Health services and environmental factors in urban slums

and shanty towns of the developing world

Alessandro Rossi-Espagnet

Introduction started growing rapidly and are not exempt from the
problems that affect the bigger cities. Finally, contrary to
A report sponsored by the World Bank has stated that the what happened in the past in the industrialized world,
frequency and severity of malnutrition in the developing urbanization in the developing countries is primarily
world are increasing more rapidly in urban than in rural the result of rejection of the rural areas. Therefore it is
areas [1]. Clearly, a major problem exists, but its real a negative phenomenon that has caught the cities totally
extent is apparent only if one considers that urbanization, unprepared. The consequence is an invasion of squatters
as the major new factor in the demographic growth and the establishment of populations that by most
of the developing countries, is itself expanding and measurements can be classified as poor.
accelerating. It has already reached dramatic proportions
in some countries and is likely to do so in others.
Facts and figures
The increasing interest manifested during the last
few years in the problems of urbanization should not be As is known from UN statistics [5], by the year 2000 the
interpreted as an attempt to shift attention away from the world’s population will grow by 41%, from 4.4 billion to
rural areas, where the problems are still tremendous, to 6.2 billion people, about half of whom will be living in
the cities, which, globally considered, enjoy a relatively urban areas. Thus, the urban population will rise 78%,
privileged situation. Rather, it is the response to a from 1.8 billion to 3.2 billion people, of whom about 2
recognized need to emphasize the dimensions of the billion will be living in develop
urbanization phenomenon, the profound heterogeneity As the urban growth rate is increasing, the rural
of the city, and the inequitable and discriminatory growth rate is decreasing; it is projected that by the
treatment applied to certain population groups in urban year 2010 the aggregate rural population in developing
areas. It should also suggest that the rural and the urban countries will decrease in absolute terms (fig. 1). While,
are interrelated elements of the same universe and between 1975 and 1980, 55% of all population increase
should be looked at in this wider context. It is therefore was urban, this figure will climb to 83% by the year 2000.
not surprising that the FAO (Food and Agriculture
There is considerable variation among countries and
Organization of the United Nations) devoted 10 of the
regions in the extent and speed of urbanization, but no
39 pages of its report to its Council in November 1984
developing nation can afford to ignore the phenomenon.
[2] to discussing, under the title “Urbanization a growing
Where the rate of urban growth is high, as in sub-
challenge to agriculture in developing countries,” a variety
Saharan Africa and parts of Asia, the repercussions can
of problems relating urbanization to agriculture, some of
be considerable, even if the level of urbanization is still
which, incidentally, have clear health implications.
relatively low, because of the intolerable burden placed
At least five reasons justify increasing attention on existing facilities and services.
to the health effects of urbanization and suggest that
The number of cities with populations of one million
remedial actions must be considered with urgency [3].
or more has increased considerably during the recent
The first is that urbanization has become in speed and
past. There were 118 such cities in less-developed regions
size a severe problem everywhere. The second is that, in
in 1980, and it is estimated that there will be 284 (65%
spite of this universality, urbanization primarily affects
of the total) by the year 2000. Likewise, of 26 cities with
the developing countries. Third, it is not a temporary
populations of 5 million or more in 1980, 16 were in
phenomenon and no longer depends on rural-urban
developing countries. There will be 60 such cities in the
migration, as two-thirds of urban growth is now the
year 2000, of which 45 will be in the developing world.
result of natural increase 14]. Fourth, it is no longer
confined to capitals: secondary and tertiary cities have

Food and Nutrition Bulletin, vol. 9, no. 4 © 1987, The United Nations University. 1
2 Health services and environmental factors

Major hazards of urbanizationDisease accidents, are mainly related to the man-made conditions
of the urban environment. The third group consists of
As the urban poor are at the connecting point between
disorders that are a result of the social instability and
underdevelopment and industrialization, their disease
insecurity that have become characteristic of life in many
patterns reflect the problems of both. Three main groups
urban areas. They include alcoholism, drug addiction,
of diseases have been identified [3]. The first, most
venereal diseases, and the effect of different types of
directly related to poverty, includes infectious diseases
child abuse and other conditions that overlap with
and malnutrition. The second includes cardiovascular,
those mentioned.
neoplastic, and mental diseases that, together with

