Conditions of Life in Urban Areas
Conditions of life in the cities, especially for the most vulnerable groups, are either poorly documented or the data are difficult to access, and are underanalysed and underused. There is an urgent need for improved indicators for measuring the quality of individual lives.
The most serious problems in all sectors are experienced by the urban poor. It is still difficult to assess the nature and seriousness of urban poverty and suggest specific policy solutions. But it is not hard to conclude that more attention to the problem is needed. Better basic services, education and health, with emphasis on equal opportunities for girls and women, will improve the competitive advantage of the urban poor.
For all the relative advantages of city life, widespread poverty casts a shadow over the urban future. Difficult questions remain concerning the definition of poverty, but it cannot be denied that a vast number of people in urban areas cannot adequately provide for their basic needs in shelter, employment, water, sanitation, health (including reproductive health) and education. Such poverty may affect a third of all urban dwellers directly, but its indirect effects are felt by the whole society. The ability to meet the challenge of eradicating extreme poverty and providing basic needs will define and to some extent determine the viability of urban centres and the economies which they increasingly dominate. A large proportion of the poorest are women. Collectively, women form a resource of great size and crucial importance. Their individual ability to provide for themselves and their families will determine whether the potential of that resource is realized.
Various estimates of the proportion of urban populations living in poverty are available; different definitions are used. One global estimate suggests that 27.7 per cent of the developing world's urban population lives below official poverty lines. Regional variation is considerable: sub-Saharan Africa, 41.6 per cent; Asia, 23 per cent; Latin America, 26.5 per cent; and the Middle East and North Africa, 34.2 per cent. Urban poverty has been increasing faster than rural poverty.
According to national studies up to half the population of several cities in some of the world's poorest countries are living below official poverty lines.1 Even this may be an underestimate: official poverty lines are often set unrealistically low, below the levels required to meet basic needs, and standard income-based definitions do not usually take into account the higher cost of living in the cities. In 1990 "at least 600 million urban dwellers in Africa, Asia and Latin America live in 'life and health-threatening' homes and neighbourhoods because of the very poor housing and living conditions and the inadequate provision for safe and sufficient water supplies and for sanitation, drainage, the removal of garbage, and health care".2
Some individuals and families move out of poverty and others fall into it. Social status, including poverty and near poverty, is not static but dynamic. The relatively poor, however, do share a particular vulnerability to life's shocks: even minor illnesses and lost opportunities can lead to deeper poverty and misery. Many millions of people never get access to the skills, resources or opportunities required to escape from poverty's grasp. The frequency of mobility out of poverty in rural and urban areas is poorly understood.
Though urban poverty has its special characteristics, the same structural factors underlie poverty in both urban and rural areas.
Bad housing with poor or non-existent services is a characteristic of poverty, with homelessness as its most extreme expression. Social disruption, environmental disaster and the effects of bad urban planning can quickly expose the vulnerability of the poor. Free space in urban areas tends to be on marginal lands such as steep hillsides, ravines and watercourses. Home-made shelter is little protection against wind, flood or landslide, as on two occasions a few weeks apart in 1995, when a hurricane in the Caribbean and typhoons in the Philippines destroyed thousands of poorer homes. Better-built housing on more secure land was relatively undamaged.
The evidence of inadequate provision of infrastructure to the poor is overwhelming. In a study of eight megacities, the ILO estimated slum populations at between 12 per cent (Seoul) and 84 per cent (Cairo) of the populations.3 (Other cities were: Shanghai, 20 per cent; Mexico City, 25; Rio de Janeiro, 34; Bombay, 57; and Lagos, 58.) National studies in Asia show large percentages of the urban population in slum or squatter settlements: Bangladesh, 47 per cent; India, 36; Sri Lanka, 21; Malaysia, 15; Thailand, 15; and Indonesia, 54.4
In Rio de Janeiro, residents on the periphery were three times more likely than those in the wealthier city centre to lack access to electricity. Eight times as many peripheral buildings (41.8 per cent) lacked running water than buildings in the centre (5.2 per cent); 64 per cent of poor households (those with income less than three times the minimum wage) in the periphery lacked adequate running water compared to 30 per cent of poor households in the central district. Sewerage was lacking in 35 per cent of the periphery and only 14 per cent of the central area. The number of health professionals per capita in the periphery was one third that of the centre.5
While many aspects of Rio's infrastructure improved during the 1980s, comparisons consistently showed large disadvantages for poorer populations. By the end of the decade, more than a third of the poor lived in dwellings lacking piped water while only one eighth of the non- poor did so. Nearly a third of the poor lacked sewerage service compared to less than a tenth of the non-poor. Half of the poor lived without garbage collection, compared to a quarter of the non-poor.6
Poor housing affects the whole community. Overcrowded, ill-ventilated and poorly drained settlements are breeding grounds for infectious diseases of all kinds. Inadequate housing is a major contributor to social breakdown, with domestic violence, unintended pregnancy and high rates of single-parent families only some of the many consequences. A high level of violent crime and illegal drug use is associated with poor housing.
Estimates of actual homelessness in northern industrial states vary considerably. In the United States, estimates range from about 250,000 to over 3 million people.7 Despite social safety nets, European homelessness is estimated conservatively at 2.55 million.8 Outside the industrialized countries, figures are hard to come by and confused by the informal nature of much housing: homelessness by the same measure as industrialized countries would give a figure of 200 million for the less developed world.
