Professional Documents
Culture Documents
ALICE SVERDLIK
ABSTRACT This paper reviews the literature on health in the informal settlements
(and slums) that now house a substantial proportion of the urban population
in Africa, Asia and Latin America. Although this highlights some important gaps
in research, available studies do suggest that urban health inequalities usually
begin at birth, are reproduced over a lifetime (often reinforced by undernutrition),
and may be recreated through vulnerabilities to climate change and a double
burden of communicable and non-communicable diseases. The review begins
with a discussion of papers with a life-course perspective on health, poverty and
housing, before considering recent literature on chronic poverty and ill-health
over time. It then discusses the literature on the cost, quality and access to care
among low-income groups, and the under-recognized threat of unintentional
injuries. This includes recent literature that discusses where low-income residents
may suffer an urban penalty rather than benefiting from urban bias although
there are also studies that show the effectiveness of accessible, pro-poor health
care. The concluding section examines emerging risks such as non-communicable
diseases and those associated with climate change. It notes how more gender- and
age-sensitive strategies can help address the large inequalities in health between
those in informal settlements and other urban residents. With greater attention
to the multi-faceted needs of low-income communities, governments can create
interventions to ensure that urban centres fulfil their enormous potential for health.
KEYWORDS climate change / equity / health services / housing / poverty / urban health
I. INTRODUCTION
1. UN Habitat (2006).
Environment & Urbanization Copyright 2011 International Institute for Environment and Development (IIED).
Vol 23(1): 123155. DOI: 10.1177/0956247811398604
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Elevated levels of infant and child mortality often result, but ill-health may
persist at older ages. Due to malnutrition or prior illness, children who reach
adolescence are frequently compromised in health and development.(4) Lowincome adults are at increased risk of occupational injury or disease, which
can quickly curtail their meagre earnings.
Although such negative outcomes may appear inevitable, urban areas
can promote major health improvements even for low-income households
(as has occurred in high-income nations). Medical centres, infrastructure and
health personnel are often concentrated in urban areas, while economies of
scale and proximity can facilitate good quality provision for water, sanitation,
drainage and health care at lower cost.(5) However, many local officials
are unwilling to provide essential services, health-related infrastructure or
recognition to informal settlements.(6) Largely due to unresponsive local
governance, low-income urban residents may enjoy few if any health
advantages over their rural counterparts.(7) Pervasive urban health inequalities
have been uncovered, as reviewed in past issues of this journal.(8) As health
inequalities are recreated over their life-course, low-income urban residents
are consistently denied the chance of improved health.
Informal settlements scale and complexity of health needs are
sometimes misunderstood. The health literature frequently concentrates
upon communicable diseases, yet low-income urban residents also
suffer from non-communicable diseases (NCDs) such as cancer, diabetes
and stroke, which are increasingly creating a double burden in these
households.(9) In low- and middle-income countries, the population
prevalence of chronic conditions climbed from 47 per cent in 1990 to
56 per cent in 2000.(10) Some estimates suggest that by 2030, mortality in
these nations will be dominated by NCDs, road traffic accidents and HIV,
while under-five mortality may fall by 50 per cent.(11) But such advances in
child health require major improvements in services and environmental
conditions, as well as overcoming significant failures in local governance.
