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7 Mortality and Morbidity: Is City Life Good for Your Health? What is it that is distinctive about urban health? Health is both an outcome and a determinant of economic development and in this way must be associated with urbanization. But when considering health in cities and rural villages, can one identify a distinctive urban health profile, or are the urban/rural differences less a matter of kind than of degree? In what ways are the concepts of urban diversity and social-spatial proximity reflected in health? The concept of an epidemiological or health transition provides a starting point for discussion of these questions. This transition is expressed in a shift from a situation in which communicable diseases are the primary causes of morbidity and mortality to one in which noncommunicable diseases predominate. As will be shown, the health transition is well under way in some cities, especially in the developing countries that have relatively high levels of income per capita. As the transition proceeds, urban populations will experience relatively more chronic disease, including cancers and heart disease; mental health will also be of growing concern. In many and perhaps most cities, however, the health transition is still in its early stages, and these cities will continue to grapple with communicable diseases for the foreseeable future. In addition to such long-standing challenges to health, some cities will face grave threats from new diseases (e.g., HIV/AIDS) and diseases that are reemerging with heightened virulence or resistance (e.g., tuberculosis). The spatial proximity of urban residents and their reliance on common public resources leave them more vulnerable to communicable health threats than are ru- ral residents, who enjoy a measure of protection owing to their spatial dispersion. This "urban penalty" was first observed in the Victorian era when city dwellers died at higher rates than their rural counterparts despite their greater average in- comes, but it has been in force throughout most of human history. It was only 259

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260 CITIES TRANSFORMED when urban populations had begun to be protected by public health investments and when advances in the understanding of disease had progressed to the point that higher incomes could purchase effective treatments that urban populations could achieve higher levels of health on average (Preston and van de Walle, 1978; Ewbank and Preston, 1990; van Poppel and van der Heijden, 1997~. In a sense, then, the urban advantage that we now take for granted is a recent and possibly fragile development. Nothing locks this advantage into place. De- teriorating economic conditions, disinvestment by governments in urban public health infrastructure, and newly virulent communicable diseases could conceiv- ably cause the penalties last seen in the nineteenth century to reemerge. Of course, some urban groups may never have enjoyed much of an urban advantage; the poor and the politically overlooked may have been at least as exposed to disease as their rural cousins, and perhaps more so. In this chapter, we look carefully for evidence of a reemergent urban penalty. As will be seen, the evidence is mixed and contradictory, but that in itself may present a challenge to complacency. The uneven distribution of health is clearly apparent within cities; it can be seen, for example, in the spatial variation of crude death rates in Accra, depicted in Figure 7-1. Although age-adjusted mortality measures would be preferred, the variation in crude death rates is suggestive of stark intraurban inequities that are unlikely to be due to age composition alone. The spatial concentration of poor health has long been recognized by epidemiologists, and its economic and social aspects are increasingly being emphasized in the public health journals. One now _ . A::' _..::::::::: ~ ':::::::::::: . it: - :,:,:,:,:,:,:,:,:,:,:,:,:,:,:,: ::::::::::::: :::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,::::::::::: l .............................................................................................................................. _ .~. ~ 1 ~ ::::::::::::::::::::::::::::~:::::~ ~ . . ~ ~ L"""""""""""""~............................ ' ~ s . ~ :.:.:.:.:.:.:.:.:.:.:.:.:.:~:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.~ ~.~ c ~ ~ ~ i .1 / ~~ . ~ ~::: ::::::::::::: :::::::: ~ ~ ~ A1~'''''''''''''''''''''''''""""""""""""""""""""""""""""'~ 222222222222222222222'''':1::::::::::::::::::::::::::::: t . :-:-:-:-:-:-.~:-:-:-:-:-:-:-:-:-:-:-:-:-:-~:-:-:-:-:-:-:= A.:.:.:.:.:.:.: :.:.:.:.:.:.:-:.: A--- i -- - I................ t:::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::t 1"""""""""""""""""'' ~"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""~ ~ """"'I ~"""""""""""""""""""""""""""""""""""""""""""""'~ :.: ~ ~ :::::~.:.:::::::::::::E :.:.:.:.:.:.:.:.:.:.:.:.:.~ ~ :,: ~ . ~ """""""""""` :,: ~ ~ ~ ........................ ~ I _ _ ., ~........................... ............. .:.:.:.:.:,:,:ja C <3.0 7.0-9.0 C 3.0-5.0 ,9.0 1 ~ 5.0-7.0 FIGURE 7-1 Crude death rates by neighborhood in Accra, 1991. SOURCE: Stephens, Timaeus, Akerman, Avlve, Maia, Campanario, Doe, Lush, Tetteh, and Harpham (1994b).

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MORTALITY AND MORBIDITY 261 sees much discussion of the roles of local social capital and social networks in ur- ban health, and efforts are under way to bring empirical content to these concepts. Although few longitudinal studies of urban sites are fully functioning as of this writing (see Kahn and Tollman, 2002, for a list of new urban research sites), there is some prospect for linking sophisticated prospective social science research to the sophisticated programs of epidemiological research already under way. The socioeconomic diversity of urban populations makes possible the devel- opment of many specialized markets and functions. Some of these can directly affect the communicability of disease; consider, for example, the markets in which sex workers participate. Rural prostitution exists, of course, but its epidemiolog- ical role in the spread of sexually transmitted diseases (STDs) and HIV/AIDS is quite different from that of urban prostitution, which probably involves denser and more highly interconnected sexual networks (Yirrell, Pickering, Palmarini, Hamil- ton, Rutemberwa, Biryahwaho, Whitworth, and Brown, 1998; Pickering, Okongo, Ojwiya, Yirrell, and Whitworth, 1997~. At the same time, urban diversity supports the development of markets that are beneficial to health. As was seen in the pre- vious chapter in connection with reproductive health, the role of the private sector is far more prominent in urban than in rural areas. Urban health providers in the public sector operate alongside a great variety of private-sector providers, who range from traditional healers to highly specialized surgeons. Various fee-for- service arrangements are found in this variegated private sector, and fees are seen increasingly in the public sector as well. These arrangements raise issues of abil- ity and willingness to pay on the part of urban residents. The urban poor who are unable to pay fees may remain as dependent on subsidized public-sector services as their rural counterparts. This chapter begins by considering the distinctive aspects of urban health in more detail. Then, guided by the concept of the health transition, it reviews the spectrum of diseases that afflict urban residents and compares this spectrum with the rural burden of disease. Much of the discussion concerns adult health; spe- cial emphasis is placed on risks for injuries and mental ill-health that have interesting urban features and have too readily been overlooked. The chapter next turns to children's health, presenting results from analyses of the Demographic and Health Surveys (DHS) on children's nutrition (as measured by height for age and weight for height) and child survival. (The panel could not explore trends over time going back to the DHS predecessor surveys the World Fertility Surveys (WFS) but this would be a useful exercise for future research.) Although the DHS data are limited in their spatial resolution and usually do not allow neighborhood effects to be discerned, they do enable a general assessment of whether urban children suffer from a newly emergent urban penalty. To this end, results from the DHS surveys are compared with findings from spatially fo- cused studies of urban slums and squatter settlements. The chapter then turns to a discussion of treatment-seeking behavior in urban populations and the new con- figurations of urban health systems. The final section presents conclusions and recommendations.