FIG. 1. Average annual population increment in less developed regions ( Source: United Nations Population Division 1980
assessment [computer print-out])

Malnutrition other agencies, could pursue the initiative undertaken

years ago when it published the book Patterns of Urban
Malnutrition is a problem of special importance because Health and Health Services in Developing Countries,
it not only constitutes a separate disease entity per se but in which it could bring out and analyse the variability,
aggravates and is aggravated by other diseases, especially often extreme, of health and health-related conditions in
infectious diseases. Thus it can be a co-factor of mortality. the cities. As has been pointed out in a recent UNICEF-
Often malnutrition, like other disease problems of WHO publication: “A comprehensive and searching
the poor, goes unnoticed or is not appreciated to its full review at the national level of the urban health situation
extent, especially when (on the erroneous assumption and an assessment of resources, real and potential, seems
that cities are homogeneous entities) information is essential for the development of rational and equitable
provided in the form of aggregated averages for large policies on urban health care” [6].
urban areas or for a whole city. This makes it impossible Where appropriate sampling procedures have been
for the reports provided to political leaders and managers used and a stratified analysis of the information has been
to reflect the intra-urban differences by geographical made, it has been possible to show, for example, that in
areas and socio-economic groups that would be essential slums and squatter areas energy intake is two-thirds to
to understanding the situation and guiding action. half the city average, vitamin-A intake one-third to half,
A systemic study of these intra-urban differences in and anaemia twice as prevalent, and up to 50% of the
malnutrition, as well as in other health and health related children may show signs of malnutrition, 10% of them
conditions, is long overdue. The Pan American Health in severe form [7].
Organization, perhaps in collaboration with UNICEF and
Alessandro Rossi-Espagnet 3

Observations from Abidjan [8], New Delhi [9, 10], and Guatemala City [15], the prevalence of second- and
Santiago [11], Sao Paula [12], and various other cities third-degree protein-calorie malnutrition was similar to
are consistent with these estimates. More important, or even slightly above that in rural groups. In Hyderabad
where the information has been disaggregated by a greater proportion of children one to seven years of
socio-economic groups, it has been found that the age were found to have nutritional deficiencies than
availability of nutrients was lower for the urban than their rural counterparts [20]. In certain sections of
for the corresponding rural groups (Colombia [13]) or Jakarta, infant mortality is 85 to 90 per 1,000, and the
that there were more severely malnourished children calorie deficiency malnutrition is worse than in rural
in low-income urban than rural areas (San Jose, Costa areas [21]. In the Egyptian national nutrition survey of
Rica [14], Guatemala City [15], and San Salvador [16]). 1978, the prevalence of stunting was 15.7% and 18.8%
It is worth noting that neither the large intra-urban in the disadvantaged areas of Alexandria and Cairo-
differences observed in Moroccan cities nor the even Giza respectively, compared with 27% in villages of
worse conditions of the urban slums compared with upper Egypt and only 1.1% in a comparison group of
the rural areas there would have appeared if city-wide socio-economically advantaged children [22]. In four
averages had been used [17]. slum areas of Bangkok the prevalence of protein-calorie
These results of rural-urban comparison may be at malnutrition was attributed to failure to breast-feed, early
variance with what is generally believed. Some possible weaning, or inadequate artificial feeding [23]. This is in
reasons can be mentioned [18]. Although in South-East contrast with the rural areas, where almost all infants are
Asia and Latin America rural labourers largely depend adequately breast-fed and rarely found to have severe
on their landlords for their food, many rural families, protein-calorie malnutrition up to the age of six months
especially in Africa, own small pieces of land on which [23]. Similar observations were made in Chile [24] and
they can grow part of their food, or from which harvest Port Moresby, Papua New Guinea [25].
surpluses are available; this is generally not possible for
the poor in the overcrowded cities. On the contrary, in Equity in health care: Problems and actions
the cities, although salaries are higher, so are costs, with
In spite of the well-known greater concentration of
the result that food itself is more expensive and the poor
health facilities in the cities than in rural areas and
have a smaller proportion of their income available
the relative proximity of hospitals and other medical
for it. The Moroccan experience, mentioned above,
facilities, standards of health care fall far below
is a good example of the fallacy of assuming the same
reasonable minimum levels for those who live in the
relationship between food availability and income when
slums and shanty towns of the developing world. Lack
environmental and social conditions are very different.
of care is far graver than each city’s overall mortality and
Furthermore, in the highly competitive situations of morbidity data suggest, for these data are, as already
the city, women are often forced to work in full- or part- mentioned, averages, and conceal the large differences
time jobs (generally in the informal sector) to supplement between the best figures and the worst. Some have
the family income or as the only family support. Under spoken of an “inverse care law” whereby those in greatest
such circumstances, women may typically have less time need of medical care have the poorest access to it [26,
for food preparation. In addition, they may resort to 27]. Paradoxically, while there is some awareness of the
early weaning, leave their infants in the custody of young health and health-service problems of rural poverty in
children unable to prepare weaning food properly, dilute the developing world, far less attention is paid to the
and divide a limited milk supply among many children, increasingly important problems of urban poverty.
fall easy prey to advertising (causing “commerciogenic’’
City administrations can hardly keep pace with the
malnutrition [19]), or become victims of various
scale and tempo of urbanization and the multiplicity of
combinations of all these factors.
problems that go with it. Health and other social services
Other examples are available. In Abidjan, while on the already existing in the city are not equitably distributed,
whole the availability of food is considered satisfactory, nor are they planned, designed, or implemented to
there are striking inequalities between socio economic help those who are in greatest need. Yet poorer people
groups and geographical areas, resulting in worse use contribute to the cost of these services through various
of food by certain urban groups than in the rural areas forms of direct and indirect taxation and through a
[8]. In the lower occupational strata of San Jose, Costa variety of additional costs imposed on them by the
Rica [14], as well as of San Salvador, El Salvador [16], location and operation of the services concerned.
4 Health services and environmental factors