Employment and sustainable livelihoods
A variety of studies in diverse settings have shown that unemployment is two to three times greater among the poor than among the middle- or higher-income groups and correspondingly higher among the very poor compared to the relatively poor.9 It is not merely that employment prevents poverty, but that poverty restricts access to skills, attitudes and opportunities for further advancement.
In all regions of the world, women in the larger cities are most likely to be found in the lower ranks of clerical, sales and service occupations rather than in production and manufacturing. The proportion of women in such occupations far exceeds that of men. In Asia, the proportion of city women in production jobs reaches a high of 33 per cent, compared to 50 per cent for men. While the proportion of women in administrative, technical and managerial positions has been increasing, educational and social barriers still trap many women in low-skilled and low-paying work.10
Many developing countries have sought to generate employment and attract industry by creating export promotion zones in which duties and taxes are significantly reduced or waived as an incentive for foreign investment. Also waived are labour regulations which protect wages, hours, and conditions of work. Women in particular are recruited for low-skilled and low-paid employment in such activities as textile, garment assembly and other small-scale manufacturing activity. Journalists' reports and systematic studies11 indicate that such employment opportunities frequently also involve opportunities for exploitation rather than for empowerment. While providing some income, they have little effect on poverty and may even contribute to it in the long run.
Women migrants have fewer opportunities than men. Though many migrants of both sexes often find their first employment in occupations lower than their aspirations, after a period of time upward mobility is stronger for men.12 Men are more likely to enter formal-sector jobs, jobs with clear career progressions such as apprenticeships, and to advance in their positions or switch to jobs closer to their initial preferences.
Cities draw migrants with the promise of higher living standards, but the wealth produced in cities does not necessarily translate into prosperity for all. The best opportunities are open to those with entrepreneurial skills, influence and access to services and support. Two issues are important: the relative degree of income inequality, and the changes in these conditions over time.
Studies of selected megacities show that in the late 1980s the proportion of the urban population under the poverty level was roughly comparable to national poverty levels in Korea, Brazil and Egypt; in Nigeria, a higher proportion were poor in Lagos than in the country as a whole.13 Data from China suggest that income differentials in urban areas have become lower than in rural areas, in contrast to the usual situation. It is clear that income distributions became more skewed (i.e., the proportions of both poor and wealthy increased) in Brazilian metropolitan areas during the 1980s.14 In Asia, urban poverty has been decreasing proportionally since the mid-1980s in a number of countries.15
However, even with this success, income inequality is increasing. Opportunities for the more advantaged are increasing at a faster rate than those available to the disadvantaged. Access to services, particularly health and education, for all, including the poor and disadvantaged, will be essential to reduce these biases and prevent their perpetuation in the next generation.
Water and sanitation
Providing adequate water supplies for burgeoning urban populations is both difficult and expensive. Many cities in developing countries have already tapped all existing water supplies and must now bring water from great distances or reprocess used water. Better management and reduction of losses from leaks and diversions could effect large savings. However, expanding the distribution system is out of the question for cities which cannot afford to maintain the present one. Newly-settled sections are far from the centre and on difficult terrain.
Private water vendors fill the gaps, supplying an estimated 20 per cent or more of the urban population of developing regions.16 But this service provides water of uncertain quality at a premium price. A review of water costs in a variety of cities indicates that private vendors charge from four to 100 times the cost charged by public utilities.17 The result is to place an additional burden on the poor, who pay high prices for bad service and at the same time subsidize cheap water for the better-off through their payment of taxes.
Expensive and poor-quality water is an additional tax on poor urban women, who are still performing their traditional role of finding water and fuel. They may spend hours waiting in line for a stand-pipe which is turned on for a few hours a day.
It seems nevertheless that urban water supplies are still better overall than rural18, and that both have improved, though there are some questions about the quality of information and the usefulness of definitions associated with these findings.19
Power for lighting, cooking and other household amenities has become more widely available in both urban and rural areas over the past decade. About three quarters of the urban population had access to the power infrastructure at the start of the 1990s. However, the poor in both urban and rural areas are seriously underserved. The richest 20 per cent of populations have access to the best available sources; only a small fraction of the poorest 20 per cent have similar access. For example, electricity is accessible to 99 per cent of the richest quintile in Mexico, but to only 66 per cent of the poorest. In Côte d'Ivoire, the corresponding access levels are 75 and 13 per cent. The poor generally have less access in urban centres as well.20
Where power supplies are not available, as is usually the case in informal settlements, it is the women who search for fuelwood or other local materials (e.g., animal waste) for heating and cooking, though men may buy and carry kerosene. Household pollution from low quality fuel sources is a common contributor to respiratory disease, particularly for women.
In urban squatter settlements, electricity is often diverted from power grids. This practice makes it difficult for utilities to finance the expansion of services to underserved areas. Where power prices are subsidized, most benefit goes to middle- and upper-income families who can best afford pumps and consumer appliances; such policies further constrain prospects for extending systems and reforming pricing policies.
Individuals' sense of well-being and security as well as productivity is directly affected by their state of health and their expectations of a healthy life for their families and communities. It is so vital a component of national capacity and so clear an indicator of development status that it has been used by the International Conference on Population and Development, the Fourth World Conference on Women and other international conferences for the formulation of short- and medium-term goals of national progress.
Over the past 30 years life expectancies have increased in all regions of the developing world, with those in East Asia and the Caribbean nearing the levels of the developed regions. In many countries infant and child mortality rates have declined and maternal mortality rates have improved. These indicators reflect the variety, frequency and intensity of the disease burden. National indicators alone, however, do not illuminate the role of urban growth in shaping health risks and opportunities.