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262 CITIES TRANSFORMED DISTINCTIVE ASPECTS OF URBAN HEALTH To understand whether and how urban health is distinct from rural, two questions need to be addressed: (1) whether the determinants of urban health are the same as those of rural health, and if so, (2) whether the levels of these determinants differ. Among the subdisciplines of health research, one finds such questions addressed most directly in the field of urban nutrition. Ruel, Haddad, and Garrett (1999: 1887) argue that there are important, urban-specific aspects of food security and nutrition, which include the following: (a) the greater dependence of urban dwellers on cash income and less reliance on surrounding natural resources, which means that having a secure source of income is critical; (b) the likelihood that, even if formal safety net programs are more prevalent, informal social networks are weaker, possibly reducing the ability of the poor to deal with economic shocks; (c) the higher levels of women who par- ticipate in the formal labor force and work away from home, with potentially negative consequences for their ability to care for other household members and their children; (d) the changes in diet and exercise patterns that may increase risk of chronic disease and obe- sity even among low-income groups; (e) the significant obstacles that the poorest segments of the population may still face to gain access to public services, such as water, sanitation, and garbage disposal, even when these services are more available than in rural areas; (f) the increased exposure of urban-dwellers to environmental contamina- tion, which increases risk of illness and, especially, infectious disease; and (g) the legal obstacles that urban-dwellers face in attempting to improve their livelihoods in such areas as employment, land, and water use. Box 7.1, which draws on Harpham, Lusty, and Vaughan (1988) and Ruel and Gar- rett (1999), shows how the characteristics of urban life may be expressed in health outcomes and the distribution of illness. Poverty, environment, and psychosocial problems may lead to specific diseases or health conditions that are more com- mon in urban areas, including STDs, accidents, and depression. However, some conditions, including malnutrition and malaria, are prevalent in both urban and rural areas. THE DISEASE SPECTRUM In Latin America, the health transition has generally appeared first in urban lo- cations (Pan American Health Organization, PAHO; Tanner and Harpham, 1995) and has tended to proceed more rapidly in countries with higher levels of

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MORTALITY AND MORBIDITY 263 BOX 7.1 Urban Problems and Their Health Implications Poverty-Related Problems Environmental Problems Psychosocial Problems Cash income and markets Hazardous informal Stress High intake of fats and sector Alienation refined sugars ("junk Inadequate water and Instability food") sanitation Out-of-home female labor force participation Prostitution Street children Within-house and community overcrowding Lack of land to grow food Lack of rubbish disposal Traffic Industrial pollution Air, water, and food contamination Implications Insecurity Smoking Drug abuse (including alcohol) Limited social support Insecurity of tenure Violence Lack of breastfeeding Accidents Depression Malnutrition Parasitic disease Anxiety Sexually transmitted Malaria Suicide diseases, including Dengue Cancer HIV/AIDS Respiratory infections Heart disease Tuberculosis Injuries Cancer Other infectious diseases (especially diarrhea!) urbanization. A link to urbanization is seen in studies of other developing regions as well. These studies document higher urban rates of cardiovascular disease, cancers, coronary heart disease, and accidents, and higher rural rates of malaria, malnutrition, maternal mortality, and respiratory disease.) Evidently, urban and rural health profiles do differ. ~ On the rural disease pattern, see Mbizvo, Fawcus, Lindmark, and Nystrom (1993), Mock, Sellers, Abdoh, and Franklin (1993), McCombie (1995), Fawcus, Mbizvo, Lindmark, and Nystrom (1995, 1996), and Root (1997). On the urban pattern, see reviews by Beevers and Prince (1991), Muna (1993), Walker (1995), Walker and Sareli (1997), and Walker and Segal (1997), and studies by McPake et al. (1999), Steyn, Fourie, Lombard, Katzenellenbogen, Bourne, and Jooste (1996), Ceesay, Morgan, Kamanda, Willoughby, and Lisk (1996), and Delpeuch and Marie (1997). Some of these studies present data on risk factors associated with disease, rather than rates of disease as such.