Optimistic projections may also overlook climate change, whose health
impacts will be context-specific but often quite negative.(12) Many
informal settlements are at high risk, due to extreme weather events that
may become more frequent and intense as a result of climate change.(13)
Promising trends in health research are also emerging, which could
be extended and could help ensure more equitable interventions. Urban
health researchers have examined how inhabitants are affected by
their physical and social environment, the availability and access
to health/social services, and the interrelationships between these
determinants.(14) A new-found emphasis on vulnerability and social
exclusion has improved understanding of health inequalities.(15) Absolute
poverty lines are increasingly criticized for neglecting cities higher costs
of living and residents need to access health care, infrastructure and
other determinants of health.(16) Replacing these static poverty lines,
dynamic conceptualizations have explored residents vulnerability and
the portfolio of assets critical to overcoming deprivation.(17) Moreover,
health and poverty reduction are enjoying greater prominence in the
international development agenda. The Millennium Development
Goals (MDGs) represent important commitments, even if the MDG
target 11 of achieving significant improvements for only one-tenth
of the worlds billion slum dwellers by 2020 is patently inadequate.(18)
Significant improvements in informal settlements are needed not
only on a wider scale but must be guided by a holistic understanding of
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health. Shelter is often viewed narrowly, and notions of urban health need
to move beyond the absence of disease to encompass well-being. There
remains a pressing need for a new analytic framework to understand health
in slums.(19) At the crux of any urban health framework must be lowincome households, who usually experience cities negative externalities
instead of the benefits. Further research could enhance understanding
of health and its linkages with patterns of low and fluctuating incomes,
urbanization and housing.(20)
To inform future studies and interventions, this paper summarizes
the findings of some recent papers on health in informal settlements
or health among lower-income urban households. Articles from social
sciences and medical databases were selected to capture key urban health
risks across different age groups and regions (by searching for lowincome urban health, slum, favela or related terms). In particular, it
sought community-based research rather than studies using secondary
and hospital-based data (since these may undercount the low-income
groups lacking access to such facilities). Existing literature often focuses
on major cities, giving less detail on small and mid-sized urban centres
even as these are home to a significant proportion of urban dwellers.(21)
Several gaps in the literature are identified, such as studies on ageing,
quality of health care, and occupational health for those working in the
informal economy. Future investigations could analyze how the linkages
between health, poverty, and housing may vary over time, and between
and within households, or under different governance structures. New
insights could help create the corpus of a new health framework, even
transforming approaches to current or emerging concerns.
This review begins with a life-course perspective on health, poverty
and housing, before examining new threats that may exacerbate ill-health
in informal settlements. The sections highlight how health inequalities
begin at birth, are reproduced over a lifetime, and may be recreated
through vulnerabilities to climate change and a double burden of
disease. Drawing on cross-sectional studies, Section II explores key risks
from infancy to adolescence, adulthood and old age, and also sketches
some effects upon other household members. Section III helps uncover the
cumulative effects of ill-health and the discussion considers how illness
may interact with chronic poverty. By examining health expenditures,
access to health services and low-quality care (Section IV), the oftenreinforcing effects of ill-health and poverty come into sharper relief. As
researchers increasingly open the Pandoras box of adult as well as child
health, the effects of inadequate living and working environments and
poverty are shown to compound threats to health.(22) Injuries are rarely
recognized as a major threat, yet Section V notes that they contribute
considerably to premature death and frequently compromise the health of
adults and children. Section VI discusses evidence of an urban penalty
among the poor, and Section VII considers how non-communicable
diseases and climate change may further entrench disadvantages in
informal settlements. However, instances of pro-poor health care are also
highlighted and may set important precedents. With greater attention
to the multi-faceted, changing needs of low-income communities,
governments can create appropriate interventions to ensure that urban
centres fulfil their potential for good health.
But before this review begins, a comment is needed on terminology.
This review discusses the health implications of inadequate housing and
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the ill-health of individuals and households with low incomes, but the
terminology used in many papers is problematic. Areas or settlements
with low-quality housing are often termed slums, erroneously implying
that they have little worth, but residents often value these structures and
improve them by upgrading. The term also conceals the considerable
range of shelter construction, land tenure and ownership arrangements
in such settlements.(23) Many studies nevertheless report their findings in
slums, and the term has been revived with the Millennium Development
Goals that seek to improve the lives and monitor housing conditions for
slum dwellers.(24) Although the term informal settlement is preferred,
it may also be pejorative, and cannot capture all low-quality housing
(for example, legally-constructed tenements). Problems also arise in the
terminology used for residents without the resources to buy, build or rent
reasonable-quality housing. Describing these households as the poor
may wrongly suggest they are poor in other aspects of their lives.(25)
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the other two groups, families purchasing cheap water were more likely
to have the youngest child suffer from diarrhoea in a multivariate model
(which adjusted for maternal age, education, household expenditure and
other socioeconomic factors). Although water quality was not tested,
these findings suggest a link between buying cheap water and childhood
diarrhoea. Additional investigations could explore the effects of water
vending not only on childrens well-being but also on adult health and
household incomes.