Understanding the dynamics of disease helps to illuminate the relative risks of urban populations. Health depends directly on the resistance of the population to disease, on the virulence of the disease-causing pathogens or disease agents, on lifestyles and social interactions, and on the nature of the responses of the health delivery system. Each of these is different in cities than in more rural areas, and is different for the poor than for the better-off.
Better nutrition, reflecting higher incomes, is usually assumed to have enhanced resistance to disease in the developed regions as they underwent urbanization.21 However, any close inspection reveals a vastly more complex situation.
Cities the healthy alternative?
Urban-rural health differences have not always favoured urban populations. Infant and child mortality in Holland in the late nineteenth century was lower in a sample of rural communities than the corresponding figures in some cities. Only the urban rich had lower infant and child mortality rates than the rural poor. Even the rural poor had lower rates than the urban middle class. Data from England as recently as 19101912 indicate that mortality from several of the commonest diseases was lower among farm labourers than among better-paid urban professional and salaried workers.22
Today, in both developed and developing countries the urban poor have the highest health risks. Lower income and poor living conditions are usually associated with poorer health status and increased mortality. At higher income levels the rural-urban balance of populations and the distribution of health services become more important than income alone.
Recent developments point to increased risks in urban areas: from pollution and other factors in environmental health; lower public expenditures in the health sector; the emergence of new diseases; the reappearance of more virulent or drug-resistant strains of older scourges; the quicker spread of infectious disease; and the interactions of viral and bacterial infections (including sexually transmitted diseases and HIV/AIDS).
Demographic, social and environmental health risks
Demographic, social and environmental conditions in cities have an affect on the incidence of both infectious and chronic diseases.
Demographic: Fertility rates continue to fall due to the impact of effective reproductive health and family planning programmes, the decline in mortality and improvements in economic conditions, while the age structure of populations continues to change, with proportionally more of the population in the older age groups. People over the age of 65 are the most rapidly increasing group in many countries.
Countries which have had the most rapidly changing age structures, particularly in East Asia, are finding a growing demand for services for chronic diseases, which affect older people more than young ones.
Social: Population densities in urban settlements generally exceed those in rural areas. Crowding is an important element in disease transmission, particularly of airborne infectious agents. The incidence of tuberculosis cases fell in the more developed countries of the world in part because of reductions in the density of populations in urban areas, though its re-emergence has more to do with drug-resistant bacteria and infections which weaken the immune system such as HIV than with population density.
In most parts of the world, women are bearing fewer children, but that does not necessarily mean less crowding in societies where the nuclear family is the exception rather than the rule. Providing shelter and support for elderly parents and poorer relatives is not only customary but an essential part of the social security system in many countries. This may be changing, in East Asia for example, where incomes are rising and there is a trend towards the nuclear family. A trend towards nuclear families can worsen environmental stress since the household is a basic unit of consumption. The continued spread of shanty towns and other informal settlements around major cities clearly indicates that local population densities continue to rise even as household sizes decline.
Environmental: Cities harbour threats to health unknown in rural settings. Most important is the pollution of air and water as a result of industrial activity, transportation and cooking exhausts. In the larger megacities, particulate concentrations are direct hazards to health. Mexico City and São Paulo, for example, are afflicted with excessive levels of carbon monoxide, ozone and particulates that lead to increases in respiratory and cardiovascular diseases.23 In Mexico City, lead poisoning caused by emissions from cars and trucks is thought to be the cause of 140,000 children requiring remedial education, and of hypertension in 46,000 adults of whom 330 die yearly from heart attacks. In Cairo, lead concentration in the air is five to six times greater than global norms and the blood of children has lead content levels three to five times higher than children in rural Egypt.24
In settings where infectious diseases remain serious health threats, often compounded by malnutrition, faulty sanitation, unsafe water and pollution, and where chronic disease and disability are also rising, different segments of the population find themselves pitted against each other in competition for public resources and for institutional priorities. Governments and local authorities have to choose among conflicting demands the needs of the old versus the young, the poor versus the better-off, the acute and pressing versus the long-term and systemic. These are hard choices and made no easier by shortages of resources for what are and must largely remain public services, paid for from taxes and revenues on the productive sectors of the urban economy.
The case for meeting the needs of the poor is frequently drowned out by the clamour of the better-off, who claim that they are the productive members of society and should have first call on resources. But failure to meet the needs of the poor will both prevent them from becoming productive and drive the already productive to locate in more congenial surroundings. This is the public policy dilemma faced in one form or another by all cities in the modern world.
Public health and the cities
Better health overall since World War II has been attributed to better drugs and medical technology, to better public health, including infectious disease prevention and control, to better nutrition and to improvements in the availability of clean water and sanitation. The extent of the improvement in water and sanitation is frequently overestimated in official statistics, however, particularly for the urban poor. Improved nutrition has helped some populations to live more healthy lives.
Nevertheless, for the poorest members of the population, both rural and urban, these amenities and services remain the exception. In both industrialized and developing countries poverty and ill-health are connected. Where improvements have been noted, they are largely the result of public health intervention measures, especially infectious disease prevention and control, and maternal and child health including family planning. On both fronts there is room for both optimism and concern as the urban future unfolds.