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264 CITIES TRANSFORMED The reasons why they differ are of course complex, stemming from the many environmental, socioeconomic, and cultural changes that are associated with ur- banization. Lower rates of communicable disease and urban advantages in child survival can be linked to lower urban fertility, better immunization coverage, and easier access to and greater use of health services.2 As communicable diseases be- gin to decline in urban areas, noncommunicable diseases (including the so-called "diseases of affluence") and diseases associated with social instability can be ex- pected to rise in relative importance, particularly among adults (Feachem, Kjell- strom, and Murray, 1990~. The growing impact of mental ill-health, violence, accidents, and chronic disease is evident in disability-adjusted life year (DALY) predictions.3 It has been predicted that by 2030, depression, traffic accidents, and heart disease will be the leading burdens of disease in developing countries overall, replacing the 1990 leaders, which were respiratory disease, diarrhea, and perinatal conditions (World Health Organization, 1996~. Health transitions generally progress unevenly, producing more rapid change in some population groups than in others. This unevenness can be seen in com- parisons of adult and child mortality. In some cities, data registers allow the main causes of death to be identified and permit comparisons of adult and child causes. A 1996 analysis by Ministerio de Salud de Peru (1996) showed the main causes of adult death in Managua, Nicaragua, to be acute respiratory infection (which accounted for 11 percent of adult deaths), hypertension (8 percent), road traffic accidents (7 percent), stroke (6 percent), and pneumonia (5 percent). Adults in Managua die from a mix of communicable and noncommunicable diseases. The children of this city, however, still die mainly of communicable diseases, which account for the five leading causes of death. Acute respiratory infections and diar- rhea alone are responsible for 39 percent of infant and child deaths.4 Other cities in Latin America have reached a more advanced stage of the health transition. In San Pedro Sula, a rapidly growing city in Honduras with about half a million residents, the Honduras Ministry of Health (1999) found the main causes of adult death in 1999 to be violence (43 percent), cardiovascular disease (19 percent), cir- rhosis (15 percent), cancer (13 percent), and AIDS (8 percent). Even child deaths are dominated by noncommunicable causes (by rank, violence, cancer, cranial trauma, and anemia). 2See Bah (1993), Bahr and Wehrhahn (1993), Taylor (1993), Fawcus, Mbizvo, Lindmark, and Nystrom (1995), Brockerhoff (1994, 1995a), Brockerhoff and Brennan (1998), and Gould (1998). 3 The DALY measure combines the years of life lost as a result of premature death with years spent in an unhealthy state. A death is premature if it occurs before age 82.5 for a woman and age 80 for a man, these being the life expectancies achieved in Japan, which is the world's current leader in longevity. To be included in the DALY measure, disabilities must be classified by severity and duration such that one DALY is equivalent to a year of fully healthy life. These concepts and measures are explained in the executive summary of The Global Burden of Disease and Injury Series, available at http://www.hsph.harvard.edu/organizations/bdu/summary.html. 4These figures should be interpreted cautiously; the quality of cause-of-death reporting is not known.

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MORTALITY AND MORBIDITY TABLE 7-1 Disability-Adjusted Years of Life Lost in Mexico, by Cause and Residence 265 Cause Diarrhea Pneumonia Homicide and violence Motor vehicle-related deaths Cirrhosis Anemia and malnutrition Road traffic accidents Ischemic heart disease Diseases of the digestive system Diabetes mellitus Brain vascular disease Alcoholic dependence Accidents (falls) Chronic lung disease Nephritis Rural Urban Rural Rank Urban Rank Rural/Urban 12.0 9.3 9.2 7.9 7.5 6.8 5.5 5.1 4.7 4.1 3.0 3.0 2.8 2.6 2.2 1 2 3 4 5 6 7 9 10 11 11 13 14 15 2.8 3.9 7.4 8.3 6.3 2.4 6.8 5.3 1.7 5.7 3.0 1.9 2.6 1.9 2.2 11 6 15 13 10 13 12 4.28 2.39 1.23 0.95 1.19 2.86 0.81 0.96 2.74 0.72 1.02 1.56 1.09 1.39 1.01 N(4E: 1991 estimates, expressed per 1000 population. SOURCE: Lozano, Murray, and Frenk (1999: 130~. Not only do cities differ as to their stage in the health transition, but some countries challenge the generalization that urban areas take the lead in the transi- tion. As Table 7-1 shows for Mexico, the 15 leading causes of DALYs lost in rural and urban areas are the same, although they appear in different rank order. Of the top five causes in urban areas, three (deaths related to motor vehicles, homicide and violence, and cirrhosis) are also in the top five in rural areas. The implications of the health transition are far-reaching, encompassing fac- tors as various as the range of drugs needed in urban primary health centers and the emphases required for effective health promotion programs. The discussion that follows focuses mainly on adults and addresses three types of disease injuries, mental health, and "lifestyle" diseases whose impact has not been sufficiently appreciated. I ~ nJurles Drawing on a DALYs analysis, Zwi, Forjuoh, Murugusampillay, Odero, and Watts (1996: 593) call attention to the effects of injuries on health and well-being: ... world-wide, intentional injuries (suicide, homicide and war) ac- count for almost the same number of DALYs lost as either sexually transmitted diseases and human immunodeficiency virus (HIV) infec- tion combined, or tuberculosis. Unintentional injuries cause as many

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266 CITIES TRANSFORMED DALYs lost as diarrhea, and more than those lost from cardiovas- cular disease, malignant neoplasm, or vaccine-preventable childhood infections. In developing regions of the world, in 1990, injuries in males aged 15-44 years led to 55 million DALYs lost, over one-third of those lost from all causes in this sex and age group. As this quotation makes clear, violence is one of the major causes of injuries. Much of the empirical work on violence has been carried out in Latin America and the Caribbean. This is for good reason: Latin America has the world's highest burden of homicides, which occur at a rate of 7.7 per 1,000 population, more than twice the world average of 3.5 per 1,000. Approximately 30 percent of all homicide victims in Latin America are adolescents, and young men are the most affected group (Frenk, Londono, Knaul, and Lozano, 1998; Pan American Health Organization, PAHO, cited in Grant, l999~. Violent crime is particularly prevalent in Latin America's large cities, and in these cities, it disproportionately affects men living in low-income neighbor- hoods (Barata, Ribeiro, Guedes, and Moraes, 1998; Grant, l999~. Data collected between 1991 and 1993 in Sao Paulo suggested that men aged 15-24 in low- income areas were more than 5 times likelier to fall victim to homicide than were men of the same age in higher-income areas (Soares et al., cited in Grant, 1999~. Gender roles and relations put men and women at risk of different types of violence. Higher rates of homicide are reported for men, but rape and domestic violence rates are higher for women. Heise, Raikes, Watts, and Zwi (1994) re- viewed community-based data for eight urban areas from different regions of the developing world and found that mental and physical abuse of women by their partners was common. with damaging consequences for women's physical and r ~ ~ ~ , ~ be, a, _ ~ En_~ psychological well-being. Traffic accidents are another major but often overlooked cause of urban death and injury (Mock, Abantanga, Cummings, and Koepsell, 1999; Kayombo, 1995; Byarugaba and Kielkowski, 1994~. Urban residents are often thought to be at greater risk of being involved in an accident than rural residents (Odero, Garner, and Zwi, 1997~. This supposition enjoys some empirical support (Mock, Aban- tanga, Cummings, and Koepsell, 1999), but higher rural accident rates at least for accidents causing injuries have been recorded (Odero, 1995~. Poor coun- tries invest less in their roads than do rich countries; they have fewer laws related to traffic and enforce them unevenly; and they probably have rates of alcohol con- sumption that are at least as high as those of rich countries. The combination puts men, adolescents, and young adults at particularly high risk of involvement in an accident. Traffic accidents account for 30 to 86 percent of all trauma-related hospital admissions, with a mean length of stay of 20 days (Odero, Garner, and Zwi, 1997, citing 15 and 11 studies, respectively). Since the majority of trauma facilities are located in cities, accidents not only are responsible for significant