Youngsters are particularly susceptible to pneumonia, a leading
cause of child mortality, as noted above, and young childrens health
burdens may far outstrip those of older residents. In a random survey
of 260 favela (informal settlement) residents in Salvador, Brazil, almost
36 per cent had pneumococcal carriage.(40) But prevalence rates diverged
markedly between age groups, so that the odds of infection for underfive children were eight times that of older subjects. About 16 per cent
of adults aged over 17 were colonized with Streptococcus pneumonia, as
against 45 per cent of children aged 517 and 67 per cent of children
under five. Pneumonia often proves fatal in younger residents in
informal settlements, as underscored by surveillance data in two of
Nairobis informal settlements. Pneumonia was the single leading cause
of premature mortality in young children, comprising 22 per cent of
under-five deaths for 20032005.(41) Contributing factors for pneumonia
were inadequate, overcrowded shelter and indoor air pollution (discussed
below). The premature mortality burden in under-five children was more
than four times that of the rest of the population combined.
Indoor air pollution exemplifies the links between poverty, health and
housing, and also how health impacts are influenced by age and gender.
Low-quality indoor air is often associated with overcrowding, inadequate
ventilation and solid cooking fuels such as wood, crop residues, coal or
charcoal. In 2000, cooking with solid fuels was linked to nearly two million
deaths and 38.5 million disability-adjusted life years, or DALYs.(42) Solid
fuels are widespread in low-income households, while wealthier families
can afford sources higher on the energy ladder, such as kerosene, natural
gas or electricity.(43) Most indoor air pollution studies focus on rural areas,
but low-income urban households may be affected as well.(44) In particular,
low-income women and children are usually most exposed to indoor air
pollution. Children often spend more time indoors as infants, or are strapped
to their mothers backs while they cook.(45) The resultant respiratory problems
include pneumonia, chronic obstructive lung disease (COPD), asthma and
tuberculosis; indoor air pollution is also associated with elevated risk of
cataracts, low birth weight, cancer and cardiovascular failure.(46) Researchers
should still quantify the full range of risks, and longitudinal analyses could
explore lasting impacts on childrens lung function.(47)
Of course, there is also the importance of malnutrition for child illhealth and premature death, as this underlies and interacts with most
other health issues and has some specifically urban dimensions.(48) The
high proportion of children that are underweight and under height in
particular studies has been noted above,(49) and is also discussed in Section
III, within discussions of chronic poverty.
But vulnerability cannot be equated with victimhood, and viewing
children as only a fragile sub-population is inaccurate. Urban residents
under the age of 18 are not a special interest group but a significant part
of the worlds population, comprising 1020 per cent of the citizenry
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50. Bartlett (2008), page 7.
51. Stephens (1995).
52. See discussion in Bartlett
(2002a) for overview; also
Environment and Urbanization
(2002).
53. See Environment and
Urbanization (2010); also
Makau (2011) in this volume;
Mabala (2011) in this volume;
and Fernndez-Castilla, Laski
and Schellekens (2008).
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97. Quoted in Mudege and
Ezeh (2009), page 252.
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infants were more likely to be wasted and underweight in their first year,
but stunting was increasingly common by the age of two or three. Only
cohort studies can offer such detailed insights into chronic malnutrition
and shifting burdens of childhood illness.
Child mortality rates have declined in Pelotas, Brazil, but cohort
studies still found enduring income-related health inequalities. In this
city of 300,000 people, researchers followed two cohorts of babies born
in 1982 and 1993. Income remained paramount in explaining child
mortality rates: for both cohorts, the poorest groups infant mortality
ratio was more than six times as large as among children born to the
wealthiest families.(119)
Another study in Pelotas analyzed the causes of death from 1982 to
2006, again uncovering stark disparities. Low-income children had higher
mortality rates in all age brackets, with a relative risk of 2.89 between the
lowest and highest tertiles when holding race and gender constant.(120)
In discussing the cohorts 288 deaths by 2006, the study helps uncover
the shifting nature of risk over the life-course. More than 40 per cent of
deaths occurred in the peri-natal period, due to infectious and parasitic
diseases. Among under-five children, parasitic and infectious diseases
remained the leading cause of death (31 per cent of cases) and another 24
per cent died from respiratory diseases. Few deaths occurred between the
ages of five and 14, with no leading cause. External causes led to nearly
two out of three deaths among youths aged 15 to 24-years old, reflecting
the widespread risk of urban violence.(121) More positively, however, the
overall infant mortality rate did decline from 36 to 21 per 1,000 between
1982 and 1993.(122) As discussed below, these reductions seem partly
attributable to Brazils subsidized health care. Amid troubling inequalities
at all age levels, reductions in infant mortality help affirm the potential of
accessible, high-quality health care.