Increasing urbanization will affect the future course of many infectious diseases:
Tuberculosis and respiratory diseases: Acute respiratory infections, tuberculosis and other airborne infections are a major source of death and ill-health in rural and urban areas in the developing world. Tuberculosis afflicts about 20 million people and is responsible for around 2.7 million deaths per year. Acute respiratory infections take the lives of 4 to 5 million infants and children. These diseases tend to be more prevalent in urban areas. The highest incidence tends to be in the poorest, most-crowded areas.25 Overcrowding and poor ventilation can lead to multiple members of families being infected.26 The emergence of diseases of the immune system, particularly HIV/AIDS, has increased the prevalence of tuberculosis, which is a common opportunistic infection of affected populations.
Malaria: In general, malaria is less common in urban areas, because urban development reduces densities of the carrier anopheles mosquito. This is still true in sub-Saharan Africa, but in South Asia the mosquitoes have adapted to urban life.
Fewer mosquitoes and better availability of anti-malarial drugs have lowered mortality. This improvement may not continue because of the emergence and rapid spread of drug-resistant strains, helped by increased contact between urban and rural populations and between countries.
About 400 million people are currently infected with malaria. It is the fifth most common cause of ill-health in the world, and causes an estimated 2 million deaths per year. Nearly half of these deaths are among children under 5, some of whom succumb to malaria in combination with nutritional deficiencies and respiratory disease.27
Vaccine development has been slower than hoped; further progress depends as much on the complexity of disease dynamics and the adaptability of disease organisms as on the ingenuity of researchers. Insecticide-treated bednets and other low-tech approaches can be effective among an aware population with resources to spend on such items. Public health information and prevention campaigns were highly successful in the 1950s and 1960s and could again yield benefits, but depend on a commitment to spending which many poorer communities are unable to make.
Cholera: Spread by contaminated water, cholera is endemic in many countries in Africa, Asia and Latin America. It also affects many other countries (including 27 in Europe). On a global basis, 377,000 new cases were reported in 1993. Cholera has reappeared recently in a wide variety of settings from which it had previously been eliminated: overcrowded settlements where there is a lack of basic sanitation and safe water create the opportunity for epidemics. Refugee camps and the poorer areas of cities have been the sites of some of the more dramatic recent outbreaks. In 1992, a new strain appeared in Asia and spread rapidly through Bangladesh, China, India, Malaysia, Nepal and Pakistan.28
Cholera can be successfully treated in most cases, and incidence has declined from its peak in 1991, but the future is uncertain. It depends in the first place on the ability of the public health services to handle a continuing high case-load, but ultimately on safe and dependable water supplies for urban populations.
Emerging viruses: Haemorrhagic fever viruses have been implicated in infections and deaths in a variety of locations around the world. In haemorrhagic fevers, patients develop high fevers followed by an agonizing general deterioration in health during which bleeding often occurs. In the most serious cases, patients die from massive superficial and internal bleeding or from multiple organ failure.
Different families of these viruses have been identified: filoviruses (which include Ebola and Marburg), arenaviruses (which include Lassa, Junín, Machupo, Guanarito and Sabià), flaviviruses (which cause dengue fever), and bunyaviruses (one of which causes Rift Valley Fever). Most of these viruses have been around for long periods of time, perhaps millions of years, in animal populations. Changing environmental conditions, both artificial and natural, have allowed them to multiply and spread. Dengue fever, and its more serious haemorrhagic form, has been spreading through Latin America in recent years and is carried by insects readily found in cities. As a virologist at the Pasteur Institute has written, "The expansion of world population perturbs ecosystems that were stable a few decades ago and facilitates contacts with animals carrying viruses pathogenic to humans."29
The 1995 outbreak of Ebola virus in the Zairean town of Kitwit galvanized international attention. The World Health Organization helped coordinate a local response and an international assistance effort which succeeded in ending the epidemic within six months and in limiting the number of individuals infected to only 316 of whom 245 died.30 This highly fatal disease had previously appeared only in relatively small and isolated communities in Zaire and the Sudan. The spread of these outbreaks has so far been limited in part because the virus kills too quickly to be spread without human assistance such as poor medical hygiene or rapid transport and because transmission involves contact with bodily fluids which can be prevented by isolating patients and by the rapid burial of the unwashed bodies of the dead.
The appearance of the disease in a large settlement with easy transport access to the capital of Kinshasa and the wider world raised the spectre of such an infection establishing itself in a large urban settlement and spreading. This could occur due to increased contact between isolated areas of disease and urban centres. If a mutation or genetic combination with other viruses were to make a virus like Ebola capable of airborne transmission, it could cause a global catastrophe, a scenario which is already the subject of novels, movies and epidemiologists' nightmares.
Antibiotic-resistant infections: The widespread use of antibiotics has contributed significantly to better health in the past 40 years. However, medical practitioners worldwide have become very reliant on antibiotic drugs, even for treating relatively benign infections. They are also used heavily in industrialized countries as prophylaxis against possible infection after injury or in hospitals after operations, and on animals and crops used for food. In combination with other factors, such as patients' natural tendency to discontinue taking medications when they feel their health improving (especially when drugs are expensive and incomes low) but before the infection is eliminated, this reliance has created the conditions for the rapid evolution of drug-resistant strains of infections.