The essence of primary health care Awareness

Primary health care concepts apply to urban health Without exception, too little emphasis is given to the
systems just as they do to the health systems of whole application of primary health care principles in the
countries, for the discrepancy between the allocation cities, and particularly to the needs of the urban poor.
of resources and health needs is equally striking in the Nevertheless, attitudes are changing, even if only very
cities, and the gaps between rich and poor, and between slowly. In addition to recognizing explicitly the needs of
need and provision, are actually widening. those living in marginal areas, serveral cities have initiated
The concept of primary health care represents a actions specifically incorporating these principles.
qualitative jump over the old concept of basic health To start with, awareness is improving. Advocacy
services. It includes, first of all, a philosophy emphasizing activities have been carried out in Ecuador, Colombia,
equity and justice in matters related to health. Second, Peru, Bangladesh, India, Indonesia, and other countries.
it delineates a strategy that starts from an improved Some of the cities that have participated in meetings
understanding of health problems at their roots (which sponsored by UNICEF and WHO within countries or at
often lie in the political, economic, and social realities an inter-country level are using the momentum created
of each nation) and attempts to find solutions that go by these activities to advance their programmes and
beyond the technological treatment of problems to change the attitude of “benign neglect” toward the urban
their fundamental causes. Thus the strategy also entails poor that has long been common in many countries.
political decisions on matters such as employment and
income, land distribution and tenure, basic education Policies
and housing; co-ordinated efforts by all the sectors It is as yet most unusual for countries to have a national
concerned with socio-economic development; and a strategy for urban health that incorporates concepts
better balance between ‘’top-down” planning and the of primary health care. Yet is is important that such a
upward expression of needs, aspirations, and possible strategy should be formulated and that it should recognize
contributions by individuals and communities to their the exceptional needs of those living in marginal urban
own development. Finally, public health care concepts areas so as to raise the national awareness of a major
emphasize actions at the primary level, that is, the level urgent human need (giving leverage in the competition
of first contact between the people and the system, for scarce resources!, gain a joint commitment among
particularly in relation to the eight tasks proposed in the agencies where this is essential for implementation,
Alma Ata Declaration (education concerning prevailing and stop inappropriate policies that do not take these
health problems and the methods of preventing and needs into account. Several countries, such as Brazil,
controlling them; promotion of food supply and proper Colombia, Ecuador, Indonesia, Mexico, Pakistan, and
nutrition; an adequate supply of safe water and basic Peru, have formulated, or are moving in the direction of
sanitation; maternal and child health care, including developing, such a national strategy, which will provide
family planning; immunization against the major for increased investment in favour of the urban poor and
infectious diseases; prevention and control of locally will upgrade slums and shanty areas instead of promoting
endemic diseases; appropriate treatment of common massive relocation.
diseases and injuries; and provision of essential drugs),
with the rest of the system being responsive and supportive Managerial processes
to action at the primary level and being conditioned by it At the city level there are also few examples of a systematic
[28]. Total coverage is the essential target. managerial process tackling the problems of urban
This strategy has been endorsed at the highest political deprivation, or of a truly comprehensive city health plan.
level by practically all the countries of the world, which While short-term and long-term plans sometimes reach
have agreed to report on how their existing medical out to vulnerable groups, they seldom encompass all the
services are being gradually converted, following that relevant needs, resources, and actions.
strategy, into health systems with the characteristics Nevertheless, cities such as Addis Ababa, Bombay,
of equity, social orientation, and efficiency that should Mexico City, and Manila are moving in the right
be at the foundation of modern medicine. Indeed, we direction, and other important providers (such as
should be proud of these accomplishments because, as hospitals outside the direct control of the department
a profession, we now know where we came from and concerned, other city services, social security agencies,
where we want to go, and, remarkably enough, we also and voluntary organizations) tend to be involved in and
know how to get there. Not improperly, somebody has committed to the plans.
called it a “revolution in medicine,” and Dennis elegantly
defined it as a “renaissance in community health’’ [29].
Alessandro Rossi-Espagnet 5

