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Urban Health in Developing Countries

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Stephens C and Satterthwaite D Urban Health in Developing Countries. In: Kris

Heggenhougen and Stella Quah, editors International Encyclopedia of Public
Health, Vol 6. San Diego: Academic Press; 2008. pp. 452-463.
 Author's personal copy
452 Universal Coverage in Developing Countries, Transition to
See also: Community Health Insurance in Developing
Countries; Competiton in Health Care; Determinants of
National Health Expenditure; Health Finance, Equity in;
Innovative Financing of Health Promotion; Insurance
Plans and Programs – An Overview; Managed Care;
Provider Payment Methods and Incentives; The Private
Sector in Health Care Provision, The Role of.
Citations
Appiah-Denkyira E and Preker A (2007) Reaching the Poor in Ghana
with National Health Insurance – An Experience from the Districts of
the Eastern Region of Ghana. Extending Social Protection in Health.
Berlin, Germany: GTZ/ILO/WHO.
Atim C (1999) Social movements and health insurance: A critical
evaluation of voluntary, non-profit insurance schemes with case
studies from Ghana and Cameroon. Social Science and Medicine 48
(7): 881–896.
Bennett S, Creese A, and Monasch R (1998) Health Insurance Schemes
for People Outside Formal Sector Employment. Geneva,
Switzerland: WHO Analysis Research and Assessment Division.
Carrin G and James C (2005) Social health insurance: Key factors
affecting the transition towards universal coverage. International
Social Security Review 58: 45–64.
Carrin G, Waelkens MP, and Criel B (2005) Community-based health
insurance in developing countries: A study of its contribution to the
performance of health financing systems. Tropical Medicine and
International Health 10(8): 799–811.
Dror D and Jacquier C (1999) Micro-insurance: Extending health
insurance to the excluded. International Social Security Review 52(1):
71–97.
Ensor T (1999) Developing health insurance in transitional Asia. Social
Science and Medicine 48(7): 871–879.
Frenk J, Knaul F, Gonzalez-Pier E, and Barraza-Llorens M (2007)
Poverty Health and Social Protection. Extending Social Protection in
Health. Berlin, Germany: GTZ/ILO/WHO.
Kutzin J (1998) Enhancing the insurance function of health systems: A
proposed conceptual framework. In: Nitayarumphong S and Mills A
(eds.) Achieving Universal Coverage of Health Care, pp. 27–101.
Bangkok, Thailand: Nontaburi Ministry of Public Health Thailand.
Mesa-Lago C (1991) Social security in Latin America and the
Caribbean: A comparative assessment. In: Ahmed E, Dreze J,
Hills J, and Sen A (eds.) Social Security in Developing Countries,
pp. 356–394. New York: Oxford University Press.
Tangcharoensathien V, Prakongsai P, Patcharanarumol W, and
Jongudomsuk P (2007) University Coverage in Thailand: The
Urban Health in Developing Countries
C Stephens, London School of Hygiene and Tropical Medicine, London, UK
D Satterthwaite, International Institute for Environment and Development, London, UK
ã 2008 Elsevier Inc. All rights reserved.
Introduction
The future of our planet now seems irrevocably urban, and
we need to be sure that this urban life is healthy, equitable,
and sustainable. A major study in 2007 by the Worldwatch
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
Respective Roles of Social Health Insurance and Tax-Based
Financing. Extending Social Protection in Health. Berlin, Germany:
GTZ/ILO/WHO.
Twigg J (1999) Regional variation in Russian medical insurance:
Lessons from Moscow and Nizhny Novgorod. Health and Place 5(3):
235–245.
World Bank (1993) World Development Report 1993: Investing in Health
Executive Summary. Washington, DC: World Bank.
World Health Organization (2000) The World Health Report 2000, Health
Systems: Improving Performance. Geneva, Switzerland: World
Health Organization.
World Health Organization (2006) The World Health Report 2006:
Working Together for Health. Geneva, Switzerland: World Health
Organization.
Further Reading
Barnighausen T and Sauerborn R (2002) One hundred and eighteen
years of the German health insurance system: Are there any lessons
for middle- and low-income countries? Social Science and Medicine
54(10): 1559–1587.
Dror DM and Preker AS (eds.) (2002) Social re-insurance: A new
approach to sustainable community health financing. Washington,
DC: ILO and World Bank.
Gertler PJ (1998) On the road to social health insurance: The Asian
experience. World Development 26(4): 717–732.
International Labour Organization (1999) Social Health Insurance.
Geneva, Switzerland: International Labour Organisation/International
Social Security Association.
Nitayarumphong S and Mills A (eds.) Achieving Universal Coverage of
Health Care. Bangkok, Thailand: Nontaburi Ministry of Public Health
Thailand.
Ron A and Scheil-Adlung X (2001) Recent Health Policy Innovations in
Social Security. New Brunswick, NJ: New Jersey Transaction
Publishers.
Relevant Websites
http://www.ilo.org – International Labour Organization (ILO).
http://www.OECD.org – Organisation for Economic Co-operation and
Development (OECD).
http://www.worldbank.org – World Bank.
http://www.who.int/health_financing – World Health Organization,
Health Financing Policy.
Institute reported that ‘‘by 2005, the world’s urban popu-
lation of 3.18 billion people constituted 49 percent of the
total population of 6.46 billion. Very soon, and for the first
time in the history of our species, more humans will
live in urban areas than rural places’’ (Lee, 2007:4).
 Author's personal copy
These findings were based on United Nations (UN) pro-
jections suggesting that nearly all of the population growth
in the future will be in cities and towns. Most notably, this
population growth will be in low- and middle-income
nations. Asia and Africa, today the most rural continents
of the world, are projected to double their urban popula-
tions, from 1.7 billion in 2000 to about 3.4 billion in 2030.
Overall there will be 60 million new urban citizens every
year living in the towns and cities of the poorest countries
(UN Population Division [UNPD], 2006; Lee, 2007).
This article discusses the public health challenge
of urbanization. It looks at current trends in urban
demography, discusses the state of urban health, and con-
cludes with a brief outline of some current urban policy
options.
The Scale of Urbanization
Urban areas in developing countries now have more than
a third of the world’s total population, nearly three quar-
ters of its urban population and most of its large cities.
