Salvador found that
poorer residents of informal
settlements were at greatest
risk of leptospirosis, perhaps
due to inadequate sanitation
and hygiene practices (Reis
et al. (2008b), page 8).
242. Confalonieri et al. (2007).
The projected increase in
malaria cases is disputed,
but by 2080 perhaps 260320
million more people may be
affected (cited in Costello et
al. (2009), page 1703). For an
annotated bibliography of urban
malaria articles for 20082009,
see http://urbanhealthupdates.
wordpress.com/2009/03/17/
urban-malaria-annotatedbibliography-jan-2008-feb-2009/.

I L L - H E A LT H A N D P O V E R T Y
243. See, for instance, Hardoy
and Pandiella (2009) for
Latin America, and Adelekan
(2010) for Lagos. For further
discussion of urban adaptation
that addresses the needs of
those in informal settlements,
see Satterthwaite, Dodman
and Bicknell (2009); also
Satterthwaite et al. (2007).
244. Bartlett (2008), page 31.

Climate change adaptation thus needs full integration into


development strategies and provision for disaster risk reduction. Lowincome groups may require special assistance, although communities
are already adapting to climate-related risks and much can be learned
from these efforts.(243) For their part, local governments must prioritize
vulnerable groups and incorporate sensitivity to age, gender and other
axes of difference. Environmental health has always demanded an
integrated approach, since risk factors generally exist in clusters and
problems are seldom faced one at a time.(244) When facing the wideranging risks of climate change, a swift and multi-sectoral response is
the only way forward. Climate change may finally catalyze initiatives to
create healthier, more resilient cities for poor and rich, old and young.

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