Common and harmless bacteria such as E. coli can become dangerous when antibiotic-resistant strains develop and spread by exposure to waste and by the unsanitary preparation and storage of food. Staphylococci and streptococci infections, long routinely controlled by antibiotics, can seriously complicate recovery from wounds, surgery and respiratory infections, especially in already weakened patients. The development of strains resistant to common antibiotics has forced doctors to switch to less common drugs, which are becoming less effective in their turn. The biology of bacterial resistance to antibiotics poses additional problems: direct exchange of genetic material, including antibiotic resistance, between diverse strains of bacteria has been observed by researchers.
The effectiveness and low cost of routine antibiotics encouraged the belief that bacterial disease could be defeated altogether and discouraged research on new antibiotic compounds; but common infections are regaining strength. Urban life, with its dependence on modern medicine and its constant interaction with a wide variety of people, creates ideal conditions for easy transmission. Urban areas, especially crowded poor urban areas, provide the opportunity for people with multiple infections to serve as incubators for new resistant strains.
Whether future medical ingenuity can outpace the evolutionary adaptation of bacteria remains to be seen. Making new countermeasures available in poor urban areas will be a challenge but will be necessary if bacterial resistance is not to deepen and spread still further afield. Still more necessary are public health intervention measures in all countries to limit the use of antibiotics and encourage their effective use, as well as limiting the transmission of infection. This must include better health facilities, better and less-crowded housing, cleaner food and water, and more efficient waste disposal. Otherwise the health crisis of the urban poor could rapidly become a global crisis.
STDs/HIV/AIDS: Sexually transmitted diseases (STDs), including HIV/AIDS, account for more than 10 per cent of the disease burden for both men and women on a worldwide basis.31 The World Health Organization recognizes that sexually transmitted diseases are most frequent in sexually active young people aged 1524 and that these high incidences are continuing. The highest rates for notifiable STDs are generally seen in the 2024 age group, followed by those aged 1519, then those aged 2529. However, in most of the world the age peak of infection is lower in girls than in boys.
Two STDs, gonorrhoea and chancroid, are now reported to be resistant to inexpensive antibiotics.32 The relative prevalence of STDs in urban and rural areas is not well documented. Anecdotally, however, STD risks to teenagers are higher in cities than in rural areas. Traditional barriers to early sexual activity are more likely to have broken down in urban settings.
According to WHO, an estimated 20 million people globally have been infected by the HIV/AIDS virus; 18.5 million adults and 1.5 million infants. The annual number of deaths has been increasing as those infected in earlier years progress to AIDS. It is estimated that the death toll will exceed 8 million per year by 2000. While other diseases have higher annual death rates, the tragedy of AIDS is compounded by the fact that it causes many of its deaths in the prime years of family formation and productive work life. Its impact on families and society is therefore not in proportion to its relative incidence.
STDs are a frequent co-factor for the accelerated transmission of the HIV/AIDS virus. This is reflected in the historical epidemiology of the disease. In both developed and developing countries, urban areas initially demonstrate the highest levels of HIV incidence. Over time the epidemic diffuses to rural areas, generally spreading over heavily used road networks and then to the general population. Even small groups of people who engage in high-risk sexual behaviours in urban centres such as intravenous drug users, prostitutes, transport workers and migrants separated from their spouses may suffice to fuel successive waves of the infection into the population at large.33
Those at highest risk for STD/HIV/AIDS infection include individuals with large numbers of sex partners (including prostitutes) and drug users, and their sexual contacts. The AIDS epidemic in a single country has been described as an intersection of different epidemic episodes in different risk groups followed by the diffusion of the disease into transmission via heterosexual intercourse through the larger population.34
The groups at highest risk, particularly in the earliest stages of the epidemic, are present in disproportionate numbers in urban populations. Young women are often either already at risk or are taken to be desirable sexual partners by older male members of high risk groups, including those infected. It is estimated that half of HIV infections have been contracted by people under 25 years of age. Up to 65 per cent of infections in females are believed to occur by age 20.35 STDs in general are more treatable in urban areas with their higher concentration of health facilities and better public health services, but the challenge is also greater here.
The HIV/AIDS epidemic spreads from urban centres during the early stages of the epidemic. A noteworthy portion of poor women migrants turn to prostitution to support their families in the village. In sub-Saharan African samples, estimates range as high as one half of migrants, in Indonesia around one third. Higher proportions may be observed elsewhere in East Asia. In Thailand, a large proportion of the migrants to cities are young women, and prostitution, voluntary and coerced, has been tolerated. It is a common source of income and remittances, but also ensures a steady flow of HIV-infected women back to their villages. The high return of prostitution compared with other employment is a strong incentive for some poor young women seeking to support themselves and their family members, but it is also highly dangerous for these women and coerced women, for their clients and their clients' other partners.36
Migration will have serious implications for the course of the AIDS pandemic. Returnees to rural areas tend to have more sexual partners than those who stayed at home, and they may also have picked up other high-risk habits such as drug use. Better roads and easier transport point to increased transfer of disease risks, including HIV/AIDS, between rural and urban populations.
As AIDS is most predominantly a disease of young adulthood, it exacts a heavy toll in cities on highly skilled and educated early and mid- career workers precisely those most needed for development, and those in shortest supply. The immediate economic effect of the loss of such workers, the cost of replacing them and the long-term effects of losing so many men and women in their most productive years has yet to be fully experienced; but it may have serious effects in some rapidly developing countries. Social costs include the damage to young families of the loss of one or both parents, and the creation of a generation of orphans. Some of the rural families hardest hit by AIDS are already making their way to join the ranks of the urban poor.