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MORTALITY AND MORBIDITY 267 mortality and morbidity among urban residents, but also place a heavy burden on urban health systems. Little is known about the urban incidence of other types of accidents, such as accidental falls, drownings, poisonings, and injuries from fire. Some unintentional injuries are likely to be more common in urban areas because of overcrowding and related factors (Bartlett, Hart, Satterthwaite, Barra, and Missair, 1999; Mock, Abantanga, Cummings, and Koepsell, 1999; Knobel, Yang, and Ho, 1994~. Urban communities are vulnerable to some forms of natural disaster, such as landslides, earthquakes, and floods. The urban poor in Rio de Janeiro, for example, are forced to live where landslides kill or leave homeless thousands every year.5 Mental Health According to the World Health Organization (1996), by 2020 unipolar depression is expected to account for the greatest burden of disease in developing countries. Indeed, community-based studies of mental health in developing countries already show that 12 to 51 percent of urban adults suffer from some form of depression (see 16 studies reviewed by Blue, l999~. Although these studies employ a range of samples, definitions, and instruments, their conclusions underscore the importance of mental ill-health in the urban spectrum of disease. A diverse set of risk factors is implicated, including lack of control over resources, changing marriage patterns and increased divorce rates, cultural ideology, long-term chronic stress, exposure to stressful life events, and lack of social support (Harpham, 1994~. There are differences across urban neighborhoods and even from person to person in abili- ties to devise successful coping strategies. Anxiety and depression are typically more prevalent among urban women than men and more prevalent in poor than in nonpoor urban neighborhoods. Those suffering from stress may be able to call upon various forms of emotional support, as well as material support in the form of goods, services, and information. These resources can help in coping with stress and mitigating its damage (Thoits, 1995~. Nonetheless, urban environments in general, and poor urban environments in particular, have a number of harsh physical and social aspects, including poor housing and services and limited prospects for good jobs and incomes (Ekblad, 1993; Fuller, Edwards, Sermsri, and Vorakitphoka- torn, 1993; Satterthwaite, 1993, 1995~. Day-to-day life in poor communities can subject individuals to sustained, chronic stress. As discussed in Chapter 5, poor urban residents often show great resilience and creativity in meeting such chal- lenges. Nevertheless, they can be beaten down by the chronic stresses of poverty, jolted by other stressful life events, and wearied by the constant need to improvise new coping strategies. 5Of the 568 major natural disasters that occurred in the world between 1990 and 1998, 94 percent took place in developing countries, and 97 percent of all natural disaster-related deaths occurred in those countries as well (World Bank, 2001).

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268 CITIES TRANSFORMED In empirical analyses, differences in social support the degree to which basic social needs are gratified through interaction with others have been estimated to account for 5 to 10 percent of the variance in levels of mental ill-health (of all types) in different areas (Harpham, 1994; Committee to Study Female Morbidity and Mortality in Sub-Saharan Africa, 1996; Aidoo and Harpham, 2001; Harpham and Blue, 1995~. Urbanization can be associated with reductions in social support resulting from the breakdown or reorganization of family life, a potential increase in single-parent households and decrease in the support networks of extended fam- ilies, reduced fertility (and thus fewer children to care for parents in old age), and the need to work outside the home (Harpham, 1994; Parry, 1995; Harpham and Blue, 1995~. Although some of these aspects of stress appear to be worse in large developing-country cities than in small cities, researchers have not yet compared levels of social support and stress in large and small cities. Another knowledge gap has to do with the interrelationships between mental illness and social support. Most of the available research is cross-sectional, leav- ing open the possibility that mental illness itself reduces social support and that the positive relationship between social support and mental health may be over- stated. Also, the literature has yet to explore the contribution of community-level factors, such as levels of violence and social cohesion (Blue and Harpham,1998~. Regarding the latter, an ecological variable that may play a role is social capi- tal, or the density and nature of the network of contacts and connections among individuals in a given community. Strong social capital has been linked to re- duced mortality at the state level in the United States (National Research Council, 2000~. In low-income urban communities, social capital has been found to weaken as households' ability to cope decreases and community trust breaks down, and to be severely eroded by various forms of violence (Moser and McIlwaine, l999~. Chronic "Lifestyle" Diseases As noted above, urban areas have higher risk factors for and rates of diabetes, obesity, cardiovascular disease, cancers, and coronary heart disease. These are sometimes termed chronic "lifestyle" diseases, the idea being that they are at least partly attributable to behavior. Risk factors associated with this group of diseases include smoking; alcohol consumption; increased intake of fat and reduced in- take of fiber; lack of exercise; and inhalation of potentially toxic pollutants, such as carbon monoxide, sulfur dioxide, nitrogen oxides, and suspended particulate matter. In many developing countries, substantial proportions of the population are either underweight or overweight, with the increase in the overweight percentage being a recent development. One review (Delpeuch and Marie, 1997) suggests that over 30 percent of the national population is overweight in Latin America, the Caribbean, the Middle East, and Northern Africa. (The highest prevalence of obesity is found in Pacific and Indian Ocean island populations.) In Asia and

