WHY SHOULD URBAN development professionals be concerned about variations in
health statistics within and between urban
areas? Firstly, because the statistics represent vast numbers of early deaths and debilitating illnesses. Secondly, because the
distribution of health inequalities in urban
areas reflects wider social inequalities: on
average the urban rich live for longer and in
better health than the urban poor. In Tondo,
a squatter settlement in Manila, Philippines,
nearly three times as many children die before their first birthday as in non-squatter
areas, while diarrhoea is twice as common
and tuberculosis nine times as common. In
the Bronx, New York City, children are five
times more likely to contract tuberculosis
than their wealthier neighbours. In London,
heart disease and respiratory diseases are
twice as common in poor as in rich areas. A
useful introduction to urban health inequalities is provided by the chapter on “Urban
Environment and Human Health” in the
1996/97 World Resources Report, from which
the above examples are taken.
Why are the urban poor less healthy than
their wealthier urban neighbours? The same
chapter gives a good overview of the arguments. The urban poor are more likely than
their richer counterparts to live in poor physical environments with sub-standard, overcrowded housing, inadequate water supply,
sanitation and waste disposal, and higher
levels of air pollution and other hazardous
substances. Their incomes are generally low
and insecure, they own few assets, lack access to resources and are thus less able to
cope with adverse events, including ill-health.
Additionally, the stressful nature of their social environment may contribute to higher
levels of tobacco, alcohol and drug use, accidents and violence than among their
wealthier neighbours.
The living conditions of the urban poor can
be measured in absolute terms but can also
be measured relative to the status of their
wealthier neighbours. Poverty is both an
absolute and a relative concept. The close
proximity of rich and poor in urban areas
means that the poor may be painfully aware
of what they have not and what others have.
Relative poverty, or social inequality, acting
through psycho-social processes may have
as deleterious an effect on health as absolute poverty.
The relative nature of the concept of inequality is important: one can only be unequal - in terms of health or other social attributes - in relation to others. Health inequalities describe differences in health status between two or more groups. It is the
inclusion of a comparative (generally less disadvantaged) group that distinguishes the
study of health inequalities from the study
of the health of the poor.
A previous guide to the literature focused
on the health of the urban poor (Atkinson
1993). This guide, however, concentrates on
urban health inequalities. Most of the literature relates to the South but occasional reference is made to the North to illustrate the
global nature of the subject. Two restrictions
have been placed on the guide’s contents.
Firstly, only published material in the English language is included, in the hope that
such material will be accessible. Secondly,
literature on health care, health service provision and usage has been omitted as theguide aims to show the influence on health
inequalities of all aspects of urban policy, not
just health policy.
The guide is structured as follows. Section II, Introducing Health Inequalities, describes the growing interest in the international arena in urban health research in the
South over the last two decades. Section III,
Investigating Health Inequalities, provides the
background information necessary to an
understanding of the research undertaken.
Section IV, Describing Health Inequalities, illustrates the scale and diversity of the phenomenon in terms of the health problems
involved and the comparative groups concerned. The final section, Explaining Health
Inequalities, discusses approaches to investigating their underlying causes and considers briefly interventions designed to close the
health gap.