Urban Health

Dr.Kedar Karki
The health of those who live in the more densely populated areas of the world is of
interest and concern for two reasons: (1) the large numbers of persons involved, and (2)
the fact that the population density of an urban area changes the potential for both public
health problems and public health solutions. The potential for problems includes
increased exposure to large a number of individuals who can spread infectious conditions,
larger volumes of waste products at risk of poor handling, the presence of pollutants, an
apparent increase in stress, and a concentration of more serious mental health problems.
Solutions are influenced by economies of scale in providing services, a more varied array
of resources, and the potential for closer proximity to others with similar interests and
needs. Opportunities to work with others who share a concern increases the likelihood of
identifying appropriate actions and generating political support for solutions.

Social cohesion and social breakdown are the two ends of a spectrum describing the
relationship people in a given setting experience. The greater the cohesion, the more
likely the group is to work together, to share common values, and to find positive
solutions to problems in ways that are inclusive of all members of the group. Conversely,
when social breakdown has occurred, individuals are left to struggle with the challenges
of living alone, people turn on one another in ways that are damaging, and problems
accumulate to a level incompatible with a healthy life. Urban areas of today have within
them neighborhoods that could be described as fully cohesive, but far too many urban
areas are at, or are closer to, the other end of the spectrum.

AREAS OF CONCERN

Cities are a center of immigration, both from rural areas (as evidenced by the population
shift of the last century) and from other countries. Port cities (which may not be coastal in
this age of airport travel) experience a constant influx of people from other cultures and
climates. This may add to the health challenge in a number of ways. For example, during
the period following the end of the Vietnam War in which a large number of refugees
from Southeast Asia were arriving in the United States, many health care providers had to
learn about an entirely new range of parasitic diseases that were endemic in these people's
countries of origin. Beyond specific diseases, immigrants bring different expectations of
the health care system, and a different understanding of the range of interventions
appropriate to various disease states. Some immigrant health practices have moved
toward the mainstream, as in the increasing use of acupuncture, once seen as an odd
practice of the Chinese immigrant community. And the increasingly popular herbal
remedies are an echo of the role the botanica plays in Hispanic cultures.

HOUSING
Assurance of safe housing has long been an issue for urban areas, and the history of the
city is one of many cycles of housing development and reform. Failure to plan for
housing infrastructure (water and sewer systems, electricity) when the population is
moving into an urban area can result in extensive, substandard housing for those at lower
income levels. This can be found in the barrios, favelas, and other overnight city
extensions found around many cities in the developing world. Substandard urban housing
more often takes the form of older buildings in central city neighborhoods that have not
been maintained and are not well-served by public or private services of any kind. Health
hazards in such settings include exposure to lead-based paint, cockroach feces
(implicated in the increase in asthma), temperature extremes, or unsafe windows and
stairs.

In addition to issues of inadequate housing, the combination of a limited supply of

affordable housing and low-income levels leaves some individuals and families with no
place to call home. The homeless concentrate in urban areas. This may be in part due to
the cost of housing in some urban areas, forcing people out of safe housing and into the
streets. For example, the economic boom of the 1990s in New York City led to a
tightened housing market; those serving the homeless reported a marked increase in
families with children finding themselves without a permanent place to live. This has
important implications for health care, as homelessness may be associated with a lack of
a way to pay for care, and the struggle for safe shelter may obscure early indications of
need for care and thus more serious illness problems later on. Housing policy that does
not offer ready assistance may also consider a person as having a home as long as there is
some extended family member with room on the sofa or living room floor. While such an
arrangement may work for a short time under emergency circumstances, the loss of
privacy and crowding that results adds another dimension of stress to the risks of mental
and physical ill health.

As would be true in rural as well as urban areas, control of indoor temperature is a

significant issue. Experiences during periods of extreme heat during the 1990s have led to
an increasing awareness of the risks, especially for the elderly or infirm in urban areas,
when the temperature remains over 95 or 100 degrees Fahrenheit for several days.
Windows may be locked shut for fear of intruders and fans or air conditioning may be
seen as an expensive luxury. Neighborhoods attentive to the needs of the housebound
during a severe winter (are they frozen in without adequate food? have we made
adjustments in the cost of heating so that freezing is unlikely?) have not understood that
there were perils at the other end of the thermometer. In areas in which housing is
multilevel, and especially where it is high-rise, the isolation of individuals may mean that
neighbors do not know who is alone and unable to make appropriate adjustments to either
hot or cool weather, and excess media attention to crime and violence may distort views
of personal safety and mitigate against cooperation.