Illness is something we are all scared of here. How can we live without
working? If my husband is ill, we have to get money from somewhere
for food and for the medicine, we have to borrow. (Selvaraja)(123)
Selvaraja, who comes from poorest income quartile in Colombo, admits that
sickness is widely feared, and her household may be forced into debt during
a breadwinners illness (We have to borrow). While direct expenditure
on drugs or hospitalization can be highly burdensome, the indirect costs
of missed workdays may be even more unmanageable (How can we live
without working?). Health expenditures often comprise a larger proportion
of low-income households incomes, as compared to wealthier households,
so that costs of illness inflict a far greater burden on poor families.(124)
Low-income households may adopt various coping strategies during healthrelated crises, and they manage a portfolio of assets including social networks,
productive capital and labour.(125) Yet if savings are exhausted, or children
have to work rather than attend school, long-standing vulnerabilities may be
magnified.(126)Patients may encounter a medical poverty trap, with limited
options that only exacerbate their deprivation and ill-health.(127) The poor
may endure untreated morbidity or reduced access to care, minimizing
their expenditure but inviting future complications.(128) Alternatively, they
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Even normal delivery costs may be excessive for those living in informal
settlements. Normal delivery fees average KSh 1,700 (US$ 23), while
caesarean deliveries range from KSh 3,000 (US$ 42) in a public district
hospital to 10 times that in a mission hospital.(136) Moreover, mothers in
two of Nairobis informal settlements often lacked access to transport,
qualified staff or emergency services. Women used 25 health facilities
altogether, but just two had comprehensive emergency obstetric care.
Of the 14 unlicensed private clinics in these settlements, none was
considered adequate and few staff could perform basic emergency
obstetric procedures. Just five facilities provided on-site transport, so
that women usually walk even in emergencies and mothers resort to
using facilities near to them irrespective of their quality.(137) Another study
underscored the low-quality care and uncovered inequalities within the
two settlements.(138) Although 70 per cent of mothers in the settlements
delivered in a health facility, just 48 per cent had a skilled attendant. But
compared to the poorest mothers, the wealthiest women were more than
twice as likely to deliver at a health facility and 45 per cent more likely to
deliver at appropriate health facilities.
However, Brazils experience indicates that high-quality maternal
services can be accessible to low-income groups. The Pelotas birth cohort
again provides insights, by exploring womens utilization of the Unified
Health System (SUS). Begun in 1988, this provides full maternal care from
antenatal to post-delivery through a decentralized mix of providers.(139)
Data on expenditure and providers were collected from nearly 4,000
mothers in Pelotas, who were interviewed three months after giving
birth. Expenditures were progressive, since the richest mothers spent
nearly eight times as much as the poorest.(140) The unified health system
financed 80 per cent of the deliveries, although utilization peaked in the
poorest households (it was used by 98 per cent of mothers in the first
income quintile, 95 per cent in the second and 90 per cent in the third).
The proportion dropped to 75 per cent in the fourth quintile and onethird in the richest quintile, but findings suggest that the programme was
still widely utilized and well-regarded. Appealing to mothers across the
income spectrum, the programme also sets a notable precedent in highquality public care.(141)
Access to health care is widespread in Sri Lanka, services are wellregarded and levels of direct expenditure are low in deprived communities.
Under Sri Lankas public health care provision, the state provides access
to tertiary hospitals and local municipal dispensaries (where GPs offer
free consultations). Of 400 households surveyed in two low-income
Colombo settlements, 77 per cent spent less than five per cent of their
monthly income on health, and mean costs did not vary significantly
between income quartiles.(142) Even for patients with chronic disease,
just three per cent had monthly burdens that exceeded 10 per cent of
household income. These encouraging findings were complemented by
life histories, which explored how illness and poverty may interact even
under progressive health systems. For patients in the poorest quartile,
expenses usually triggered coping strategies that pushed them deeper into
poverty.(143) Transport costs, missed workdays and other indirect costs
often resulted in a downward spiral.(144) Yet there were several factors
in households declines, such as drink and other drug problems, earlier
shocks, the loss of land [or] broken relationships.(145) Findings suggest a
need to address indirect costs, overcome past shocks and bolster assets.