They contain most of the economic activities in these
nations and most of the new jobs created over the last few
decades. They are also likely to house most of the world’s
growth in population in the next one to two decades
(UNPD, 2006). Thus, how they are governed and what
provisions are made to house and service their expanding
populations has very large implications for economic and
social development – and for public health.
Urbanization in developing countries needs to be
understood as part of a global trend toward increasingly
urbanized patterns of production; changes in urbanization
levels in all the world’s regions and most of its nations
follow the increasing proportion of gross domestic
product (GDP) generated by industry and services and
the increasing proportion of the economically active
population working in industry and services. The world’s
urban population in 2007 was around 3.2 billion people
(UNPD, 2006) – more than the world’s total population in
1960. By 2007, half of the world’s population lived
in urban centers compared to less than 15% in 1900
(Satterthwaite, 2007a). Many aspects of urban change in
recent decades are unprecedented, including not only the
world’s level of urbanization and the size of its urban
population, but also the number of countries becoming
more urbanized and the size and number of very large
cities. The populations of dozens of major cities have
grown more than 10-fold in the last 50 years, and many
have grown more than 20-fold (Satterthwaite, 2007a).
There are also the large demographic changes apparent
in all nations over the last 50 years that influence urban
change, including rapid population growth rates in much
of Latin America, Asia, and Africa after the Second World
War (although for most these have declined significantly),
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
Urban Health in Developing Countries 453
and changes in the size and composition of households
and in age structures (Montgomery et al., 2003).
Table 1 shows the scale of urban population growth
since 1950; it also shows how the proportion of the world’s
urban population living in different regions and between
high-income and developing countries has changed. Since
1950, most of the growth in the world’s urban population
has been in developing nations. Developing countries in
Asia contain close to half the world’s urban population.
Africa now has a larger urban population than North
America or Western Europe, even though it is generally
perceived as overwhelmingly rural. In 1950, Europe and
North America had more than half the world’s urban
population; by 2000, they had little more than a quarter.
Africa had 10% of the world’s urban population in 2000
compared to less than 5% in 1950. Asia increased its share
of the world’s urban population from less than one-third
to nearly one-half in these same five decades and most of
this was in developing nations.
The Growth of Large Cities
Two aspects of the rapid growth in the world’s urban
population since 1950 are important to understand in
the context of urban health: the increase in the number
of large cities and the historically unprecedented size of
the largest cities. Just two centuries ago, there were only
two ‘million-cities’ worldwide (i.e., cities with 1 million
or more inhabitants) – London and Beijing (then called
Peking). By 1950, there were 75; by 2000, 380. A large (and
increasing) proportion of these million-cities are in devel-
oping countries.
The average size of the world’s largest cities has also
increased dramatically. In 2000, the average size of the
world’s 100 largest cities was around 6.3 million inhabi-
tants. This compares to 2.0 million inhabitants in 1950,
728 270 in 1900 and 187 520 in 1800 (Satterthwaite, 2007a).
While there are various examples of cities over the last two
millennia that had populations of 1 million or more inha-
bitants, the city or metropolitan area with several million
inhabitants is a relatively new phenomenon – London
being the first to reach this size in the second half of the
19th century. By 2000, there were 45 cities with more than
5 million inhabitants.
Aggregate urban statistics can be interpreted as imply-
ing comparable urban trends across the world or for
particular continents. But they obscure the diversity in
urban trends between nations. They also hide the partic-
ular local and national factors that influence these trends.
Aggregate urban statistics may suggest rapid urban change,
but the rate of increase in urbanization levels, and the rate
of increase of urban populations, has slowed in many
developing countries. Many of the world’s largest cities,
including Mexico City, São Paulo, Buenos Aires, Calcutta,
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454 Urban Health in Developing Countries

Table 1 The distribution of the world’s urban population by region, 1950–2010

Region or country 1950 1970 1990 2000a Projected for 2010

Urban populations (millions of inhabitants)

World 732 1329 2271 2845 3475
High-income nations 423 650 818 874 922
Low- and middle-income (‘developing’) nations 309 678 1453 1971 2553
‘Least-developed nations’ 15 41 110 166 247
Africa 33 85 203 294 408
Asia 234 485 1011 1363 1755
Europe 277 411 509 522 529
Latin America and the Caribbean 70 163 315 394 474
North America 110 171 214 249 284
Oceania 8 14 19 22 25
Urbanization level (percentage of population living in urban areas)
World 29.0 36.0 43.0 46.8 50.8
High-income nations 52.1 64.6 71.2 73.2 75.2
Low- and middle-income (‘developing’) nations 18.1 25.2 35.2 40.3 45.5
‘Least-developed nations’ 7.3 13.1 21.0 24.7 29.0
Africa 14.7 23.4 32.0 36.2 40.5
Asia 16.8 22.7 31.9 37.1 42.5
Europe 50.5 62.6 70.6 71.7 72.9
Latin America and the Caribbean 42.0 57.2 70.9 75.4 79.1
North America 63.9 73.8 75.4 79.1 82.2
Oceania 62.0 70.8 70.3 70.5 71.2
Percentage of the world’s urban population living in:
Major area, region, country, or area
World 100.0 100.0 100.0 100.0 100.0
High-income nations 57.8 49.0 36.0 30.7 26.5
Low- and middle-income (‘developing’) nations 42.2 51.0 64.0 69.3 73.5
‘Least-developed nations’ 2.0 3.1 4.8 5.8 7.1
Africa 4.5 6.4 8.9 10.3 11.7
Asia 32.0 36.5 44.5 47.9 50.5
Europe 37.8 30.9 22.4 18.4 15.2
Latin America and the Caribbean 9.6 12.3 13.9 13.9 13.6
North America 15.0 12.9 9.4 8.8 8.2
Oceania 1.1 1.0 0.8 0.8 0.7
a
The statistics for 2000 are an aggregation of national statistics, many of which draw on national censuses held in 1999, 2000, or 2001,
but some are based on estimates or projections from statistics drawn from censuses held around 1990. There is also a group of
countries (mostly in Africa) for which there are no census data since the 1970s or early 1980s so all figures for their urban (and rural)
populations are based on estimates and projections.