Diseases migrate too
The emerging viruses are only the most dramatic example of rural diseases establishing themselves in urban areas. Chagas fever, for example, is transmitted to humans by beetles which have now adapted to life in the scrap wood used for building in shanty towns. This disease is controllable but difficult to diagnose and has seriously debilitated many sufferers, particularly in Brazil.
Urban environments, particularly in poorer sections of cities without proper water, sanitation and solid waste services, are hosts to rats, mice and insect carriers of disease. Dengue fever has reached epidemic proportions in Central and South America with over 135,000 reported cases in 1995. Dengue is carried by an urban mosquito. It thrives where there is no running water and the larvae of the mosquito can grow in places where water collects, such as barrels and tyres.37
The health effects of tobacco use, junk food, drug and alcohol abuse and sexual experimentation are increasingly coming to the attention of health professionals in urban areas of developing countries, partly as a side-effect of exposure to the media and mores of more affluent countries. A WHO conference on the health situations in the United States, Britain, China, Bahrain, India and Kenya took note of this new burden on health systems. Indu Capoor, a health activist from India, noted, "In urban areas we are getting the problems of the West drugs, sexual experimentation and fast food like chocolate and soda." Dr. David Nyamwaya of the African Medical and Research Foundation in Kenya observed, "We are seeing that kids are copying what they see on television in terms of violence, drug abuse and sexual experimentation."38
The international mass media and the spread of a world-wide youth culture may present a threat, but they also present an opportunity to send effective messages about positive and responsible behaviour if the will and the resources exist to do so.
Infant and child health issues
Poverty is a pointer to infant and child as well as adult health problems. In Porto Allegre, Brazil, the infant mortality rate (IMR) in squatter settlements is three times that of non-squatter areas, over 75 deaths per thousand live births.39 In Quito, Ecuador, in the early 1980s the IMR in upper-class districts was 5 per 1,000 live births, comparable with more developed countries today. At the same time, manual workers in Quito's squatter settlements saw their children die at a rate of 129 per 1,000 live births, a rate slightly below the global average at that time for least developed countries. Similarly large differentials have been observed in the Philippines, Sri Lanka, England and Wales and elsewhere.
Childhood exposure to many diseases and the incidence of, for example, leprosy, hookworm, diarrhoea, cholera, other parasitic infestations and polio are clearly related to income differentials within urban areas. The higher levels of disease incidence are also tied to malnutrition and lower levels of available or affordable medical care.
Death among newborn children is higher in rural areas, except for a few countries such as Malawi, Panama, Colombia, Tanzania, Turkey and Vietnam. Infant mortality is lower in urban areas except in Namibia, Vietnam and Panama where the differences are very small or non-existent, and Tanzania, a highly urbanized country strongly affected by a weak economy and the effects of structural adjustment policies.
Infant survival chances are generally much better in urban areas, except among the poorest groups who have little or no access to regular health care. Squatter and shanty settlements usually have no services of any kind, and residents may be barred or discouraged from using those in nearby neighbourhoods. Even emergency services, which are generally in town centres, may not be readily available to the many who live in settlements on the outskirts.
Higher proportions of women receive care during their pregnancies in urban than in rural settings.40 While over two thirds of women receive prenatal care in rural areas, the corresponding figure for pregnant urban women is nearly 90 per cent. Together with better maternal nutrition, this greatly increases the survival chances of newborn infants. Public medical services are located overwhelmingly in urban settings (particularly district hospitals, teaching hospitals and other tertiary care facilities). Because of better access to medical services, urban women are likely to receive higher levels and better quality maternity care than their rural counterparts. The urban poor, however, often lack access to these services. They are likely to have fewer contacts with the health system during the course of their pregnancies than those more advantaged.
Institutional deliveries are much more common in urban areas of developing countries than in rural. The median proportion of births which take place in an institutional setting in urban areas is over 77 per cent. In rural areas, the median percentage of births in medical settings is only 35 per cent.41 The place in which women choose to give birth is the result of a wide variety of considerations. Social, cultural and economic factors all enter into family preferences and into their ability to act on them. Even where non-medical settings are preferred as the place of birth, however, trained birth attendants significantly reduce the health risks of childbirth to both mother and baby. Such help is much more likely to be on hand in an urban setting.
Trained attendants are more often present at births in urban areas than in rural areas. Doctors are more likely to be the attendants in urban settings than in rural settings. Higher attendance by registered nurses and midwives also contribute to the overall advantage of urban settings. Traditional birth attendants generally constitute a higher proportion of the overall percentage of trained personnel in rural areas even in countries where their services are used in both rural and urban settings.42
Maternal mortality is devastating and almost completely avoidable, although around 585,000 women still die each year in developing countries from complications associated with pregnancy or delivery, or from perinatal infection. Reliable separate estimates of urban and rural maternal mortality ratios are rarely available; where they are, urban maternal mortality is consistently lower than rural.43 This is probably the result of better medical treatment during pregnancy and, particularly, of greater access to emergency obstetric care in the case of pregnancy and delivery complications. This pattern may not hold for the many poor urban women living in informal settlements on the outskirts of cities, however, since emergency services are usually located in the centre and they have little if any better access to routine pre- and perinatal care than their rural counterparts.
Reduction of maternal mortality in rural areas to urban levels means overcoming problems of transport and distribution of services. Both urban and rural areas will require trained medical personnel, available safe blood and necessary equipment and supplies. The Mother-Baby Package44, supported by WHO, the World Bank and UNFPA, describes the necessary inputs and priorities for effective intervention to reduce both maternal mortality and early infant mortality. The ICPD Programme of Action calls for the elimination of programme-based differentials in service access by the year 2005 and universal access to reproductive health care services by the year 2015.
