Health inequalities in urban areas: a guide to the literature

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 the Alison Todd has a background in medicine and anthropology. Her principal research interests relate to the health concerns of the urban poor, and especially of homeless people and street children. She has recently started a PhD at the London School of Hygiene and Tropical Medicine.