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Future of urbanisation and the role of British aid: Primary health care in an urban environment
HABITATINTL. Vol. 12, No. 3, pp. 133-137,1988. Printed in Great Britain.
0197-3975188 $3.00 + 0.00 Pergamon Press plc
Future of Urbanisation and the Role of British Aid: Primary Health Care in an Urban Environment* DAVID MORLEY Professor of Tropical Child Health, Institute of Child Health, 30 Guilford Street, London WClN 1 EH, UK
INTRODUCTION
People move to the city for good reasons. They hope and expect that their material way of life will improve, as shown in Fig. 1. Cities contain the political elite of the country. This elite persuade governments to spend resources in the city rather than in rural areas (Morley and Lovel, 1988). Money is spent where there is a high concentration of people who benefit from a water supply, education and other resources. The maldistribution of resources between urban and rural (Lipton, 1977) development is well illustrated in health care. Most of the world’s doctors live in the towns and the majority are determined to remain there with their children. As many of the present medical students are the children of doctors and other urban-based elite, the doctors of the future will have an increasing bias to urban life. Currently there is a dramatic increase in the cities of the world. Around two thirds of this is through natural growth of city populations of which just over a third in most countries is due to rural-urban migration (Fig. 2). The last 20 years has seen a mass of publication on health care in rural areas but relatively less on the needs of cities and particularly basic needs. Research into urban health care is more difficult. In rural areas they have a
Fig. 1. The shanty town will be the home to even more children. *This paper was a contribution to the seminar on “The Future of Urbanisation and the Role of British Aid”, held at the Development Planning Unit, University College London, on 24 February 1988.
133
134
David Morley
relatively “clean slate” and the communities appear homogeneous. In the cities there are great variations in community structure and much greater variety of competing health resources available. It is significant that one of the better teaching resources for health workers studying urban health problems has been produced by an expert in health care management (Ranken, 1987). This consists of 48 slides from Nai Basti, a Bombay slum. These can be used for two day workshops in which participants will improve their skills in community diagnosis, understanding health problems of slum areas, community planning, problemsolving, creative thinking to find solutions to problems, working out criteria for evaluating a health programme and how to present a plan. Mention has already been made of maldistribution of resources between rural and urban areas. Maldistribution of the most fundamental resource, family
The move to the cities f
=lOOmillion
people
living
in the cities
MORE
DEVELOPED COUNTRIES
1975
(W.H.O. '80. Rept.Wld.Hlth.p234)
(20)
Fig. 2. Cities in the Norfh may grow by a third those in the South which may increase two and a half times in the last quarter of this century.
Wages FAMILY INCOME PER PERSON
and infant (Rupees
per
deaths
Dsiths before the age of one year per 1000 babies born alive
month)
Less than 20rupees
up to 50
Fig. 3. Our concern must not be for the poor but the very poor if we are to reduce mortality.
Future of Urbanisation and Role of British Aid
135
income, can have a dramatic influence on the mortality of children with one city as shown in New Delhi (Fig. 3). Disparities between health care are unacceptable when families with a life expectancy for their children, similar to that in Europe, live within a stones throw of those with a mortality similar to that in remote villages. The health worker who wishes to be effective in the urban situation will be the one who can work closely with other disciplines. Some indication of the advantages of this inter-disciplinary approach are as follows. EDUCATION
Most developing countries rightly spend at least four times as much on education as on health; this is most effective when the majority of the expenditure is for the primary school. Child-to-child is a specific programme that brings schoolteachers and health workers into contact. Together they study how the tenets of primary health care, set out at Alma Ata, can be integrated into teaching in schools. Some of the existing and very varied child-to-child programmes are developing at the present time in cities such as New Delhi, Bombay, Nairobi, Kampala and Lusaka. Much of the world-wide spread of AIDS will be initially through the cities. In terms of long time survival of community the children in the top forms of the primary school are an obvious priority. Still largely uninfected this cohort is moving into a high risk age group. They are also a group to whom information and understanding which might lead to a behavioural change, can be most effectively directed once there is political acceptance of the need. HOUSING
Deprivation in the home environment results in social problems such as alcoholism, drug abuse, prostitution and street children, all of which have great health implications. The spread of urban violence also is a matter for concern to health workers particularly as it is both a producer and a byproduct of psychological ill health. Crowded living conditions lead to the transmission of viruses and bacteria in much larger doses. Although well recognised as a cause for more serious disease in animals, a large infecting dose has only recently been established as a cause for a four-fold increase in mortality in measles (Aaby, 1986). WATER
AND SANITATION
Inappropriate water supply is recognised as a major health hazard. Emphasis is now less on the absolute purity and more on the adequate quantity of the supply. Not only is the supply limited but the cost of what is available is high. In the Philippines studies show the poor may spend from lo-30% of their income on water supplied to them in cans at a price forty times higher than the middle class who obtain their water from a tap conveniently placed in their kitchen or bathroom. Human waste disposal is an enormous problem. There are only a limited number of options but success will depend on local knowledge of existing culture, together with a health education programme in which both men and women are involved. There is much to be taught, for example, the much greater infectivity of small childrens faeces is rarely understood by their guardians.