In certain cities, such as Mexico City, however, care strategy is based and the proof of its correct
the present economic recession has jeopardized large implementation. It has not materialized to the extent that
scale implementation of existing plans. Also, plans would have been desirable, either because of the heavy
are generally written in conventional terms, such as burden placed on health budgets by the cost of existing
providing additional medical facilities, or increasing tertiary-level facilities or because of the opposition of
ratios of health care personnel to population; it is rare powerful conservative professional and business groups,
for them to give the required priority to the items that or a combination of the two.
will actually have the greatest impact on health, such as The distribution of facilities and the financial and
water supply, sanitation, housing, and nutrition. So long cultural constraints on access to services are such that
as resources are as scarce as they currently seem to be most marginal groups are patently underserved. Hospitals
in these cities, managers are going to have to achieve have traditionally been the main vehicle for delivering
the difficult and radical feat of reallocating them and medical care to urban populations. However, hospitals
reshaping services. are generally removed (physically and socially) from the
Legislation
new urban poor. Moreover, they are already overcrowded,
and they emphasize sophisticated technology rather
Legislation affecting health is everywhere voluminous, than simple remedies for common conditions. There
but it can inhibit the improvement of health and is a relative scarcity of more peripheral and accessible
living conditions for the urban poor, for example, by ambulatory and social services; where they exist, their
prescribing unrealistically high standards for housing quality may be so low that people are discouraged from
or unrealistically low housing densities. Often these using them. Referral to health services is often difficult
standards were initially established for restricted elites, for the poor, and the emphasis within services is on
according to criteria that are not appropriate to the slums curative medicine. Most of the health problems of the
of the big cities of the developing world [30]. There are, urban poor would be more appropriately dealt with
however, a few instances in which laws and regulations by preventive medicine, by relatively straightforward
do now discriminate in favour of the poor. primary health care, and by well-integrated social action,
For example, in Colombo, Sri Lanka, shanty dwellers all of which are largely deficient.
are encouraged to improve their shelters through On the other hand, it is unrealistic to expect healthy
exemption from the urban development authority and behaviour and compliance with medical advice from a
zoning regulations, being granted tenurial security for a population whose basic needs in terms of employment,
40-year lease and allowed a minimum plot size of 37 to shelter, education, food availability, and lifestyle are
50 m² (instead of 150 m²). In addition, acquisition of the grossly unsatisfied.
right to hold a lease makes people eligible for financial If health administrations are unable to fulfil the
assistance through a proposed low income shelter loan essential requirements of the primary health care
scheme [31]. approach in an equitable and cost-effective manner
Similarly, in Brazil an interministerial order [32] in the cities, bringing multisectoral action to bear on
prescribes that in poor urban areas agencies should essential health needs, how likely are they to do so under
use simplified, effective, low-cost technology in fields the much more demanding conditions of rural areas? Yet
such as health care, sanitation, and technical and the organization and functioning of health programmes
administrative services. in many urban areas in fact leave much to be desired.
A variety of ministries, social security organizations,
Implementation
municipal health departments, quasi governmental
Attempts to tackle urbanization at the roots or at organizations, and private-sector institutions all
different stages of the process so as to slow down rural- participate. All these sources of action and elements
urban migration or to reverse the trend have met with of power, far from constituting a well-organized and
limited success. Policies, comprehensive health plans, synergistic network, conflict with one another, duplicate
and legislation are necessary but are not enough. They action and leave gaps, struggle for funds and power,
are only as good as the commitment behind them, the and produce an irrational and inefficient distribution
ideas in them, and, most of all, the action that follows. At of services. The indefensible result is high costs,
the implementation level most remains to be done. dissatisfaction among clients and providers, and inability
The redistribution of resources in favour of needy to cope effectively with needs and demand.
groups and of services at the primary level is the
indispensable condition on which the primary health
6 Health services and environmental factors