and Seoul had more people moving out than in during
their last intercensus period. The increasing number of
megacities with 10 million or more inhabitants may seem
to be a cause for concern but there are relatively few of
them (17 by 2000). In this year, they concentrated less than
5% of the world’s population and most are in the world’s
largest economies. Also, taking a longer-term view of
urban change, it is not surprising that Asia has most of
the world’s largest cities as this reflects the region’s grow-
ing importance within the world economy (and Asia has
many of the world’s largest national economies).
Urban Change and Economic Change
Although rapid urban growth is often seen as a problem,
it is generally the nations with the best economic
performance that have urbanized most in the last
50 years. In addition, perhaps surprisingly, there is often
an association between rapid urban change and better
standards of living. Not only is most urbanization asso-
ciated with stronger economies but generally, the more
urbanized a nation, the higher the average life expectancy
and the literacy rate and the stronger the democracy,
especially at the local level. Many of the largest cities
may appear chaotic and out of control, but most have
life expectancies and provision for piped water, sanitation,
schools, and health care that are well above their national
average – even if the aggregate statistics for each megacity
can hide a significant proportion of their population living
in very poor conditions. Some of world’s fastest growing
cities over the last 50 years also have among the best
standards of living within their nation – as in the case of
Porto Alegre in Brazil (Menegat, 2002).

International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
 Author's personal copy
It is also important not to overstate the speed of urban
change. Recent censuses show that the world today is
also less urbanized and less dominated by large cities
than had been anticipated. For instance, Mexico City
had 18 million people in 2000 – not the 31 million people
predicted 25 years earlier (UNPD, 2006). Calcutta, São
Paulo, Rio de Janeiro, Seoul, Chennai (formerly Madras),
and Cairo are among the many other large cities that, by
2000, had several million fewer inhabitants than had been
predicted (Satterthwaite, 2007a).
What Drives Urban Change?
Understanding what causes and influences urban change
within any nation is complicated. Consideration has to be
given to changes in the scale and nature of the nation’s
economy and its connections with neighboring nations
and the wider world economy, and also to decisions
made by national governments, national and local inves-
tors, and the 30 000 or so global corporations who control
such a significant share of the world’s economy. Urban
change within all nations is also influenced by the struc-
ture of government (especially the division of power and
resources between different levels of government), and
the extent and spatial distribution of transport and com-
munications investments. The population of each urban
center and its rate of change are also influenced not only
by such international and national factors but also by local
factors related to each very particular local context –
including the site, location, natural resource endowment,
demographic structure, existing economy, and infrastruc-
ture (the legacy of past decisions and investments) and the
quality and capacity of public institutions.
The immediate cause of urbanization is the net move-
ment of people from rural to urban areas. The main
underlying cause is the concentration of new investment
and economic opportunities in particular urban areas.
Virtually all the nations that have urbanized most over
the last 50–60 years have had long periods of rapid eco-
nomic expansion and large shifts in employment patterns
from agricultural/pastoral activities to industrial, ser-
vice, and information activities. In developing countries,
urbanization is overwhelmingly the result of people
moving in response to better economic opportunities in
the urban areas, or to the lack of prospects in their home
farms or villages. The scale and direction of people’s
movements accord well with changes in the spatial loca-
tion of economic opportunities. In general, it is cities,
small towns, or rural areas with expanding economies
that attract most migration, although there are important
exceptions in some nations, such as migration flows away
from wars/conflicts and disasters. By 2004, 97% of the
world’s GDP was generated by industry and services
and around 65% of the world’s economically active
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
Urban Health in Developing Countries 455
population works in industry and services, most of which
is located in urban areas. Political changes have had con-
siderable importance in increasing levels of urbanization
in many nations over the past 50–60 years, especially the
achievement of political independence and the building
of government structures that were important for most of
Asia and Africa; however, these had much less effect in
most nations from the 1980s onward.
Agriculture is often considered as separate from (or
even in opposition to) urban development, yet prosper-
ous, high-value agriculture, combined with prosperous
rural populations, has proved an important underpinning
to rapid development in many cities. Many major cities
first developed as markets and service centers for farmers
and rural households, and later developed into important
centers of industry and/or services. Many such cities still
have significant sections of their economy and employ-
ment structure related to forward and backward linkages
with agriculture.
Analyses of urban change within any nation over time
serve as reminders of the diversity of this change, of the
rising and falling importance of different urban centers, of
the spatial influence of changes in governments’ economic
policies (e.g., from supporting import substitution to sup-
porting export promotion), of the growing complexity
of multinuclear urban systems in and around many
major cities – and of the complex and ever-shifting
patterns of in-migration and out-migration from rural to
urban areas, from urban to urban areas and from urban
to rural areas. International immigration or emigration
has strong impacts on the population size of particular
cities in most nations. But it is not only changing patterns
of prosperity or economic decline that underpin these
flows of people. Many cities have been impacted by
war, civil conflict or disaster, or by the entry of those
fleeing them.
What Is Urban Health in Developing Countries?
In many of the towns and cities in Africa, Asia, and Latin
America – the so-called developing countries, only an
urban minority lives in healthy living conditions and has
access to good health services, education, and employ-
ment. Already, nearly one in two urban dwellers in devel-
oping countries live in low-income urban settlements,
known pejoratively as slums, with all that this implies in
terms of living conditions and health (Lee, 2007). Low-
income settlements are areas of a town or city where
people have no, or very limited, access to necessities
that would secure good health: clean and ample water,
sanitation, sufficient living space, and adequate housing
are all missing from these environments. Water and food
are often biologically contaminated, education and work
opportunities are available to a tiny minority and the
work that does exist is often in hazardous industries on a
 Author's personal copy
456 Urban Health in Developing Countries
wage that does not provide a route out of poverty. Health
services are often inaccessible to the urban poor – not
because they are at a long distance, as in rural areas, but
because poorer people in low-income settlements often
do not have the financial means to access them. To make
things still more difficult, low-income urban citizens often
live with insecure tenure to their land and homes –
making the risk of homelessness a regular threat to their
well-being.