136
David Morley
TRANSPORT Many of those attending this meeting will spend around 2 hr travelling a day in relative comfort. In Nigerian and Indian cities workers have to spend 2-3 hr travelling under appalling conditions. The same applies for those seeking health care, rarely has room been left in slums for health centres although urban based physicians find lack of dispensaries profitable in slums. The relationship between distance from health facilities, their use and mortality is well shown in this figure concerning Bangladesh (Fig. 4). IMPACT
r
1000
Caseattendance per 1,000 diarrhoeal patients (+SE)
750
OF DISTANCE FROM TREATMENT ON ATTENDANCEANDMORTALITY (Ann. Rep.'SO, ICDDR Dacca)
CENTRE
c -200 Diarrhoeal mortality per 100,000 (+SE)
500
250
0
1
2 3 Distance
4 5 (miles)
6
Fig. 4. Those who live near health resources make more use of. them _ for the treatment of diarrhoea and have a lower mortality than those at a distance.
Appropriate Appropriate
Appropriate
aerlculture
education
community development
Approprlat health
I
boxes
Where
do we go from
here?
fo
11___
BREAK DOWN THE WALLS
GETTO KNOW EACH OTHER
WORK TOGETHER
Fig. 5. An interdisciplinary approach is essential
Future of Urbanisation and Role of British Aid
137
CONCLUSIONS
The cities of the developing world absorb a high proportion of the national expenditure on health. Maldistribution of these and other resources however leads to a morbidity and mortality among the poor similar to that in remote villages. Better distribution will depend both on political will and management expertise. Success will depend on an interdisciplinary approach. The UK in common with other countries of the North has a great responsibility towards a more equal distribution of resources. In our efforts to prevent dependency, resources can be best used if made available to help in training for and evaluation of existing and new programmes initiated within and by communities themselves.
REFERENCES Aaby, P., Bukh, measles mortality. Lipton, London,
J., Lisse, I.M. and Smits, A.J., Am. J. Epidemiol. 120, 49-63,
Overcrowding 1984.
and intensive
exposure
as determinants
M.. Why Poor People Stay Poor; A Study of Urban Bias in World Development. 1977.
Morley, D. and Lovel, L.. My Name Is Today. MacMillans, Basingstoke, Box 49, St. Albans AL1 4AX, UK for f3.00 including p. & p., 1986.
UK. Available
Temple
from TALC,
of
Smith, P.O.
Ranken, J., Planning urban community health. Set of 48 transparencies and work sheets available from TALC, P.O. BOX 49, St. Albans AL1 4AX. UK. Price f6.00 including p. & p. (f5.00 for developing countries), 1987.
0197-3975188 $3.00 + 0.00 Pergamon Press plc
Future of Urbanisation and the Role of British Aid: Primary Health Care in an Urban Environment* DAVID MORLEY Professor of Tropical Child Health, Institute of Child Health, 30 Guilford Street, London WClN 1 EH, UK
INTRODUCTION
People move to the city for good reasons. They hope and expect that their material way of life will improve, as shown in Fig. 1. Cities contain the political elite of the country. This elite persuade governments to spend resources in the city rather than in rural areas (Morley and Lovel, 1988). Money is spent where there is a high concentration of people who benefit from a water supply, education and other resources. The maldistribution of resources between urban and rural (Lipton, 1977) development is well illustrated in health care. Most of the world’s doctors live in the towns and the majority are determined to remain there with their children. As many of the present medical students are the children of doctors and other urban-based elite, the doctors of the future will have an increasing bias to urban life. Currently there is a dramatic increase in the cities of the world. Around two thirds of this is through natural growth of city populations of which just over a third in most countries is due to rural-urban migration (Fig. 2). The last 20 years has seen a mass of publication on health care in rural areas but relatively less on the needs of cities and particularly basic needs. Research into urban health care is more difficult. In rural areas they have a
Fig. 1. The shanty town will be the home to even more children. *This paper was a contribution to the seminar on “The Future of Urbanisation and the Role of British Aid”, held at the Development Planning Unit, University College London, on 24 February 1988.
133
134
David Morley
relatively “clean slate” and the communities appear homogeneous. In the cities there are great variations in community structure and much greater variety of competing health resources available. It is significant that one of the better teaching resources for health workers studying urban health problems has been produced by an expert in health care management (Ranken, 1987). This consists of 48 slides from Nai Basti, a Bombay slum. These can be used for two day workshops in which participants will improve their skills in community diagnosis, understanding health problems of slum areas, community planning, problemsolving, creative thinking to find solutions to problems, working out criteria for evaluating a health programme and how to present a plan. Mention has already been made of maldistribution of resources between rural and urban areas. Maldistribution of the most fundamental resource, family
The move to the cities f
=lOOmillion
people
living
in the cities
MORE
DEVELOPED COUNTRIES
1975
(W.H.O. '80. Rept.Wld.Hlth.p234)
(20)
Fig. 2. Cities in the Norfh may grow by a third those in the South which may increase two and a half times in the last quarter of this century.