Neighbourhood health programmed their ability to point the way along which development
should take place. Three stages can generally be
In spite of this, truly innovative initiatives have been
recognized in the evolution of successful programmes: (1)
undertaken in three fundamental areas: (1) the
test or demonstration, (2) expansion and consolidation,
decentralization, expansion, and strengthening of
and (3) institutionalization. This process of “going full
infrastructure and services; (2) the integration into
scale” is meant to bring a limited operation up to a level
the health development process of health-promotion
at which it can maintain continuity and work toward
activities that fall under the responsibility of other sectors
total coverage and long-term effects.
(so-called multisectoral action); and (3) the mobilization
and involvement of communities. Examples are to be In practice, too often we see projects that would be
found in the cities of many developing countries in judged successful by local criteria remain confined for
different regions of the world [3, 6, 33, 34, 35]. years to the areas and populations where they were initially
started. This may be due to various factors: the resource
An interesting, popular, and probably the most
inputs of the initial effort may have been unrealistic
important example of intervention where two or all
in quantity or quality to allow wider replication; there
the initiatives mentioned above are combined is the
may have been difficulty adapting to the variety of local
neighbourhood health programme. This approach is the
situations and to the cultural context; the responsible
urban equivalent of the district-level primary health care
persons may not have had the same appeal and initiative
complex promoted by WHO for rural areas. It not only
as those who started the project; the involvement of
reduces the areas and the population to be cared for to
governments or communities may have been insufficient.
manageable proportions but also makes sure that the
These and other reasons were analysed and discussed in
activities undertaken truly reflect the priorities perceived
a consultation jointly sponsored by UNICEF and WHO
by the communities concerned to integrate intervention
in Guayaquil, Ecuador, in October 1984 [36].
appropriately to increase efficiency, to make referral
systems and logistic and managerial support function It is important to emphasize that, even under the
more effectively, to be less vulnerable to possible political most favourable conditions, going full scale will not
and managerial changes at the national level, and to be automatic. The possibility and feasibility of later
achieve a more effective intersectoral articulation. expansion and replication must be built into the project
from the beginning, and the process must be allowed to
The neighbourhood health programme is becoming
run naturally and sometimes slowly.
a popular technical device in applying public health care
strategy to urban areas. It has no established blueprint, Ultimately, scaling up is a political decision that may
since the fundamental characteristic should be to adjust involve changing the balance of power within the health
to local conditions. Different models exist in different system in a way that is better suited to the size and the
cities, and more are being developed. Sometimes an tempo of urbanization and the health problems related
approach successfully initiated in the countryside, and to them. All this requires imagination, hard work, and
based on family spirit and solidarity, has later been the ability to be constructively critical and inquisitive,
adapted to specific urban settings, as in the barrio, and to put oneself and what is being done continuously
kebele, and kampung community health development in question in the pragmatic search for the most
schemes of Call, Addis Ababa, and Jakarta. appropriate alternatives. It also requires initiative and
resourcefulness, qualities with which urban communities
Others were originally formulated as urban schemes;
have proved to be largely endowed, as is being recognized
the barangay development programme of Manila is a
increasingly by politicians and managers.
good example. Its main features, which are common to
other similar programmes, include close knowledge of Nutrition interventions are often included in
the community, prevention and care of malnutrition, neighbourhood health programmes and are integrated
vaccination, treatment of easily recognizable diseases, among themselves and with other types of interventions
systems of referral, environmental improvement, and having to do with health services development, water,
information and education for the families concerned. and sanitation, and family planning. All these contribute,
The programme is based in the community health directly or indirectly, to nutritional wellbeing, and may
centre, the upgrading of which is continuously pursued. influence each other.
It emphasizes the training and wide deployment of Many types of neighbourhood health programmes
community health workers and the education of the have been tried in various countries. They respond to
public by all available means. local priorities and include patterns of activities related
In the beginning, neighbourhood health programmes to these priorities. They use quickly trained, community-
have mostly limited coverage. Their importance lies in based personnel, the community health workers (or those
Alessandro Rossi-Espagnet 7