Towards better reproductive health
While reproductive health services are more readily available in urban than rural settings, the capacity of existing institutions to expand their outreach and improve their quality in the face of expanding demand and contracting financial resources is uncertain. Public budgets for health services have been shrinking in many countries, particularly those which have adopted structural adjustment programmes. The energies of non-public sources of reproductive health services must be effectively mobilized. Non-governmental organizations, community-based approaches and private-sector activity will need to supplement public efforts to strengthen the entire health delivery system.
Extending the reach of reproductive health care services has been a historical priority: improving quality is now recognized as equally necessary for effective service. This applies to urban as well as rural settings, though quality is generally better in urban areas.
A Situation Analysis undertaken by the Population Council in Peru dramatizes the difference. An index was constructed to describe eight important elements of the quality of care: health provider competence, range and freedom of choice, adequacy of counselling and follow-up, privacy and cleanliness, supply availability, attention to a variety of reproductive health needs. Highest quality service delivery points (SDPs) would score eight points. Clinics in urban areas averaged 5.31 compared to 1.64 in rural areas. Differences favouring urban settings were observed for all of the dimensions denoting quality of care.
Even in urban settings, greater attention to the quality of services is needed. Shortcomings were noted in both information and services: for example, information important for proper or informed use of different methods was not regularly provided. Providers imposed restrictions on the services offered based on the marital status, age or parity of the client or the presence or absence of explicit partner consent. Services in rural areas were of low quality on all dimensions. The clinics performed worst in providing information and maintaining cleanliness.
Rural clients also had the fewest contact points offering reproductive health services including family planning methods. Many rural service points did not offer immunization, pap smears or pregnancy tests: many urban service points offered at least two of these.45
These differences are clear in Peru which has a moderately well- developed maternal and child health system. In Peru nearly 60 per cent of the women use some method of contraception, nearly 90 per cent of women know a source for family planning services, 60 per cent of births are attended by a trained physician and more than three quarters of one- year-olds have been immunized against TB, diphtheria, pertussis, tetanus and polio. Peru is, however, heavily urbanized (72 per cent of the population) and other social indicators reveal large urban-rural differences. For example, sanitation is estimated as being available to 58 per cent of the urban population but only to 25 per cent of the rural.
Situation analyses in sub-Saharan African countries with health systems at different stages of development46 and in selected single cities further highlight differences between rural and urban areas. Urban service delivery points in Ghana, Senegal, Kenya and on Zanzibar were more likely to have running water. Only 29 per cent of rural service delivery points in Ghana had running water compared with 52 per cent of urban centres and, in Senegal, 54 per cent as against 96 per cent of urban SDPs. Electricity was widely available in urban SDPs but even less likely to be found in rural settings than running water. Both are essential for hygiene and thus for good quality of care.
The use made of individual SDPs depends on the size of the surrounding population, how much choice they have and local demand for services. It also depends on the effectiveness of the SDP's outreach and the quality of services it offers. In Ghana, urban SDPs averaged over 1,000 client visits per year, two to three times more than SDPs in rural or semi- urban settings. In Kenya, urban and semi-urban SDPs averaged over 1,700 family planning visits per year, twice as many as rural SDPs. In Senegal, urban SDPs, with over 2,000 visits per year on average, were more than twice as active as semi-urban SDPs which in turn serviced more than three times as many client visits as rural SDPs. On Zanzibar, urban SDPs account on average for more than 11 times the number of visits of the rural clinics but the total geographical area is relatively small and the urban area is also accessible to many rural residents.47
Both urban and rural SDPs with better facilities draw more visits. The difference is greater for rural SDPs: the 29 per cent of Ghana's rural SDPs which had running water accounted for 47 per cent of the annual visits. It is not clear whether better-equipped SDPs generate and sustain more client contacts, or whether client demand encourages investment in better facilities: the answer is probably some combination of the two. In any case improvement in all settings, and particularly in poorly-equipped rural SDPs, should be an important priority.
In other respects, the study found that differences between rural and urban services are neither clear nor consistent. There is no evidence of urban bias in programme capacity or in the services offered.48 IUD insertion, which requires trained personnel, is generally more available at urban SDPs, which also usually have somewhat better equipment and stocks. Supervision of staff, a key to service quality, varies little between urban and rural settings within countries but differs considerably between countries. Better supervision is often seen in clinics in urban areas with larger numbers of annual visits, but again it is hard to say whether better supervision encouraged more visits or vice versa.
Overall, programme effort and capacity was distributed relatively evenly between rural and urban SDPs49, with broadly similar training levels, logistics management, completeness of examinations, quality of the interaction between provider and patient, and attention to broader reproductive health concerns (especially STD/HIV information and services).
Continued improvement in the quality and coverage of services is a national challenge: infrastructure improvement needs more attention in rural areas, but better management, logistics, supervision, and counselling is a universal requirement.
Reproductive health in the cities: Examples from Africa
Situation analyses in individual African cities50 revealed needs more clearly. In Mombasa, Kenya, for example, demand for family planning services may increase by 200 to 700 per cent over the next 20 years, but even the current demand cannot be met. Most SDPs lack the equipment and commodities to provide a full range of contraceptive methods, and some lack laboratory facilities and running water. Existing services are not well advertised and information about family planning methods is selectively given. Staff training in STD/HIV information and in communicating with clients need improvement. On the positive side, clients were given adequate information to facilitate follow-up and were well instructed about their future needs. Most clients were satisfied with the services they received. Reproductive health services other than family planning were available at many SDPs but were not well integrated with family planning activities.