Wages FAMILY INCOME PER PERSON
and infant (Rupees
per
deaths
Dsiths before the age of one year per 1000 babies born alive
month)
Less than 20rupees
up to 50
Fig. 3. Our concern must not be for the poor but the very poor if we are to reduce mortality.
Future of Urbanisation and Role of British Aid
135
income, can have a dramatic influence on the mortality of children with one city as shown in New Delhi (Fig. 3). Disparities between health care are unacceptable when families with a life expectancy for their children, similar to that in Europe, live within a stones throw of those with a mortality similar to that in remote villages. The health worker who wishes to be effective in the urban situation will be the one who can work closely with other disciplines. Some indication of the advantages of this inter-disciplinary approach are as follows. EDUCATION
Most developing countries rightly spend at least four times as much on education as on health; this is most effective when the majority of the expenditure is for the primary school. Child-to-child is a specific programme that brings schoolteachers and health workers into contact. Together they study how the tenets of primary health care, set out at Alma Ata, can be integrated into teaching in schools. Some of the existing and very varied child-to-child programmes are developing at the present time in cities such as New Delhi, Bombay, Nairobi, Kampala and Lusaka. Much of the world-wide spread of AIDS will be initially through the cities. In terms of long time survival of community the children in the top forms of the primary school are an obvious priority. Still largely uninfected this cohort is moving into a high risk age group. They are also a group to whom information and understanding which might lead to a behavioural change, can be most effectively directed once there is political acceptance of the need. HOUSING
Deprivation in the home environment results in social problems such as alcoholism, drug abuse, prostitution and street children, all of which have great health implications. The spread of urban violence also is a matter for concern to health workers particularly as it is both a producer and a byproduct of psychological ill health. Crowded living conditions lead to the transmission of viruses and bacteria in much larger doses. Although well recognised as a cause for more serious disease in animals, a large infecting dose has only recently been established as a cause for a four-fold increase in mortality in measles (Aaby, 1986). WATER
AND SANITATION
Inappropriate water supply is recognised as a major health hazard. Emphasis is now less on the absolute purity and more on the adequate quantity of the supply. Not only is the supply limited but the cost of what is available is high. In the Philippines studies show the poor may spend from lo-30% of their income on water supplied to them in cans at a price forty times higher than the middle class who obtain their water from a tap conveniently placed in their kitchen or bathroom. Human waste disposal is an enormous problem. There are only a limited number of options but success will depend on local knowledge of existing culture, together with a health education programme in which both men and women are involved. There is much to be taught, for example, the much greater infectivity of small childrens faeces is rarely understood by their guardians.
136
David Morley
TRANSPORT Many of those attending this meeting will spend around 2 hr travelling a day in relative comfort. In Nigerian and Indian cities workers have to spend 2-3 hr travelling under appalling conditions. The same applies for those seeking health care, rarely has room been left in slums for health centres although urban based physicians find lack of dispensaries profitable in slums. The relationship between distance from health facilities, their use and mortality is well shown in this figure concerning Bangladesh (Fig. 4). IMPACT
r
1000
Caseattendance per 1,000 diarrhoeal patients (+SE)
750
OF DISTANCE FROM TREATMENT ON ATTENDANCEANDMORTALITY (Ann. Rep.'SO, ICDDR Dacca)
CENTRE
c -200 Diarrhoeal mortality per 100,000 (+SE)
500
250
0
1
2 3 Distance
4 5 (miles)
6
Fig. 4. Those who live near health resources make more use of. them _ for the treatment of diarrhoea and have a lower mortality than those at a distance.
Appropriate Appropriate
Appropriate
aerlculture
education
community development
Approprlat health
I
boxes
Where
do we go from
here?
fo
11___
BREAK DOWN THE WALLS
GETTO KNOW EACH OTHER
WORK TOGETHER
Fig. 5. An interdisciplinary approach is essential
Future of Urbanisation and Role of British Aid
137
CONCLUSIONS
The cities of the developing world absorb a high proportion of the national expenditure on health. Maldistribution of these and other resources however leads to a morbidity and mortality among the poor similar to that in remote villages. Better distribution will depend both on political will and management expertise. Success will depend on an interdisciplinary approach. The UK in common with other countries of the North has a great responsibility towards a more equal distribution of resources. In our efforts to prevent dependency, resources can be best used if made available to help in training for and evaluation of existing and new programmes initiated within and by communities themselves.
REFERENCES Aaby, P., Bukh, measles mortality. Lipton, London,
J., Lisse, I.M. and Smits, A.J., Am. J. Epidemiol. 120, 49-63,
Overcrowding 1984.
and intensive
exposure
as determinants
M.. Why Poor People Stay Poor; A Study of Urban Bias in World Development. 1977.
Morley, D. and Lovel, L.. My Name Is Today. MacMillans, Basingstoke, Box 49, St. Albans AL1 4AX, UK for f3.00 including p. & p., 1986.
UK. Available
Temple
from TALC,
of
Smith, P.O.
Ranken, J., Planning urban community health. Set of 48 transparencies and work sheets available from TALC, P.O. BOX 49, St. Albans AL1 4AX. UK. Price f6.00 including p. & p. (f5.00 for developing countries), 1987.