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included 1,046 falls, 135 poisonings, 286 burns and 401 RTIs, with more
than 70 per cent of the 1,868 injuries considered serious. Excluding the
111 victims with multiple injuries, as many as 1,757 out of the 10,210
children (17 per cent) had a lifetime injury. Boys were more likely than girls
to be injured (odds-ratio of 1.6), in keeping with past studies. Households
with one injured child were at increased risk, suggesting the need for an
integrated approach to prevention. About 55 per cent of the households
lived in poverty, and injuries displayed some interesting differences by
socioeconomic status. In this study, poorer children were at greater risk
of burns, pedestrian RTIs and multiple injuries, yet poverty was not a risk
factor in falls or poisonings. Children in larger households were actually less
likely to fall, perhaps because watchful older siblings helped prevent these
accidents. Moreover, patterns of risk shifted over the life-course, as RTIs
were increasingly common after the age of five. In sum, childrens injuries
were a widespread problem influenced not only by poverty but also by
gender, household characteristics, settlement hazards and life-course stage.
Children in South Asia seem prone to other accidents, such as
drowning and cuts, and the regions injury burden may far exceed
some previous estimates. In Bangladesh, perhaps 2025 per cent of all
childhood deaths are from drowning.(157) This systematic review examined
South Asias unintentional injuries in under-five children, but findings
diverged widely. Studies from 1980 to 2007, mostly in Bangladesh and
India, suggested that injuries annually cause between 161,000 and
586,000 childhood deaths. The review found that the weighted mean was
284,000 deaths, or triple the estimated 94,000 fatalities in the 2002 Global
Burden of Disease study. Figures do not distinguish between rural/urban
populations, yet injuries are clearly a major concern in South Asian cities.
In Kathmandu, more than 200 deprived youths aged 1017 were
asked what their most serious injuries had been over the past year.(158)
Responses indicated the widespread occurrence of injury, as well as
the range of risks. The most common injuries were falls (59 per cent),
transport-related accidents (50 per cent), cuts (44 per cent) and burns
(16 per cent). Adolescents aged 1417 years were slightly more likely to
experience cuts and burns than children aged 1013. Transport accidents
usually involved pedestrians, as in other low-income settings, and victims
were more likely to be male (65 per cent of boys vs. 38 per cent of girls
reported traffic injuries). Further studies could clarify the regional burden
of injury and identify cities particular risks.
A study in South Africa found that injury patterns not only differed
according to a childs gender, race or age, but also by city. Based on six
cities surveillance data between 2001 and 2003, there were 2,923 fatal
injuries in children aged 014.(159) The three leading causes of death
were pedestrian injuries, drowning and burns, in all cities except Cape
Town. Although income data were not recorded, race can offer a proxy
for socioeconomic status, and highlight major inequalities. Black Africans
represented 65 per cent of the population in the 2001 census, but black
African children comprised 77 per cent of the victims of fatal injuries. For
some causes of injury, racial differences were especially profound. The
rate of fatal burns for black African and coloured children reached 4.5 and
2.7 per 100,000, respectively, but just 0.3 and 1.2 for whites and Asians.
For pedestrian road injuries, the mortality rate was 0.7 per 100,000 white
children as against 7.9 for coloured and 9.4 for black African children. Boys
had significantly higher rates of drowning and pedestrian RTIs (although
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gender was not a risk factor for passenger RTIs). The broader urban setting
also influenced injury patterns, and cities ranged widely in road safety.
Pedestrian fatalities in Tshwane (Pretoria) were far less common than in
eThekwini (Durban) or Nelson Mandela (Port Elizabeth).(160) Given the
influence of urban context and socioeconomic factors, injury prevention
campaigns must be informed by disaggregated micro- and meso-level data.
Older peoples falls are a major cause of morbidity and mortality as
well as a significant economic burden, but research is scarce in low-income
settings. Worldwide, injury is the fifth-leading cause of death in elderly
people and these fatalities are usually due to falls.(161) Falls also result in
extensive disability and functional impairment, comprising more than
80 per cent of injury-related hospital admissions in people over 65. This
review on preventing elderly peoples falls, while helpful, largely utilizes
data from high-income nations.