Both the wealth of a country and scales of urbanization
affect urban health patterns. In regions such as Asia, urban
populations are huge, but the proportion of urban popu-
lation in the region as a whole is still less than 50%. In the
‘least-developed’ nations only a quarter of the population
is urban. This can affect government and donor policies
toward urban areas – and can mean that rural areas are
prioritized for basic interventions that affect health (such
as vaccination, water and sanitation, and other infrastruc-
ture). In contrast, more urbanized regions, such as Latin
America, do not have this urban–rural divide in policy
terms – which can mean that national policies are aligned
to urban priorities. The rate of urbanization is also impor-
tant for urban health: where rates of urban growth are
very high, urban services are quickly overwhelmed and
large proportions of the new urban population live with-
out adequate infrastructure – including water, sanitation,
housing and transport, but also education, health, and
employment.
The Myth of the Healthy City
There is still a myth among health professionals – the idea
that rural peoples are less healthy than their urban coun-
terparts. The myth of the healthy city has been linked for
decades to a problem of data aggregation – where total
health statistics are sometimes presented for cities with
populations greater than those of nation states. Megacities
suffer particularly from a problem of super-aggregation,
in which health data on the whole city tell only part of the
story. Each city’s health will depend on a range of contex-
tual factors, just as a national health profile does.
A key predictor is often the overall state of ‘development’
of the city–measured in proportions of people with clean
water, sanitation, adequate housing, and access to health
measures such as vaccination and primary care. Thus a
megacity with a large proportion of people living in poverty
will have a health profile that reflects the profile of these
people. However, there is another problem: megacities
account for only about 9% of the total urban population
of approximately 3.2 billion citizens. Just over half of the
world’s city dwellers live in settlements with fewer than
500 000 inhabitants, and we still know little of the health
situation in smaller towns and cities internationally.
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
In every town and city, data that have been broken
down by income group tell a different story of urban
health – it is the tale of urban inequality. Within cities
and towns, disaggregated data show that there are inequa-
lities in living conditions and in access to services such
as health, water, and sanitation. There are also inequal-
ities in access to education and work. Thus, it is hard to
generalize about urban health profiles, as each city and
town may have a distinctive pattern of development and
distribution of resources. Even a rich town in a rich
country may have sharp inequalities that affect health
drastically – for example, a classic study in New York
found that black men in Harlem were less likely than
men in Bangladesh to reach the age of 65 (McCord and
Freeman, 1990).
Urban Health Profiles
Both the physical and the social environment of cities and
towns today affect urban health. The overall quality of the
urban environment is important for health, and so is the
extent of inequality within an urban environment. Some
problems of the urban physical environment, such as
ambient air pollution, may affect almost everyone in a
city. Other problems, such as contaminated water, indoor
air pollution, or lack of sanitation, may disproportionately
affect some groups more than others. Urban violence may
also affect some urban dwellers more than others. Rapid
urbanization in most cases exaggerates these problems, as
cities are unable to build enough infrastructure and pro-
vide enough jobs for an influx of migrants, many of whom
may be fleeing war or drought.
In the poorer countries of Africa and Asia a majority
of urban citizens live without clean water and sanitation,
and with limited public health interventions such as
vaccination. This is a consequence of a complex mix of
national economic situations, and of the scale and rate
of urbanization. In some urban areas, urban health indi-
cators can be worse than in rural areas. In poorer
countries, urban areas often have the worst of all
worlds–contaminated air, land, and water; deep poverty;
and a health profile that includes both the infectious
diseases of deep poverty and the so-called diseases of
modernity (obesity, cancers, and heart disease). In these
cases people carry a double burden of disease that poses a
daunting challenge for human health on an urban planet
(Stephens and Stair, 2007).
In wealthier countries, such as Brazil in Latin America,
most urban people have access to water and sanitation
even if their housing is precarious. Urban public health
interventions, such as vaccination, are also widespread. In
these urban areas, infant mortality rates are low, and urban
health problems are linked more to social outcomes, such
 Author's personal copy

Urban Health in Developing Countries 457

as educational attainment and employment, and relate to Table 2 Examples of high infant and child mortality rates
social inequality between urban groups. Urban violence is among national urban populations
a major problem in many cities of Latin America, where Urban infant (age < 1) Average for sub-Saharan
rates of death from homicide affect adolescent health mortality rates of 80–101, Africa. Mozambique (1997),
profiles particularly. In some cities, urban industry affects per 1000 live births Chad (1997), Mali (1996),
Ethiopia (2000), Zambia
pollution levels, and the particular mix of industries
(1996), Rwanda (1992), Haiti
affects the type of health problems that will be associated (2000), Benin (1996), Malawi
with the pollution. The key challenge for urban profes- (2000), Tanzania (1996),
sionals is to understand the complex mix of urban health Central African Rep.
problems that result from the unique mix of demographic (1994–95), Eritrea (1995),
Niger (1998)
change, economic development, infrastructure, and social
Urban infant (age < 1) Guinea (1999), Madagascar
conditions that make up every town and city. The follow- mortality rates of 60–79, (1997), Côte d’Ivoire (1994),
ing sections outline some of these urban health challenges per 1000 live births Yemen (1997), Pakistan
in turn. (1990–91), Sudan (1990),
Uganda (1995), Bangladesh
(2000), Cambodia (2000),
Burkina Faso (1998/99),
Infant and Child Survival in Urban Areas Togo (1998), Comoros
(1996), Namibia (1992),
In most low-income and many middle-income nations, Cameroon (1998), Gabon
infant, child or under-5 mortality rates in urban areas (2000), Nepal (1996)
Urban child (1–4 years) Niger (1998), Mali (1996),
are 5 to 20 times what they would be, if the urban popula-
mortality rates of more Chad (1997)
tions had adequate nutrition, good environmental health, than 100 per 1000 live births
and a competent health-care service (Satterthwaite, Urban child (1–4 years) Zambia (1996)
2007b). In some low-income nations, these mortality mortality rates of 80–100
rates increased during the 1990s (Montgomery et al., per 1000 live births
Urban child (1–4 years) Guinea (1999), Rwanda (1992),
2003). However, there are also nations with relatively
mortality rates of 60–79 Benin (1996), Malawi (2000),
low urban infant and child mortality rates (e.g., Peru, per 1000 live births Burkina Faso (1998–99),
Jordan, Vietnam, and Colombia) – while there are also Uganda (1995)
particular cities that have achieved low infant and child
Adapted from Satterthwaite D (2007) In pursuit of a healthy urban
mortality rates – for instance, Porto Alegre in Brazil
environment in low- and middle-income nations. In: Marcotullio PJ
(Menegat, 2002). and McGranahan G (eds.) Scaling Urban Environmental Challenges:
Table 2 gives examples of nations with high infant and From Local to Global and Back, pp. 69–105. London: Earthscan.
child mortality rates within their urban populations.