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MORTALITY AND MORBIDITY 269 sub-Saharan Africa, the prevalence of obesity is low on average but is evidently higher in urban than in rural areas. Obesity tends to appear first among the affluent and then among low-income groups, including young children and teenagers. Its main causes include the adoption of lipid-rich diets and (more important) the re- duction in physical activity that often accompanies city life. Malnutrition during fetal development and early childhood is a predisposing factor for later obesity. Undernutrition, food insecurity, dietary excess, and obesity often coexist in urban populations. Popkin (1999: 1908) shows that more urbanized developing countries have a higher consumption of sweeteners and fats, noting that "a shift from 25 percent to 75 percent urban population in very low income countries is as- sociated with an increase of approximately four percentage points of total energy from fat and an additional 12 percentage points of energy from sweeteners." A1- though this pattern is often attributed to the urban rich, Monteiro, Benicio, Conde, and Popkin (2000) show that in urban Brazil, it is the city residents with more education who are less likely to be overweight. Much the same pattern has been observed in South Africa (South African Department of Health, 1998~. In Latin America, there is an upward trend in cancer mortality, which is especially marked for cancers of the lung, gallbladder, and breast (Timaeus and Lopez, 1996~. In Accra and Sao Paulo, circulatory disease has been found to be the second most important cause of death among those aged 15-44 and the most important cause for those aged 45-64 (Stephens, Timaeus, Akerman, Avlve, Maia, Campanario, Doe, Lush, Tetteh, and Harpham, 1994a). Community-based urban studies among the elderly likewise have documented high rates of mortality and morbidity due to chronic and lifestyle diseases (Belle, Baiyewu, Bamigboye, Adeyemi, Ikuesan, and Jegede, 1993; Allain, Wilson, Gomo, Mushangi, Senzanje, Adamchak, and Matenga, 1997~. The prevalence and increase of risk factors for these diseases among urban populations, coupled with gradual population aging, imply that they will become increasingly important causes of death. Yet they remain poorly described, particularly in African and Asian cities. Unfortunately, the DALYs data available from the Global Burden of Disease studies have not been systematically disaggregated by rural and urban place of residence. Diagnoses of chronic diseases may be better in urban than rural areas, and the studies cited above suggest that urban populations will continue to be at the forefront of health transitions. It remains uncertain just how urban disease patterns will be influenced by urban population growth, poverty, and emerging and reemerging communicable diseases. New and Reemergent Communicable Diseases Communicable diseases continue to be important causes of adult mortality in many urban areas. In Dar es Salaam, HIV/AIDS is the main cause of death among urban men and, along with maternal mortality, is the primary killer of urban women (Kitange, Machibya, Black, Mtasiwa, Masuki, Whiting, Unwin,

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MORTALITY AND MORBIDITY 289 The terms in which poverty is described have political implications. As Mitlin, Satterthwaite, and Stephens (1996) note, when poverty is described in absolute rather than relative terms, this can suggest that the responsibility for alleviating poverty rests with poor individuals and households themselves. Somehow the societal mechanisms that bring about and maintain deprivation tend to be over- looked. A focus on relative poverty and inequality, by contrast, may force a recog- nition of inequities and thereby encourage governments and the poor to grapple with the institutional and societal factors that perpetuate poverty. HEALTH SERVICE PROVISION AND TREATMENT SEEKING A defining feature of urban health systems is the diversity of providers who offer a multiplicity of services. These providers include government services run by district councils, municipal councils, or state or central ministries; private (for- profit) hospitals, laboratories, and practitioners (offering modern or traditional services); and a variety of nongovernmental providers, including missions and charities (Lorenz and Garner, 1995~. Medications are also available in shops, pharmacies, markets, and various clandestine outlets. This diversity of providers in urban settings is an expression of the demand for private (for-profit) services; the very different ideas, needs, and purchasing power of diverse urban popula- tions; the availability of social or private health insurance coverage for some formal-sector employees; and a continuing urban bias in the provision of gov- ernment health services (Hanson and Berman, 1998~. Official statistics often fail to convey this diversity; as Hanson and Berman (1998) note, there are almost no data on pharmacies, nurses, traditional healers, and kiosks. The conceptual distinctions we have mentioned between the public and private sectors, for-profit and not-for-profit providers, the formal and informal sectors, and modern and traditional providers can be difficult to detect (see Giusti, Criel, and Bethune, 1997; Londono and Frenk, 1997; Ferrinho, van Lerberghe, and Gomes, l999~. The urban health sector presents many arrangements that defy easy categorization dual public and private practices by government-employed physicians, the introduction of private wards in public hospitals, the self-referral of patients between healers and Western doctors and between public and private facilities, and the introduction of user fees into government services. The urban system is less a system than a patchwork: there is often little formal interaction or cooperation among the different types of providers (Ogunbekun, Ogunbekun, and ~ ~7 Orobaton, l999~. Urban Treatment Seeking The pluralism of urban health care provision is both an outcome and a determinant of treatment-seeking patterns. In urban as in rural areas, household responses to illness are highly complex, influenced by perceptions of illness severity, views of

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290 CITIES TRANSFORMED causation and appropriate therapy, and access to sources of treatment. Recogni- tion of symptoms, their definition in terms of recognized illnesses, and decisions about treatment are all influenced by a plethora of macro-, mesa-, and micro-level factors (Igun, 1979; Kleinman, 1980; Phillips, 1990; Berman, Kendall, and Bhat- tacharya, 1994; Andersen, 1995~. Responses can therefore very for differentill- nesses or syndromes, and in many cases more than one therapy source is contacted over the course of an illness. Against this general background of diversity, empir- ical studies have identified a number of key features of urban treatment-seeking patterns. Self-medication When they fall ill, many urban residents turn to the drugs available in private for-profit shops and pharmacies (see also Chapter 6~. For example, community studies show that at least 40 percent of those seeking treatment for fever pur- chase drugs from these sources, and for most this is their first response to illness (Glik, Ward, Gordon, and Haba, 1989; Carme, Koulengana, Nzambe, and Bodan, 1992; Mwenesi, 1993; Kilian, 1995; Chiguzo, 1999; Molyneux, Mung'Ala-Odera, Harpham, and Snow, 1999~. From the viewpoint of many urban residents, such self-treatment is a sensible first step because formal clinics and hospitals are less convenient and more expensive in time and money terms. Small shops can offer drugs on credit or sell them in small, affordable doses (Molyneux, Mung'Ala- Odera, Harpham, and Snow, l999~. Traditional healers Herbalists, diviners, midwives, fertility specialists, and spiritualists are an im- portant source of health care in Africa and in much of Asia and Latin America. These traditional healers are thought to be the main source of health care for up to 80 percent of rural residents in developing countries, and Good (1987) argues that they are retaining and even expanding their influence in many cities. Heal- ers have their specialties: empirical studies suggest that urban healers are more likely to be consulted for convulsions, nonspecific pains, and psychological prob- lems than for other illnesses and symptoms (Winston and Patel, 1995; Carpentier, Prazuck, Vincent-Ballereau, Ouedraogo, and Lafaix,1995~. Many urban residents are eclectic, using healers even while they are attending modern health facilities, and healers often assume an important role when modern services fail to effect a cure or are perceived to fail (Molyneux, Mung'Ala-Odera, Harpham, and Snow, 1999~. Private providers Private facilities are an important urban treatment source for STDs, malaria, tuber- culosis, and diarrhea (Brugha, Chandramohan, and Zwi, 1999; Brugha and Zwi,

