By Ramanath Jha
It is generally accepted that urbanisation has been instrumental in bringing about greater economic prosperity to nations. Cities, however, have certain negative fallouts and one of these is the rise of a class of human health issues that could be categorised as ‘city ailments’. These are spawned by the specific urban environment of the urban settlement and the quality of life that it stimulates. The city gives rise to big human populations, large geographic size, high human and built density, and a bewildering variety of economic activities. These, in turn, engender issues of transportation, air and noise pollution, time management, a variety of stress and such other urban manifestations that are peculiar to the urban locale. Unfortunately, they seem to severely impact the health of city dwellers and give rise to health issues that call for a customised strategy.
These health issues can broadly be trisected — diseases that are primarily related to slums and the urban poor, diseases that afflict the class of people who have sedentary jobs and odd hours of work and diseases that go beyond socio-economic boundaries and afflict all city dwellers. It must, however, be added that these boundaries are getting blurred as diseases are crossing socio-economic limits, as has been witnessed in the case of the ongoing COVID-19 outbreak.
The habitat that the urban poor are for the most part forced to occupy are run down zones. Since they are largely unplanned, they develop into slums that could be termed as environmentally deprived. Their numbers rise as cities grow in size. These are areas of high human density and have limited access to potable water, sanitation and other basic services. As a consequence, many times, their health indicators are worse than those in rural areas. High human densities and lack of ventilation make them prone to communicable diseases such as tuberculosis. It was a disease that was considered comprehensively tackled, but it has reappeared in slums with worrisome force. Waterborne and vector-borne diseases such as dengue are linked to unsafe water storage and poor waste management, especially seen among urban poor settlements. Additionally, they also are susceptible to acute respiratory diseases from indoor air pollution and diarrhoeal diseases from unsafe drinking water and sanitation.
Surprisingly, slums in many parts of India have started revealing symptoms of lifestyle diseases such as obesity, hypertension and diabetes. These were considered ‘diseases of affluence’ that were not visible among the urban poor. However, these assumptions now need to be revisited in the light of evidence emanating from slum dwellers. Some studies indicate that about one-fourth of the adult population in slums suffers from hypertension, diabetes or obesity.
Among the middle classes, their current lifestyle includes fast-paced life with sedentary duties. Many of the jobs require odd hours of work and promote a stressful environment and unhealthy food habits. Indian cities, in general, have more people living per square kilometre of space than other cities around the world, leading to under-provision of public open spaces for recreation and exercise. These factors in totality predispose them to diseases such as obesity, diabetes, and hypertension. Work stress, unhealthy lifestyle, and polluted food intake also lead to different kinds of cancer. Different varieties of cancer, in particular, seem to be tightening their grip on India, and about a million new cases of cancer are being reported every year. A worrying factor is that a five-fold increase is predicted by 2025.
Urbanisation also brings about profound changes in social organisation and in the pattern of family life. A key outcome is reduced social support so readily available in villages. The rise of nuclear families especially makes urbanites vulnerable to psychological trauma and to mental disorders. These include dementia, depression, substance abuse, alcoholism and family disintegration. A report by World Health Organisation (WHO) titled The Mental Health Context, has enumerated that mental disorders account for nearly 12 percent of the global burden of disease. By 2020, these will account for nearly 15 percent of disability-adjusted life-years (DALYs) lost to illness. The incident of mental disorders is highest in young adults, the most productive age of the population. It is estimated that about 150 million people in India are in need of active psychiatric intervention. Given the fertile conditions, Indian cities are likely to have a very large share of this global health challenge in the coming decades.
There is rising incidence of air pollution across many Indian cities. In 2016, the World Health Organisation (WHO) listed 14 Indian cities among the world’s 20 most polluted. Air pollution has given rise to a diverse group of respiratory diseases. As people breathe, microscopic particles get drawn into lungs and to the bloodstream causing asthma, chronic obstructive pulmonary disease, lung cancer and heart disease. They have a negative impact on the development of children and even affect the brain. Air pollution indeed has acquired teeth to become an occult killer in India’s highly polluted cities and remains one of the most relevant and intimidating challenges of urban health.
In India, there has been an accelerated spread of dengue and chikungunya, both transmitted by the Aedes mosquito, which is particularly well adapted to urban areas. Recent estimates indicate that India has the highest prevalence of these two diseases. There are about 33 million apparent cases and 100 million asymptomatic cases of dengue occurring annually. Studies indicate, for instance, that nearly 40 percent of the population in the national capital have been infected by the dengue virus at least once in their lifetime. Because all parts of the city are now hyper-connected, emerging diseases such as dengue affect both privileged and the deprived. The incidence of chikungunya is much lower — 64,057 cases of chikungunya were reported in 2016, up from 27,553 in 2015.
Urban health, as is true of many other urban sectors, has traditionally attracted less governmental attention. This has resulted in the past of some neglect in systematic planning for health care infrastructure and delivery of comprehensive healthcare services for the urban population. There were sporadic and scanty efforts such as World Bank-funded India Population Projects. These yielded limited results, more so as the urban population continued to rise. It is true that the tepid governmental response did not had an impact on the more affluent class, since Indian cities with only about one-third of the total country’s population, have cornered 75 percent of dispensaries, 60 percent of hospitals and 80 percent of doctors. These are for the most part available to one-third of urban population. However, in view of rising urbanisation of poverty and the peculiar nature of some of the diseases that have a purely urban profile, there is an urgent need to separately address urban health issues. To control these diseases in a more sustainable manner, the health of the inhabitants has to become a key factor of urban development.
The National Health Policy (NHP) 2002 acknowledged this need to focus on the urban population and a National Urban Health Mission (NUHM) was launched in 2013. The pace of this programme, however, has been sluggish. While there is a case for scaling up NUHM with a strong focus on the urban poor, cities themselves need to recalibrate their local health programmes to respond to these health challenges. These renewed efforts would evidently necessitate a larger public funding for urban health. Given the state of municipal finances, however, that appears to be a tall order. It is obvious that the Centre and the States would have to play the major part.
The views expressed above belong to the author(s).