These are all the more surprising in that in all these
nations, most middle- and upper-income groups live in Infectious Diseases
urban areas and will generally experience much lower
infant and child mortality rates. So these ‘averages’ for In many towns and cities, particularly in Asia and Africa,
national urban populations can hide the extent of the there is a major lack of water and sanitation facilities. This
problem faced by low-income populations. has huge health repercussions – digestive-tract diseases
The few empirical studies on infant and child mortal- are a leading cause of death in the world and a major
ity rates in low-income urban settlements suggest that urban health problem (UN Habitat, 2006).
these are generally at least twice the urban average. For Crowding is another major health hazard for the
instance, for Nairobi, Kenya’s capital and largest city, urban poor. People in low-income settlements often live
under-5 mortality rates were 150 per 1000 live births in in highly crowded homes, with four or more people
its informal settlements (where over half the population per room, often shift-sleeping and with many children
live) and 61.5 for Nairobi as a whole (African Population per bed. Contact-related diseases such as measles, tuber-
and Health Research Center [APHRC], 2002). culosis (TB), and diarrhea are all linked to living in
In virtually all cities in low-income nations for which crowded environments. Notably, some richer cities have
data are available, and for most in middle-income nations, such deep pockets of disadvantage that diseases related to
there are also dramatic contrasts between different areas urban poverty and crowding have reemerged during
(districts, wards, municipalities) of the city regarding periods of increased inequality within the city. A study
infant and child mortality rates – as well as in living looking at TB in New York from 1970 to 1990, for exam-
conditions and other health outcomes (Hardoy et al., ple, found an increase in childhood TB in the period and
2001; Stephens and Stair, 2007). that children living in areas of the Bronx, where over 12%

International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
 Author's personal copy
458 Urban Health in Developing Countries
of homes are severely overcrowded, were 5.6-fold more
likely than children in other New York neighborhoods
to develop active TB (Drucker et al., 1994).
Urban Nutrition
Although undernutrition is generally considered to be a
rural problem, the urban poor – forced to pay high prices
for food shipped into the city and often unable to grow
their own food – can often have the most difficulty
obtaining enough nutritious food. This has major impacts
on urban nutritional health, particularly for children.
A recent analysis of child health in 15 countries in
sub-Saharan Africa found that differences in child mal-
nutrition within cities were greater than urban–rural
differences (Houweling et al., 2006).
It is common for a third of all urban children to be
stunted within the lowest income nations. A study of
10 nations in sub-Saharan Africa showed that the propor-
tion of the urban population with energy deficiencies
was above 40% in all but one nation and above 60% in
three – Ethiopia, Malawi, and Zambia (Ruel and Garrett,
2004). Table 3 shows this.
As with infant and child mortality rates, there are large
differentials in most cities in the prevalence of severe mal-
nutrition between wealthy and poorer areas. For instance,
the prevalence of severe malnutrition among boys in the
slums of Bangladesh’s two largest cities was nearly two and a
half times that in the ‘non-slums’ – measured by the per-
centage of children aged 12–59 months with mid-upper arm
circumference less than 12.5 cm (UNICEF, 2000).
A study of the contribution of illness to poverty in the
slums in Dhaka highlights another aspect of the scale of
Table 3 Percentage of urban children stunted in a sample of
27 African nationsa
Percentage of urban
children stunted Nations
Over 50% Madagascar
40–49% Ethiopia, Rwanda
30–39% Cameroon, Chad, Malawi, Mali,
Nigeria, Tanzania, Uganda
20–29% Benin, Burkina Faso, Central African
Republic, Comoros, Guinea, Kenya,
Mozambique, Namibia, Niger,
Zambia, Zimbabwe
10–19% Cote d’Ivoire, Egypt, Ghana,
Morocco, Senegal, Togo
a
These statistics are drawn from demographic and health survey
data for surveys carried out between 1992 and 2001. The per-
centage of urban children stunted is likely to have changed
significantly in many of these nations, including levels of stunting
increasing in some of these nations since the survey (e.g., in
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
the health burden faced by low-income groups – in this
instance, the extent to which ill health caused a deterio-
ration in households’ financial status. In this study of 850
households, ill health was the single most important cause
of such deterioration, explaining 22% of cases where
households reported a deterioration in their financial
status. Illness led to reductions in income and increased
expenditures; often more loans taken out, assets sold, and
more adults resorting to begging (Pryer, 1993). Although
it is dangerous to draw general conclusions from one
or two studies, the living conditions described by these
two studies are similar to those in informal settlements
or tenements in many other urban centers in low- and
middle-income nations, so comparable links between high
health burdens and impoverishment would be expected.
Within this general picture, there are important excep-
tions. For instance, many Latin American nations that now
have predominantly urbanized populations have managed
to sustain long-term trends of falling infant and child
mortality rates and increasing average life expectancies.
This is also true for some Asian and African nations,
although the scale of the improvements in urban areas is
not clear, as the data are for nations or subnational (state
or provincial) units, not for urban populations or particu-
lar urban areas.
The industries that power urbanization also create
quantities of air pollution in urban areas. The combustion
of solid fuels (biomass and coal) in millions of homes
can contribute to ambient air pollution. In developing
countries, this domestic pollution combines with the
greater cocktail of coal-burning industries, diesel trucks
or cars, and small, two-stroke motorcycles.