known by other equivalent designations), who constitute Director-General of WHO, has noted: ‘’A health system
the link between the existing health infrastructure and based on PHC cannot, and I repeat, cannot be realized,
the community and extend into the community some of cannot be developed, cannot function and simply cannot
the activities of the health units. In the urban areas they exist without a network of hospitals with responsibilities
are primarily concerned with promotion, prevention, for supporting PHC; promoting community health
and community mobilization. Where the health development action and continuing education of all
infrastructure is deficient and fully trained personnel are categories of health personnel; and research” [38, 39].
scarce, they are the only means to involve communities The conclusions of the WHO/Aga Kahn Foundation
in the health-development process. Conference pointed to a new and important role for the
There are essentially two types of community health hospital in public health care, for which prerequisite
workers: one is selected by the community and is an conditions are unambiguous support by political
unpaid, part-time volunteer; the other is recruited leaders and appropriate guidance for co-ordinating
and paid by the government, is a full-time worker, and mechanisms established by national governments
constitutes the first-line government representative at each administrative level. This structure should
in the community. Some neighbourhood health include a committee, council, or board made up of
programmes start on the initiative of governments, representatives from each part of the health system
others on that of non-governmental organizations (hospitals, health centres, and primary care workers)
(NGOs) or international organizations, from which they as well as representatives of the community, who meet
receive support. The NGOs have been promoters and together to deal with questions concerning policies,
an important positive influence on urban development management, and resources. Every hospital should be
in the developing world by enhancing individual and associated with a well-defined catchment area within a
community resourcefulness, and by promoting self-help regionalized framework, and should have a department
and achieving self-reliance and a better quality of life. of community health to mobilize interest, develop
As they are very close to people, especially the poorest, expertise, and interact on the one side with other health
NGOs are good advocates of their needs. They have been personnel inside and outside the hospital and on the
said to be the “pace setter, the innovators, the leading other with the community in its catchment area.
edge of development forces at the grass-roots level, The responsibilities of these departments of community
which is where it matters” [37]. health should include support and encouragement to
The interaction of NGOs with other organizations primary health care in the hospital’s catchment area;
and with governments is not always easy. Sometimes in-service training to reorient hospital workers so as to
NGOs are not prepared to be identified with certain change their ‘’hospital” outlook to a “health” outlook; co-
government policies and may be reluctant to be partners operation in the education and supervision of primary
in a joint effort with other organizations. At the same health care workers in the field, including helping to
time, governments are not always willing to accept the improve management and administration; collaboration
participation of NGOs in planning and carrying out with the community in seeking relevant information on
health programmes. At the technical discussions of the health problems and appropriate solutions; making sure
World Health Assembly in 1985 it was pointed out that that the hospital meets its referral and logistic support
“the establishment of an operational partnership between responsibilities; development of effective ways in which
governments and NGOs is overdue and indispensable” the community can assist in improving hospital services;
[37]. It is from this partnership, in fact, that the best work with other public agencies, NGOs, and community
results are likely to emerge. associations (including women’s groups) active in the
catchment area; identification of gaps in the primary
Hospitals and the referral system health care services and introduction of appropriate
The concentration of curative facilities in urban areas innovations; and stimulation and conduct of relevant
diverts resources from the preventive services that are so health services research that focuses on practical issues
crucial for the health problems of the urban poor. In most to achieve progressive improvement of services.
countries and cities, hospitals consume an extremely high Reorientation of the hospitals should facilitate and
proportion of the total health budget (as much as 80% in proceed in parallel with reorganization of the referral
some cases). But in too many instances hospitals have too system within the city and redistribution of the patient
little commitment to or interest in public health care, and workload, to allow a more efficient and coordinated use
play a very limited role in helping to develop strategies of all health facilities and to offer better access to users.
and plans for such care in the city. Halfdan Mahler, the
8 Health services and environmental factors