In Beijing, a survey of 1,500 residents over the age of 60 yielded
findings about falls and their steep costs. A total of 379 falls occurred in 272
individuals over the previous year, or a frequency of 18 per cent.(162) Women
and older respondents were at greater risk but it seems that most falls were
not severe. Just 143 resulted in injuries (38 per cent) and there were only
16 hospitalizations. Nevertheless, the economic burden of hospitalization
was very high; hip fractures cost more than twice the average annual
income in Beijing. Even for falls without fractures, households must make
heavy expenditure on drugs, hospitalization, etc. A 2001 study suggests
that 25 million falls occur annually among 20 million elderly people in
China, and the direct medical costs reach five billion Yuan.(163)
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urban residents are less physically active than rural households but more
likely to consume such foods, in turn suffering higher rates of hypertension,
stroke, obesity, etc. Thus, NCDs initially occur among urban middle-aged
adults, but increasingly [affect] semi-urban and rural areas and younger age
groups.(190) One estimate suggests that by 2020, NCDs may comprise 69
per cent of all deaths in low- and middle-income countries, and most
victims will be relatively young [and] of lower socioeconomic status.(191)
Quality of life is often impaired, and in impoverished households the
long-term costs of chronic disease may prove particularly burdensome.
Yet changes are still incipient in many cities, so that outreach and other
interventions could help to minimize the impacts of NCD. With careful
planning and age-sensitive strategies, policy makers may also curtail the
projected increase in RTIs and vulnerabilities among the elderly.
Since NCDs arise gradually and unevenly at the household and city
levels, studies may not find clear associations between urbanization,
poverty and NCDs. In Quetzaltenango, a Guatemalan city of 100,000
people, wealthier children are still at higher risk of obesity.(192) This survey
of 600 children aged from eight to 10 compared outcomes by public and
private school attendance, as a proxy for socioeconomic status (SES).
Nearly one-third of wealthier students were overweight or obese, as against
just 12.9 per cent of their low SES peers. Better-off children were thus more
than twice as likely to be overweight, while stunting was nearly four times
more common among poorer students (27 per cent of low SES children
vs. 7.3 per cent of high SES children were stunted). Nor were NCDs in
Buenos Aires consistently linked with socioeconomic status according to
a risk survey of 1,500 residents. Low-income respondents were more likely
to report hypertension, but not diabetes.(193) In a community-based survey
of 1,300 women in Accra, chronic and communicable conditions were
widespread, but low-income respondents were not at greater risk.(194) By
continuing to explore the dynamic relations between NCDs and urban
poverty, research may pinpoint priorities for intervention in low-income
settlements.(195)
However, data shortfalls and limited awareness of NCDs may
conceal the magnitude of todays problems, underscoring the need for
enhanced surveillance and outreach. Chronic conditions in low-income
households are often neglected, as the formal health system records only
the complications or outcomes that require their intervention.(196) Prospective
surveys have already yielded sobering results. In Soweto, Johannesburg,
risks of heart disease were widespread among 850 individuals seeking
care in a local hospitals cardiology unit.(197) As many as 60 per cent of
respondents had hypertension, 47 per cent smoked and 34 per cent were
obese.(198) Long-term residents, particularly black African women (52 per
cent of the cohort), were at elevated risk of cardiovascular disease. Another
prospective study followed 50,000 Kolkata residents between 2003 and
2005 to assess stroke outcomes. Comparable to wealthier regions, the agestandardized incidence was 145 strokes per 100,000 persons per year.(199)
The overall 30-day stroke fatality rate was 41 per cent, exceeding highincome nations average rates of 1733 per cent. In informal settlements, the
stroke fatality rate was 31 per cent as against 44 per cent in non-slum areas.
But lower fatalities in informal settlements are highly unlikely, and these
findings suggest improper reporting procedures or mis-attribution.(200) Better
surveillance and reporting are crucial to ascertain the risks and, in turn, to
forge an appropriate response in these communities.
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144
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I L L - H E A LT H A N D P O V E R T Y
214. Guzman and Saad (2008),
page 261.
215. Montgomery et al. (2003).
145
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146
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I L L - H E A LT H A N D P O V E R T Y
243. See, for instance, Hardoy
and Pandiella (2009) for
Latin America, and Adelekan
(2010) for Lagos. For further
discussion of urban adaptation
that addresses the needs of
those in informal settlements,
see Satterthwaite, Dodman
and Bicknell (2009); also
Satterthwaite et al. (2007).
244. Bartlett (2008), page 31.
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