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MORTALITY AND MORBIDITY 291 1999; Hotchkiss and Gordillo, 1999; Molyneux, Mung'Ala-Odera, Harpham, and Snow, 1999; Ngalande-Banda and Walt, 1995~. The relatively high costs of pri- vate for-profit services might appear to put them out of the reach of the poor, but a growing body of research shows that many low-income urban residents are heav- ily dependent on such services (Ogunbekun, Ogunbekun, and Orobaton, 1999; Ngalande-Banda and Walt, 1995; Yesudian, 1994; Molyneux, Mung'Ala-Odera, Harpham, and Snow, 1999; Thaver, Harpham, McPake, and Garner, 1998; Deve- lay, Sauerborn, and Diesfeld, 1996; Hotchkiss, 1998; Hanson and Berman, 1998~. The preference for private services despite their higher costs as compared with public services is attributable to the availability of staff and drugs, easier physical access, shorter waiting times, extended or more flexible working hours, better in- terpersonal communication between staff and patients, and the promise of greater confidentiality. Nevertheless, government hearth services remain an important source of health care. Wyss, Whiting, Kilima, McLarty, Mtasiwa, Tanner, and Lorenz (1996), for example, interviewed residents of Dar es Salaam about their use of services in the previous 2 weeks. They found that although poor and rich alike use private fa- cilities, the poor rely more often on government health services. In some settings, richer households are as likely as poorer households to depend on public facili- ties (Hotchkiss, 1998; Makinen, Waters, Rauch, Almagambetova, Bitran, Gilson, McIntyre, Pannarunothai, Prieto, Ubilla, and Ram, 2000~. Selected Issues in Health Service Provision and Use Aspects of urban health service use that have attracted research attention include the Malfunctioning of the referral system, the impact of user fees on rates and patterns of use, quality of care as a key influence on treatment seeking, and urban/rural linkages. These are addressed in turn below. The referral system In many cities, those seeking treatment often bypass clinics and other facilities at the lower tiers of the public health system and present themselves directly to the outpatient clinics of city hospitals (World Health Organization, 1 993; Holdsworth, Garner, and Harpham, 1993; Sanders, Kravitz, Lewin, and McKee, 1998; Akin and Hutchinson, 1999~. This behavior may be sensible from the viewpoint of those seeking treatment, given their perceptions of the low quality of services available at the lower tiers. From the perspective of the health system overall, however, such behavior contributes to overcrowding and to poor quality of care in hospitals, which arguably should be specializing in the severe health problems that require more sophisticated treatments. Basic primary care and first-contact services have been introduced in many cities, although they often cannot keep pace with urban growth. Secondary and

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292 CITIES TRANSFORMED tertiary services (offering major inpatient and specialist care) are also generally located only in cities. The principal weakness identified in urban health systems is at the second tier of services, these being the units that should manage referrals, supervise primary care and first-contact services, and provide basic care for pa- tients with obstetric difficulties and trauma (Lorenz and Garner, 1995~. A World Health Organization strategy to strengthen this tier is to promote the development of urban intermediate-level health services or "reference centers," either by up- grading health centers or by giving referral hospitals authorization to provide dif- ferent levels of care in the same institution (Sanders, Kravitz, Lewin, and McKee, 1998). As shown by a study of patient flow in a national referral hospital in Lesotho (Holdsworth, Garner, and Harpham, 1993), however, clinicians may not be quite as overburdened by patients as they appear to be. Patient load as such may be less of a factor than poor management of the patient flow resulting in the over- crowding and long delays experienced in outpatient waiting rooms. Nor is it clear that establishing reference centers would necessarily ease such crowding. In Zam- bia, Atkinson, Ngwengwe, Macwan'gi, Ngulube, Harpham, and O'Connell (1999) found that accessible, inexpensive reference centers could well attract even more patients to the public health system, including many who would otherwise have used self-medication. User fees Proponents of health-sector reforms have often given top priority to financing, proposing that user fees be introduced or raised and urging consideration of pre- payment and insurance schemes. The impact of such policies on the poor has been a subject of intense debate, with empirical studies yielding conflicting findings (see, for example, McPake, 1993; Gilson and Mills, 1995; Gilson, Russell, and Buse, 1995; Gilson, 1997; Stierle, Kaddar, Tchicaya, and Schmidt-Ehry, 1999~. In some urban areas, the poor spend a higher proportion of total household funds on health than do the nonpoor. In 1992, for example, the poorest tenth of Mexican urban families spent 5.2 percent of their income on health care, as compared with 2.8 percent for the richest tenth of families (Londono and Frenk,1997~. Although many studies have found that user fees reduce utilization of care, particularly for low-income households, some studies suggest that fees have little effect on de- mand and can even increase demand if higher fees are thought to be linked to better-quality cared Quality of care and the perception of services may be as i3Even where utilization has not decreased, it is important to distinguish between willingness to pay and ability to pay. Where willingness to pay among low-income groups exceeds ability to pay, the strategies adopted by the poor to pay for health services (such as claims on kin, loans, sales of assets, and shifting of resources from other critical needs) can have broader consequences for livelihoods and health (Russell, 1996).