Such a bold reorganization was successfully attempted In rural areas the need for water supply is greater
in Cali, Colombia [40], in response to a continuously than for improved sanitation. In urban areas, because
deteriorating situation of overcrowding and improper of lack of space and high population densities, both
use of central hospital facilities and bypassing and are extremely important. Yet governments and private
underuse of peripheral health units. This project landlords are reluctant to invest in areas that they
particularly benefited poor populations living in consider to be illegally occupied and that are scheduled
peripheral barrios. In fact, one of its main achievements to be cleared, sooner or later, supposedly with a view to
was to strengthen peripheral facilities, thus removing more productive uses. So the paradox of ‘’permanent
the main obstacle to their correct use and the main temporariness” is created. The situation is aggravated by
reason for hospital congestion. By influencing the public the tendency to consider only high-cost conventional
through the planned involvement of the mass media, solutions to the problems of the slums and to refuse
religious and other organizations, and the schools, by alternative, decentralized methods that cost less and may
including the home as the basic unit of service provision, still be effective, provided that they have the support of
and by informing health professionals and medical those who live there and that the physical measures are
students, awareness of the urban health system was accompanied by behavioural changes.
improved; people were guided toward self-help or the The people themselves may add to the problem.
appropriate use of health facilities; and feedback was Their perception of priorities will be influenced by the
encouraged. At the same time, supportive supervision of immediacy of their needs and the visibility of the results.
the peripheral clinics and the logistic system supplying For a mother with a sick child, for example, medical
them were revitalized. treatment and the money to pay for it are what really
Environmental conditions and services
count at the moment. Or people may be unconcerned
with cost and maintenance, and adopt the attitude that
Closely related to the health problems of the urban poor, “it’s the government’s duty to collect the garbage” [46].
namely, infectious diseases and malnutrition, are the Worse, they can, for instance, break into a water supply
environmental conditions in which these people live. system to establish illegal connections and, in doing
The high population density of slums and shanty areas so, contribute to the deterioration of the equipment
places an intolerable burden on the urban infrastructure and leakage, waste, and possibly the contamination
and physical environment. Among the resulting problems, of the water.
the worst are those related to water supply (quantity and Population densities are very important, not only
quality) and sewage disposal. They influence each other, in terms of the numbers of people to be served but
and their frequent absence or unsatisfactory handling also because they may influence the choice of systems.
provides the most striking evidence of the neglect with Densities are often extremely high: In the old city of Kabul
which the urban poor are treated in many cities. As I in 1975 the housing conditions of 37% of the 541,000
have pointed out on a previous occasion, “No amount of inhabitants were such that more than two families had
statistics or reports can convey the true feeling and the to live in one unit and two to three persons in one room.
real dimension of the destitution, and even abjectness, In Old Delhi there can be as many as 270,000 people
under which large population groups in many cities of the per km² [45]. In the medina of Casablanca the average
world are forced to live. Only exposure to that destitution density is 70,000 per km² (ten times as many as in upper-
and direct observation of it can create the awareness and income residential areas). In the three cities of Ghana
motivation required for dedicated involvement” [41]. with more than 50,000 people, 35% of the population
Water and sanitation are very closely related in the lives 20 and more to a house. And three-quarters of
sense that improvements in one may provide little benefit Bombay’s families live in one room or share a room with
in terms of disease prevalence without corresponding another family [46].
improvements in the other. Moreover, the quantity of Drinking water is particularly critical, and the
water is an important prerequisite for the removal of the availability of a piped system does not by itself ensure
sewage, and precarious conditions of the sewage system the expected supply: relative scarcity in relation to the
may well lead to contamination of the water. Vice versa, a numbers to be served, low pressure, and intermittent
water supply without a waste-water disposal system leaves delivery may make the service very unsatisfactory.
stagnant pools of domestic wastes, where mosquitos may Numerous supply methods are generally available. In the
breed, and where animals will bathe and children play. Klong Toey settlement of Bangkok (population 30,000),
Teller [43] says that it is on the development of these for example, 55% of the dwelling units purchase water
services that the success or failure of preventive work in from vendors; 30% get their water from neighbours who
poor urban areas largely depends. have running water from the city main; 3% have outdoor
Alessandro Rossi-Espagnet 9