FOOD AND WATER

Urban areas offer inhabitants little opportunity to obtain food other than through
purchase. The larger the urbanized area, the further foods have to travel to reach stores
and eventually households. This also makes "fresh" a relative term: the produce delivered
straight from the field to the store is going to be much fresher when the journey is one
hour than when it is one day. On the other hand, large concentrations of people make it
economically reasonable to regularly import food from all over the globe, making
formerly seasonal fruits and vegetables available year-round.

Delivery of fresh water to residents was often one of the first public health activities
taken up by municipal authorities in the eighteenth century. Using simple surface
impoundment, wooden piping, and gravity, water that was not contaminated by urban
sewerage and waste products could be made available to central pumps and to individual
residences. Over time, the systems have become more elaborate, and contamination
concerns have expanded to include not only the infectious diseases of the past and
present, but a wide range of potentially damaging chemical agents associated with
modern industrial life.
For urban areas, concern about water is not only related to use for human consumption, it
is a significant part of safety, given the role that water plays in control of fire. The
concentration of housing and industry in urban areas has made fire safety an urban
concern since the colonial era. Benjamin Franklin is cited as the father of the modern fire
insurance and fire fighting systems in the United States. Urban areas devote an extensive
portion of zoning and construction regulation to assuring that heating, cooking, and
industrial fires, and electrical transmission systems, are such that the probability of fire is
minimized.
WASTE DISPOSAL
The concentration of populations in urban areas also means an increased accumulation of
waste products. Removal of human waste and garbage is a major commitment in any city,
whether the mechanism chosen is completely public or funded by a mixture of public and
private resources. The treatment of human waste is costly, and new requirements that
protect both people and the environment from contaminants has meant a steady
investment in upgrading treatment facilities and building new ones. Treatment plants
running at or near capacity in systems in which storm runoff drains into the common
sewers may overflow or be bypassed during rainy seasons, causing downstream
problems.

Trash and garbage that accumulate in urban areas must be disposed of safely. The old-
fashioned garbage incinerator is no longer feasible, due to both volume of material and
the air pollution caused by burning. Landfill disposal requires moving the material
outside the urban boundary, and safety requirements for landfills have become
increasingly stringent. While many areas do not want any waste disposal nearby, the
acceptance and processing of urban waste has been welcomed by some economically
suffering rural areas. Trash from East Coast urban areas may be moved long distances by
land or sea for final disposal. The volume of waste is directly related to the degree of
attention paid to recycling of materials. Paper, glass, metal, and plastics all can be
returned to use with proper treatment, but efforts to fully recycle met with varying
degrees of success. Some urban areas have come very late to full recycling efforts, but
most now offer curbside or individual pickup of separated recyclable materials.

At the same time as communities search for more ways to dispose of waste, attention to
the siting of waste disposal has increased due to the awareness that racial and ethnic
minorities have found themselves disproportionately exposed to these sites. Whether this
is because landfills are deliberately located in minority communities, or their proximity is
the indirect result of lower income levels and lower property values adjacent to
environmental hazards, the practice has fueled both rage and concern, and government
action has been taken to address the problem. This issue of environmental justice could
be easily expanded to other land-use issues in urban areas, since neighborhoods with
lower income levels and greater concentrations of minority populations generally have
less open space for parks and playing fields, and the ones they have are often in poor
condition. Lack of safe park space leaves low-income urban children playing in the street
or other unsafe areas, increasing chances of injury.

HEALTH AND HEALTH SERVICES

Urban hospital systems have provided a critical link in access to health care. Many have a
long history of service that dates to the waves of immigration and the epidemics of
communicable diseases during the nineteenth and early twentieth centuries. Those that
are publicly owned have been particularly important because of their continuity of
presence, visibility, and obligation to serve all within the jurisdiction. One example of the
continuing evolution of such systems is the shift from a combination of inpatient care,
specialty clinics, and emergency rooms to community partnerships featuring community-
oriented primary care. Shifts in payment approaches by public insurances such as
Medicaid's use of prepaid group coverage requires adaptation to global and capitation
payment methods, and has drawn some traditional patients (and their money) away from
these public hospitals, leaving them strapped financially but still serving an essential
function in urban areas.

While there are many negatives to health and health services in urban areas with large
uninsured populations and antiquated care systems, there are also positives associated
with urban health. The concentration of people means that specialized services are
economically viable. It is medical services in urban centers that have pioneered many of
the interventions now taken for granted and that are now being transferred to less
populated areas. The person with a relatively unusual condition who lives in an urban
area is more likely to find the needed care within close proximity than a similar
individual in a rural location.

Urban health is a complex web of both threats to health and supports to health. It cannot
be understood apart from an appreciation for the size and density of the populations
involved, and it continues to evolve as economics shift, technology advances, and public
expectations develop. But the likelihood that urban areas will continue to concentrate
people, problems, and opportunities makes its health concerns unique and important.