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MORTALITY AND MORBIDITY 293 important as price and income in the use of health services (McPake, 1993; Rus- sell, 1996; Okello, Lubanga, Guwatudde, and Sebina-Zziwa,1998~. The introduction of user fees can price some low-income groups out of the market unless more effective exemption or third-party payment mechanisms are devised (Stierle, Kaddar, Tchicaya, and Schmidt-Ehry, 1999~. It is not yet clear, however, how such mechanisms can be developed. Some researchers stress the need for better ways to identify the poor families that need exemptions; others stress the need to better monitor exemptions so as to prevent use of the subsidies by groups who can afford care; and still others stress the need to focus on the fundamental causes of poverty and inequity. Quality of care Sanders, Kravitz, Lewin, and McKee (1998: 366) conclude that "the inappropriate utilization of referral facilities will remain a problem until quality accessible (and affordable) primary and secondary level care is available." Quality of care is now mentioned frequently, and, as just noted, its importance is underscored by studies exploring how user fees affect utilization. The aspects of quality found to be asso- ciated with use include drug availability, prescribing and dispensing practices, the physical condition of health facilities, service availability, number of personnel, crowding and length of waiting time, attitudes displayed by health workers to- ward clients, and the degree of confidentiality (Hotchkiss, 1998; Brugha and Zwi, 1999; Bassett, Bijlmakers, and Sanders, 1997~. A study of rural and urban Zimbabwe highlights the interactions between nurses and women from the community (Bassett, Bijlmakers, and Sanders, 1997: 185~: All groups were agreed in much of their assessment of the state of health services. Clinic fees, drug shortages and long waiting times were all identified as sources of dissatisfaction and declining quality of care.... To community women, the expectation of abrupt or rude treatment was the main complaint about the health services. Commu- nity complaints were voiced most strongly in the urban areas, where accusations of patient neglect and even abuse suggested a heightened hostility between the clinic and community in the urban setting. Sev- eral explanations for nurse behavior were put forward, chief among them was elitism.... it is in urban areas that class differentiation is most advanced. [The perspective of nurses differed. For them] over- work and low pay promote the adoption of the attitude of an industrial worker to do what is required and no more. Most nurses work more than one job, not to get rich but to survive. As elsewhere, efforts to professionalize nursing have benefited only a few.

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294 CITIES TRANSFORMED As noted above, the main reason for use of private facilities, despite what are often high costs relative to government services, has to do with quality of care. Private practitioners appear to be more responsive to patient needs, both in inter- personal relations and in the establishment of opening and closing times that suit community needs (Bennett, 1992; Thaver, Harpham, McPake, and Garner, 1998~. Nevertheless, the relatively few studies that have explored the quality of care in private facilities from the technical point of view (Nichter, 1996; Brugha and Zwi, 1999) have produced disturbing findings, such as inappropriate prescription of antibiotics as a prophylaxis for STDs. Urban/rural linkages At a time when thinking on urban health is broadening to include social aspects of the environment and recognizing the multiple factors that operate at different levels, attention must also be paid to the sociodemographic linkages between rural and urban areas. The importance of urban/rural links in health is most frequently illustrated in the transmission patterns of HIV (and other infectious diseases). As noted in Chapter 6, a number of studies in sub-Saharan Africa have reported large differences in HIV prevalence among urban areas, roadside settlements, and ru- ral areas (Boerma, Nunn, and Whitworth, 1999), with prevalence generally being higher in urban areas. In Africa, however, many urban/rural links spread HIV to rural areas. The spread of disease from rural to urban populations can also result when migrants lack immunity to an endemic urban disease and spread it upon their return to rural areas or when urban residents lack immunity to diseases prevalent in rural areas. In some contexts, then, the interaction between urban and rural populations contributes to a sharing of disease patterns and risk factors. Poor urban and ru- ral populations may also exhibit similar responses to ill-health. One study on the Kenyan coast demonstrated similar treatment-seeking patterns on the part of low-income urban and rural mothers in response to childhood fevers and convul- sions (Molyneux, Mung'Ala-Odera, Harpham, and Snow, 1999~. The similarity in responses was unexpected given the significant differences between the two groups in socioeconomic status and distance to health services. It may be that urban and rural households exchange information and ideas about illnesses and appropriate therapies through migration and mobility, as well as through com- munication among spatially dispersed family members. Molyneux et al. (1999) found urban/rural ties to be strong: One of every three lifelong rural-resident mothers had a husband who lived elsewhere, most of them (80 percent) in urban areas. One of three urban-resident mothers had spent at least 10 percent of her nights elsewhere during the previous year (or since migration into the current household of residence), mainly in rural areas.

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MORTALITY AND MORBIDITY 295 Some 10 percent of lifelong rural-resident mothers had spent at least one- fifth of their nights during the previous year with urban residents (either in visiting cities or in hosting city visitors in their households), and 14 per- cent of urban residents had spent at least one-fifth of their nights with rural residents. Over 60 percent of urban-resident mothers reported regularly assisting one or more persons living elsewhere, and most of those who were assisted (90 percent) resided in rural areas. Fully 74 percent of urban-resident mothers stated that they wished to "retire" in a rural area. The importance of moving beyond the urban/rural divide in urban health think- ing is also highlighted by studies exploring referral systems within districts and countries (see, for example Akin and Hutchinson, 1999; Okello, Lubanga, Guwatudde, and Sebina-Zziwa, 1998) and by studies documenting the return mi- gration to rural areas of ill urban family members (Kitange, Machibya, Black, Mtasiwa, Masuki, Whiting, Unwin, Moshiro, Klima, Lewanga, Alberti, and McLarty, 1996~. CONCLUSIONS AND RECOMMENDATIONS This chapter has reviewed the extant knowledge about urban health, including health services. It has explored urban/rural, interurban, and intraurban differences in health and examined access to and quality of health care services, emerging health threats, and treatment-seeking behaviors. The major findings presented relate to urban and rural differences in health and health services; the relatively disadvantaged health status of the urban poor; and the shift from communicable diseases to chronic diseases, injuries, and mental health problems in low-income cities. These findings, based on a comprehensive literature review and analysis of the DHS-United Nations urban database, serve as the basis for the conclusions and recommendations presented below. Conclusions Child survival and child health Infant and child mortality rates are higher on average in rural than in urban ar- eas. Rural infant and child mortality is higher on average for a variety of reasons, including better urban public infrastructure, higher levels of maternal education, and better access to health care. Infant and child mortality risks also differ by region, with mortality being predictably and significantly higher in sub-Saharan