Urban industries do not simply pollute the air – they
often contaminate the land and water of the city. This can
create a paradoxical kind of urban development: an imme-
diate economic benefit, but at great expense to the health
of current and future residents. As with other urban health
problems, pollution is concentrated on the poorer people
who both live around and work in these industries – in
both rich and poor countries. The urban poor may get
work – but at what risk? Bhopal in India was perhaps the
most notorious example of this kind of urban hazard and
inequality: in 1984 more than 40 tons of methyl isocyanate
gas leaked from a pesticide plant, immediately killing at
least 3800 of the city’s poorest people and causing signifi-
cant morbidity and premature death for many thousands
more (Broughton, 2005). Not only does this kind of urban
industrial development often fail to move people out of
poverty, it can harm thousands of lives over the long term.
Urban Violence
There is another risk in cities that is not easily addressed
with infrastructure interventions such as improved living
 Author's personal copy
conditions or infrastructure: urban violence, which is
in epidemic proportions in many cities internationally.
In some cities violence has actually started to reverse
overall trends of health improvement, particularly for
young people. For example, a longitudinal study looking
at trends in mortality for 15- to 24-year-olds in São Paulo
and Rio de Janeiro from 1930 to 1991 showed a steady
improvement in adolescent health until the 1980s, when
death rates started to rise again due to violence (Vermelho
and Jorge, 1996). The death rate due to violence can be up
to 11 times higher for young people from the poorest
communities than the rate for young people from a
wealthier community (Stephens, 1996).
In Brazil, urban violence takes an enormous toll on
poor young men in terms of both mortality and morbidity:
death rates from homicide in Brazilian state capitals in
2003 for young men aged 20–24 were 133 per 100 000.
This means that 1 child in every 1000 will be a victim of
homicide in these cities, a rate higher than that of any
childhood cancer. The United States has a similar prob-
lem, with violence affecting principally economically dis-
advantaged young urban men from ethnic minorities, who
are disproportionately represented in jails and in homi-
cides (Gawryszewski and Costa, 2005).
Injuries related to traffic accidents and violence are
now respectively the second and fourth causes of hospi-
talization in Brazilian cities. This makes trauma treatment
a top priority for urban health services in this country and
challenges health systems that are generally better
prepared for infectious or chronic diseases (De Souza
and de Lima, 2006).
The fear of violence can also be a significant hindrance
to mental well-being. Long-term anxiety, stressful life
events, lack of control over resources, and lack of social
support are all key preconditions for depression. Poor
women in cities are often the most vulnerable group.
Double Burdens
In many cities and towns of Africa, Asia, and Latin
America, ‘modern’ diseases such as asthma, heart disease,
and cancer are arriving in places that have yet to fully get
a handle on ‘old’ diseases such as TB, cholera, and diar-
rhea. Figure 1 illustrates the double burden of disease
brought by dirty industrial development and polluting
motor vehicles in Kolkata, India (Stephens, 1999). Up to
40% of people still live in poverty, but the route
to development is sought through highly polluting indus-
tries, and providing service to millions of people remains
a dream. Figure 1 shows the cause of death by age –
demonstrating, albeit crudely, that if people in Kolkata
survive the insults of contaminated water, they live on to
experience the severe risks of highly contaminated air.
This double burden is particularly exaggerated in unequal
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
Urban Health in Developing Countries 459
16
14
Proportional mortality (%)
12
10
8
6
4
2
0
<5 <14 15–24 25–34 35–44 45–54 55–64 65+
Diarrheal Asthma bronchitis emphysema
disease ICD 490
Figure 1 The urban double burden of disease in Kolkata, India,
1997–98.
cities in Africa, Asia, and Latin America, where affluent
people are increasingly dealing with expensive modern
maladies such as diabetes and heart disease while lower-
income people are still plagued by undernutrition and
infectious disease.
Urban Health Inequalities
A critical issue of urban health, but perhaps the most
important of all, is that of urban inequalities and their
impacts on health. Health inequalities are a problem
internationally, but cities have become the nexus for
both deepest poverty, and also extreme wealth. This
inequality spans across almost all urban resources includ-
ing land, food, water, shelter, education, health services,
and work opportunities. As a consequence, urban health
inequalities also span many health outcomes, as the pre-
vious sections have outlined – infectious disease inequal-
ities are linked to unequal access to water and sanitation
resources, while violence can be linked to social unrest at
gross socioeconomic disparities.
But this is not just an issue of differential access to
resources. It is also an issue of inequity. For example,
unequal access to water in cities is not a simple issue of
one group having less access to water than another in the
city: the urban poor pay more in absolute and relative
terms for potable water than their wealthier urban coun-
terparts (Cairncross and Kinnear, 1992). Meanwhile,
richer urbanites may use their cheaper water for watering
their gardens or filling their swimming pools. At times
of water shortage these inequalities become more
 Author's personal copy

460 Urban Health in Developing Countries

pronounced – and richer urban citizens may be the only
group with a constant supply of water – while costs
of water may increase still further for poorer people.
These costs impact on poorer households severely –
using a large proportion of their income on water and
skewing the family budget away from other essentials
(Satterthwaite, 2007b).
Perhaps most difficult to address, many studies link
the high rates of urban violence to the gross urban
inequalities seen in cities and towns of Asia, Africa, and
Latin America. Many urban young people grow up in
grave environmental and social poverty, unable to fulfill
even their basic aspirations. Meanwhile their neighbors
may live in absolute affluence directly alongside these
disadvantaged youth. Many young people, particularly
young men, are drawn into urban violence through social
frustration or the lack of productive alternatives to occu-
pations linked to violence – for example, drug gangs often
provide work for young urban people, but it is dangerous
work requiring weapons. Some analysts see this violence
as an occupational hazard linked to high-risk professions
for urban, poor boys who have few alternatives to this
violent option. Urban violence is also linked more gener-
ally to urban inequality and this picture is true in cities
internationally (Pan American Health Organization, 1990;
Pinheiro, 1993; Wilson and Daly, 1997; Gawryszewski and
Costa, 2005).
The Growing Threat of Climate Change
An article on urban health in the twenty-first century
cannot conclude without some mention of the links of
urban health with climate change. Climate change will
affect the whole planet. However, it is increasingly
evident that cities are one of the main generators of
climate change, and that their urban peoples will be
some of the most directly affected, by impacts of the
changing climate. This includes impacts through temper-
ature changes (both heat and cold), but also through
extreme weather events, which hit densely populated
urban areas particularly hard and often very fast. Studies
show that urban citizens have adapted well to their urban
ecosystem and have developed shelter that protects them
from locally familiar heat and cold (Carson et al., 2006).