A particular problem in Bulawayo, Zimbabwe, is that most public SDPs are located in outlying residential districts and are closed during the evening. Most private SDPs and pharmacies are in the city centre. The working population that leaves the residential areas during the day but relies on public facilities (which supply nearly two thirds of the city's needs) is therefore poorly served in the evening hours. An adjustment in either the hours of availability of public services or the location of private services could increase the ability of the system to meet current and future unmet demand.
In Blantyre, Malawi, unmet need for long-term family planning methods is high, but there are alternatives to the government-provided SDPs for example pharmacists, some of whom are known to be interested, or medical clinics in industrial plants, which currently do not offer family planning or other reproductive health services. Better education of staff and clients could allow these facilities to address the demand.
Financing reproductive health and family planning in the cities
As national economies and personal incomes grow, the market can play a larger part in reproductive health services including family planning. In Thailand, for example, pills account for nearly 30 per cent of contraceptive use: in the cities over 70 per cent of users get such pills from private sources rather than government clinics, but in the poorer rural areas the proportions are reversed. Except for condoms, private sector family planning is more expensive for clinic methods between two and five times more expensive.51
The ability to pay is only one factor. In some places relatively poor people would rather spend money on contraceptives than be seen in a government clinic; elsewhere relatively affluent people queue up with the rest. Some users will pay for services if they are sure that their money will go towards better reproductive health services. Others will pay to assure a regular supply or better quality. In Bolivia, a private voluntary organization has been gaining clients from the Ministry of Health though their rates are the same. The difference involves the clients' perception of quality, even though experts found no difference.53
Cost recovery and insurance schemes can be successful in urban areas, but the poor may lose their access to services unless careful attention is paid to subsidies and means-testing, with guaranteed supplies for the poorest. In Cebu, the Philippines, for example, nearly two thirds of subsidies were found to benefit the better-off54 and the poorest quarter of the population realized only 17 per cent of the benefits. Most subsidies for permanent methods were directed to the poorest quarter.
However, it is fair to note that the proportion of subsidies going to upper-income groups for public services such as hospitals and higher education in developing countries is typically far greater than for family planning. Some spillover of benefits to the better-off may be the necessary cost of programmes to benefit the poorest. On the other hand, the collection of some contribution, however small, may actually enhance the perceived value of services among the poor. Both can help mobilize support across income groups.
Education, and especially education for girls, is widely recognized as essential for sustainable development. This fundamental fact has been recognized by all the recent international conferences: at the International Conference on Population and Development in 1994, at the World Summit on Social Development in 1995 and the Fourth World Conference on Women in 1995. In general, urban areas have the advantage over rural areas in proportions of primary schools which offer all grades, the number of schools available, and enrolment ratios.55 These advantages are further magnified at the secondary and tertiary levels. Decisions on the placement of schools in rural areas depend on a wide variety of considerations. The location of the population and ease of access for the largest number of students are frequently not decisive.56
Investment in schooling is a substantial proportion of social sector investment in many developing countries.57 Nevertheless, given the growth of school-age populations, reaching the international goals of universal primary education and universal literacy will call for unprecedented creation of new places in schools. To keep up with needs, creation of new primary school places by the end of this decade must exceed the average of the 35 years since 1960 in 58 of 81 countries assessed. In about a quarter of them the pace will have to be more than five times greater than the historical average. Sub-Saharan Africa will need to create spaces for new primary school students at more than 3.5 times the previous average annual rates; even though recent trends ominously show worsening enrolment rates. By 2025, it is expected that falling fertility will have reduced significantly the numbers of school- age children, but long-term fertility decline depends on the development process. The need for a more educated labour force cannot be deferred without making existing problems worse and creating new ones.58
The quality of education is as vital as the number of students to be educated. Overcrowded schools with inadequate supplies and facilities and failing physical conditions cannot educate effectively. Such stratagems as increasing class size and multiple shifts in the same facilities do not make up for shortages of chairs, desks, books, chalk, writing materials and paper. They reduce personal attention and accelerate the deterioration of physical plant.
Drop-out rates in primary school are high. In many developing countries, particularly in the least developed, only a small proportion of those who complete elementary school go on to secondary education. This may be a family decision encouraged by poverty or a low perceived value for education, but it may also, particularly in urban areas, be enforced by an overstrained school system which can only make room for a small proportion of secondary students. In these circumstances, there is a heavy bias against the children of poor families. The bias is greater against girls when difficult decisions are being made on priorities for allocating scarce family resources. The assumption is that girls will benefit less from education and will return less of the investment to the family. Girls are assumed to be needed at home, and education is seen as a luxury which poor families cannot afford. This has created a gender gap in education which varies from country to country but is highest among the poor.
The International Conference on Population and Development recognized both the gender gap and the need to eliminate it, agreeing that women were the strongest untapped human resource for any developing country. There is an equally strong and well-recognized connection between women's education and their ability to bring up smaller, healthier and better-educated families.
Smaller age groups coming into the education system have enabled many of the faster-growing economies to reallocate resources to quality rather than quantity in education and build a firmer base for further economic and social advance.59 This is the aim that has been accepted by the international community.