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296 CITIES TRANSFORMED Africa than in other regions. However, rural areas still have relatively high mor- tality rates in all regions. Within the urban hierarchy, mortality varies little by city size. There is no clear evidence of systematic erosion over time in the urban ad- vantage in infant and child survival, except in some areas of sub-Saharan Africa. However, urban poor children face mortality risks that are significantly greater than those faced by the urban nonpoor. On average, infant and child mortality has declined over time by about the same amount in both urban and rural areas in most countries for which data are available. In six sub-Saharan African countries, however, mortality has increased in both urban and rural areas, slightly more so in the former. In the other half of the African cases examined, however, infant and child mortality has declined somewhat, with slightly larger declines evident in urban areas. The rapid urban spread of HIV/AIDS in some African countries may help explain their urban mortality increases, although it is difficult to disen- tangle the effects of the epidemic from other contributing factors. Although urban poor children have lower mortality risks than rural children in a majority of coun- tries examined by the panel, rural children exhibit lower mortality risks in 25 of 87 surveys reviewed. If health is assessed in terms of heightfor age, children in urban areas are sig- nificantly healthier than those in rural areas. Considering variation by city size, the panelfound children living in the largest cities to be better Nathan those in the smallest cities in Latin America, but other regions showed no clear pattern. In terms of height for age, urban children are on average 0.5 standard deviation taller than rural children. Although urban and rural differences in weight for height are smaller than those in height for age, they display the same general pattern. In North Africa, Southeast Asia, and sub-Saharan Africa, urban children are signif- icantly heavier for their height than rural children, although the reverse is true in six countries. City size differences in weight for height show no interpretable pat- tern except in Latin America, where children in the largest (5 million plus) cities are better off than those in the smaller cities. With health measured by children's height and weight, we find no clear evi- dence of systematic erosion in the urban health advantage for children during the past two decades. However, poor urban children are much less healthy than non- poor urban children, and they are sometimes not as healthy as their rural coun- terparts. Although there are few countries for which changes over time can be examined, it appears that the urban health advantage for children has not changed during the past two decades. In North Africa and Latin America, children's height for age has increased in both urban and rural areas over time. In both urban and rural areas of sub-Saharan Africa, however, there has been either no change or a decline in children's height over time, perhaps because of severe famine, war and civil conflict, and economic crisis. Urban children overall may be healthier on average than rural children, but some urban children those in poor families are worse off in some countries. In

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MORTALITY AND MORBIDITY 297 nearly all countries, poor urban children are shorter and weigh less than nonpoor urban children. And although urban poor children are usually taller for their age than rural children in most countries examined by the panel, they are shorter in a few countries. Considering weight for height, poor urban children are generally heavier than rural children, but in 16 countries the reverse obtains. The urban health penalty In summary, there is no clear and compelling evidence of an emerging urban health penalty that puts urban children at greater risk than rural children. How- ever, the urban poorare generally worse Nathan the urban nonpoorand in several cases may fare worse than rural children. The panel's review of the literature and analysis of the data yielded a somewhat conflicting picture of urban health. Mi- cro studies of selected urban neighborhoods often suggest an erosion of the urban advantage in health, yet the DHS data show little evidence of this erosion. Of course, DHS surveys do not allow the effects of spatially concentrated poverty to be examined in any depth, and it may well be the spatially concentrated dis- advantage that produces the urban penalties seen in the micro studies. This is a high-priority area for future research. The disease spectrum Urban populations face growing health threats in terms of injuries, mental health problems, and chronic lifestyle diseases. Although environmental risks and com- municable diseases continue to be important, urban populations are increasingly at risk of injuries due to violence and accidents, mental health problems, and chronic diseases (e.g., heart disease, diabetes). This transformation, commonly known as the epidemiological or health transition, means that communicable diseases such as malaria and cholera become less of a threat in urban areas as these areas con- tinue to grow. Some communicable diseases, however, including HIV/AIDS and tuberculosis, are still important factors in cities. Recommendations Although health policy makers clearly must not abandon rural areas, those work- ing within urban areas should focus on reaching the urban poor. The panel's analysis clearly indicates priority areas for policy analysis and action in urban health, and strongly suggests the need for more comparative inter- and intraurban data and research on health and health service delivery. The following recom- mendations generally dovetail with those given in Chapter 5 regarding social and economic differentiation and access to public services, and with those in Chapter 6 regarding reproductive health service delivery, fertility, and reproductive health research. It may be that integrating services and synthesizing research in all of

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298 CITIES TRANSFORMED these areas would help identify problems and solutions in the three interrelated domains. Policy, data, and research needs are addressed below. Service delivery The deficient health status of poor urban children in comparison with their nonpoor urban counterparts and sometimes in comparison with rural children leaves no doubt as to the importance of a focus on urban poverty in nutrition and health programs. Urban policy makers in Africa in particular should focus on improving environmental conditions and access to health services, as well as curbing the spread of AIDS, to reduce infant and child mortality among the urban poor. Dealing with emerging health problems will require a shift in health services, including different drugs and medical equipment and training, as well as different types of health promotion campaigns. The panel has identified four substantive areas of focus for policy makers. The following recommendations are made in the hope that they will be clarified and augmented by future research: Governments should consider both inter- and intraurban differences when designing health services and public health infrastructure in cities. Both governments and international agencies should place high pri- ority on the urban poor in increasing access to health services and improving public health infrastructure. Closer attention should be paid to health conditions in smaller cities, especially in sub-Saharan Africa. The urban health sector should adapt its programs and communication strategies to address emerging health threats such as injuries, mental health issues, and chronic disease. Data collection Apart from a few small-scale individual city and neighborhood studies, inter- and intraurban data on mortality and health are generally un- available. Data on mortality, morbidity, health service delivery, and public health infrastructure should be collected for cities of different sizes and for various socioeconomic groups and neighborhoods within cities. National surveys will remain very important the panel's specific recommendations for the DHS are provided in Appendix F but we encourage the collection of data in small-scale studies that could complement and enrich the findings from such national surveys. Studies that permit comparisons among the ur- ban poor and rural populations are of particular interest. In addition, much could be learned about mortality through the judicious use of data from na- tional censuses, especially when a census contains information on the areas of origin of recent migrants. Research A lack of data has led to gaps in research in the areas of urban mortality, health, and health services and infrastructure. There is an urgent need for

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MORTALITY AND MORBIDITY 299 comparative research on inter- and intraurban differentials in health and treatment seeking, the quality of urban health services, and perceptions of quality. Although the urban advantage would appear to have persisted over time, research on urban penalties is urgently needed in sub-Saharan Africa, where there are credible accounts of stagnation and even declines in child health in some countries. We were unable to fully explore health and mor- tality trends over time using data from the WFS in addition to those from the DHS, but this could be a fruitful avenue for future research.