But unexpected changes to these temperatures can affect
people greatly – particularly vulnerable groups such as
the very young and the elderly. Heat-related deaths,
for example, can occur rapidly in extreme daily heat
episodes. These impacts can affect people even in cities
such as Delhi where the population is more used to
extreme heat (Hajat et al., 2005).
Coastal cities might be particularly at risk of extreme
weather events, and, since historically trade was by water
and sea, many major cities are on coasts or major rivers.
In an important workshop held in 2005 on Climate
Change and Urban Areas, Professor Rob Nicholls, of the
Tyndall Centre and University of Southampton, reported
that 1.2 billion people lived along coastal areas with low
elevation and were at significant risk of rising sea levels
and extreme weather events (UCL Environment Centre
and British Embassy Berlin, 2005).
Conclusions: Policies Toward
Urban Health
The first major concern of urban health internationally
is to improve basic public health in urban areas of devel-
oping countries. Around half the urban population in
Africa and Asia lack provision for water and sanitation
to a standard that is healthy and convenient (Table 4). For
Latin America and the Caribbean, more than a quarter
lack such provision. Inadequate provision for water and
sanitation contributes to many of the health problems and
the high levels of infant and child death described in
earlier sections. Public health improvements are especially
important for the 900 million or so urban dwellers who live
in very overcrowded dwellings in tenements or shacks
lacking basic infrastructure and services. This should
include a focus not only on large or fast-growing cities,
but also on smaller urban centers, as these contain a high
proportion of the urban population in developing countries.
Concentrations of people in urban areas make it easier
and cheaper to provide good-quality piped water, sanita-
tion, and drainage. There are many examples showing
this – where informal/illegal settlements with a predomi-
nance of low-income households have been provided with
good-quality provision for water and sanitation at low unit
costs – and in many instances with close to full cost
recovery from the inhabitants (UN Habitat, 2006). But
these are still the exception – and in the absence of good
Table 4 Estimates for the proportion of people without
adequate provision for water and sanitation in urban areas
Number and proportion of urban
dwellers without adequate provision
Region Water Sanitation
Africa 100–150 million 150–180 million
(c. 35–50%) (c. 50–60%)
Asia 500–700 million 600–800 million
(c. 35–50%) (c. 45–60%)
Latin America 80–120 million 100–150 million
and the (c. 20–30%) (c. 25–40%)
Caribbean
Reproduced from UN Habitat (2006) Meeting Development Goals
in Small Urban Centres; Water and Sanitation in the World’s Cities
2006, p. 258. London: Earthscan.

International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
 Author's personal copy
provision, this concentration of people and their wastes
greatly increases health risks from a great range of water-
borne, water-washing, or water-related diseases.
It may be that trends in macroeconomic inequality will
have severe effects on the urban poor. There is some
evidence of this from two very different contexts: Studies
in the United States looking at trends in mortality
between the 1970s and 1990s found that African-
Americans living in cities experienced extremely high
and growing rates of excess mortality compared with
rural and wealthier communities (Geronimus et al.,
1999). A similar study in five African countries of rising
death rates for children under the age of five between the
1980s and 1990s found that in Zimbabwe the increase was
largest among urban children (Houweling et al., 2006).
In this context, what can we do to encourage the move
toward healthier cities? There is evidence that urban
inequalities decrease when local governments listen to
low-income residents and when such individuals are
included in urban plans and actions. Inequalities may
also lessen when health is used as a criterion to establish
priorities for urban policy. In Kolkata, India, for example,
an environment and development plan was based on
health priorities and on a consultation weighted toward
the views and needs of the poorest citizens. This did not
change the city overnight, but it gradually put the needs of
the urban poor on the policy agenda. There are also many
successful stories of self-help in water and sanitation –
where health and city equality have both improved when
local governments work with local people.
Donors, too, who are seeking to help the urban poor,
can better support health by listening to them. Looking
for a set of best practices, the World Bank embarked on an
institute-wide analysis of 45 participatory urban develop-
ment programs in the 1990s. The final report concluded
that community participation was absolutely essential for
any slum-upgrading projects. The authors noted that the
people who must move their homes to make way for roads,
public spaces, and sewage lines ‘‘must be involved in the
decision making process if they are to cooperate with it.’’
The report further concluded that community participa-
tion was ‘‘the single most important factor in overall
quality of project implementation – efficiency, effective-
ness, timeliness, responsiveness, and accountability’’
(Imparato, 2003: 10).
In some countries, such as Brazil, recent local and
national government strategies have systematically sup-
ported governance and budget setting that gives priority
to the needs of the urban poor and that puts public
services high on the overall agenda. Local government
support to the efforts of low-income city dwellers can
have effects on a surprising range of health challenges.
In Ilo, a small port town in Peru, for example, air pollution
policy finally got on the agenda when communities
were included in debates with the local mining company,
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
Urban Health in Developing Countries 461
and access to public services increased dramatically as
community concerns were included in local planning
and budgeting. Green spaces increased, water contamina-
tion decreased, and sustainable development gradually
rose in importance on the agenda. During this period
the mayor noted that Ilo’s people and their mobilization
put the environment, poverty, and equity high on the
agenda – all themes that affected urban health (Palacios
and Sara, 2005).
It is not just inequalities in the physical environment of
cities that can be improved with more involvement of
citizens. It is notable that some of the most intractable
problems of urban inequality – such as urban violence –
are often only tackled in this way. It is young people
who are most affected by urban violence, and the urban
poor are often in constant threat of violence – either from
young people in other poor areas or from the police.
Interestingly, young people themselves often have the
solutions. For example, young men from one of the most
difficult favelas of Rio de Janeiro started a musical alter-
native to drug gangs, eventually spreading their combina-
tion of music and education to other favelas and starting a
health education program for young women and men
(Grupo AfroReggae, 2007).
Climate change too, can be addressed in cities. As the
participants of the 2005 UCL Environment Centre work-
shop on Climate Change and Urban Areas concluded
the world’s major cities are large contributors to CO2
emissions but also
[f]undamental to global GDP, realistic strategies for the
curbing of greenhouse gases and the reduction of its worst
effects were regarded as essential both for climate stabili-
zation and continued prosperity. Yet cities were also at the
forefront of design and innovation. They contained the
technical and creative capacity to deliver the changes in
lifestyles, energy usage, political discourse and planning
required to deliver truly sustainable development. While
cities (and especially coastal cities) might be facing the
brunt of climate change, their institutions and inhabitants
also held the key to its mitigation.
(UCL Environment Centre and British Embassy
Berlin, 2005: 2).
Finally, as health professionals we must be aware that
there are two urban worlds emerging. There is the world of
the urban wealthy, who experience the health profile of all
wealthy people internationally, whether they are born into
Asian, African, or American cities. And there is the world
of the economically and socially disenfranchised, who work
desperately to escape their poverty while risking their lives
every day in their homes, on the roads, and in their work-
places. There are many differences between these two
worlds, but perhaps the main one lies simply in the num-
bers: the wealthy urban world is for a tiny minority; the
disenfranchised urban world is for the vast majority.
 Author's personal copy
462 Urban Health in Developing Countries
Perhaps the most startling thing about these urban
worlds is that they are not separated in space or time. In
every city the peoples of these worlds live alongside each
other. They breathe the same air and may travel along the
same streets. They also have, in essence, the same set of
aspirations: to live well and long and to give their children
a better future. Our urban future provides us with perhaps
the biggest challenge as human beings that we have ever
had to face. We have to bring these worlds together and
to move them both toward a sustainable future, or there
will be no chance of healthy lives for those living in
tomorrow’s cities.
There is no easy solution to the challenges of urban
health internationally. The majority of the urban world
demands, rightly, that their health needs involve meeting
their basic rights to clean water, sanitation, adequate
housing, education, access to health services, and work
that will be safe and remunerative. Interventions toward
this would guarantee survival for the urban millions who
die unnecessarily today. But alongside this, our urban
future needs creative, new solutions too: there are no
simple interventions that will address urban violence, for
instance. Technical interventions will not address an
urban health problem that is rooted in complex social
injustice. Obesity and mental health problems also need
a new lens. Cities that isolate us from nature and from
each other cannot be described as healthy cities for the
twenty-first century.
Equity is perhaps the key to the more complex social
problems of cities – and it also can lead toward sustain-
ability. A city where all peoples live together in peace,
sharing the same spaces and the same resources, is far
from today’s urban reality. A city where people think of
the next generation and the planet as a whole is also far
from this reality. But neither vision is impossible – either
to imagine or to achieve. As health professionals we must
rise to this challenge and reinvent public health as the
urban discipline of the future.
See also: Ethnic Conflict and Public Health; Health and
Human Rights: Overview; Population Growth; Worker
Health and Safety, International Issues.
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Introduction
Demographic trends suggest that there is an urgent need
to consider the health of urban populations. Cities are
becoming the predominant mode of living for the world’s
population. According to the United Nations (UN), approx-
imately 29% of the world’s population lived in urban areas
in 1950. By 2000, 47% lived in urban areas and the UN
projects that approximately 61% of the world’s population
will live in cities by 2030. Overall, the world’s urban popu-
lation is expected to grow from 2.86 billion in 2000 to 4.94
billion in 2030. As the world’s urban population grows, so
does the number of urban centers. The number of cities
with populations of 500 000 or greater grew from 447 in
1975 to 804 in 2000. In 1975 there were four megacities with
populations of ten million or more worldwide; by 2000
there were 18, and 22 are projected by 2015. As illustrated
by Figure 1, most cities are in middle- to low-income coun-
tries; in 2000 middle- to low-income countries contained
72% of the world’s cities. During the second session of the
World Urban Forum in 2004, world leaders and mayors
warned that rapid urbanization is going to be one of the
most important issues in this millennium.
A Brief History of Urban Health
Cities and their impact on health have been a concern for
millennia. City architects as early as the fourth century
BCE designed cities to maximize exposure to the sun in
winter, minimize solar exposure in the summer, and take
International Encyclopedia of Public Health, First Edition (2008), vol. 6, pp. 452-463
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Urban Health Systems: Overview 463
Wilson M and Daly M (1997) Life expectancy, economic inequality,
homicide, and reproductive timing in Chicago neighbourhoods.
British Medical Journal 314(7089): 1271–1274.
Relevant Websites
http://www.alliance_healthycities.com/index.html – Alliance for Healthy
Cities.
http://eau.sagepub.com – Environment and Urbanization.
http://www.paho.org/English/ad/sde/espacios.htm – Healthy
Municipalities and Urban Health in Latin America.
advantage of mountain and sea breezes (Semenza, 2005).
More familiar, recurrent plague epidemics in European
cities between the fourteenth and sixteenth centuries, and
pestilence within slums early in the Industrial Age became
a major concern for urban dwellers such that authorities
were required to develop and maintain knowledge for
dealing with the epidemics.
For centuries, researchers and scholars have consid-
ered the study of how cities may shape health an impor-
tant area of inquiry. Some of the early epidemiological
studies and interventions were centered on urban popula-
tions. John Graunt, considered by many to be the first
epidemiologist, published Natural and Political Observations
Mentioned in a Following Index, and Made upon the Bills of
Mortality in 1662. In it, he presented the first life tables, as
well documenting increases in urban populations due to
immigration. Almost two centuries later, John Snow, in what
might be considered a prototypical urban health interven-
tion, removed the Broad Street pump handle after observ-
ing differential attack rates for cholera in London.
Until relatively recently, in the academic literature,
urban living and its related exposures were considered
mainly in terms of their detrimental effects. This urban
health ‘penalty’ perspective, described by Andrulis and
others, focused attention on poor health outcomes in an
inner-city environment and disparities in the burden of
morbidity and mortality, as well as disparities in health-
care access, among specific subgroups. Recent work, how-
ever, has shown that urban living may be health promoting
and may confer an urban health ‘advantage.’ Urban areas can
provide access to cultural events, educational opportunities,