connections to the city main; 10% use running water the formal system, and the informal system [50]. About
from a nearby tap; 1 % use rain water; and 1 % use other 22% of the population studied delivered their babies at
sources [47]. In a Seoul squatter settlement, water may home, assisted by a traditional birth attendant. A similar
be supplied at public water taps only in the middle of the pattern is observed in the cities of India, Indonesia, and
night, when demand is low in more privileged sections other countries, whether or not the birth attendants have
of the city [48]. been trained.
Similarly, several methods are used to dispose In Indian cities modern and traditional systems of
of human waste. The most common are defecation medicine coexist [51]. The trend is believed to be toward
trenching grounds (not practical in most cities because of an increasing adoption of modern scientific therapy, but
limited space), “wrap and carry” (where there are places the number of traditional practitioners does not seem to
for dumping close by), overhung latrines (above tidal diminish, although their use in the cities is decreasing
flats, weirs, canals, or beaches; but serious problems arise compared to the rural areas. With some exceptions,
where the water is stagnating and is used for domestic their practice appears to be limited primarily to certain
purposes), and wet and dry pit latrines (quite common ailments, particularly joint and muscle pain, and their
but difficult to maintain and highly contaminating). services are generally not sought for serious diseases.
Equally inadequate are methods of garbage disposal. Little is known about the way the two systems operate
To qualify theoretically for municipal collection, as in side by side in the same metropolitan setting. A survey
long-established slums, does not guarantee removal; indicated that all systems of medicine seem to provide
in this case the alternative is the street. Many squatter fairly satisfactory solutions for common ailments; the
settlements, as in the slums of Guayaquil, are built in the prestige of many traditional practitioners is still high,
vicinity of or above garbage dumps. Everywhere a large and their services seem to cut across all social classes.
informal industry (called by the Japanese the “regenerated Indigenous medical practitioners are considered to
resources industry”) develops, involving a variety of rag- represent a vast under-used resource outside the official
pickers, rag-buyers, rag-dealers, and processors. The health services, but collaboration between the two
health risks of all these situations are obvious. systems has hardly begun and many obstacles stand
Governments and international organizations in its way.
involved in improving water-supply and sanitation City health departments
systems usually give priority to rural projects, because
the majority of people in most developing countries live Effective support for primary health care may require the
in rural areas, and because this may help to slow down reorganization and strengthening of city and national
rural-urban migration. The numbers and conditions of health departments. More important than organizational
people living in slums and shanty towns in developing change, however, is a change in attitude throughout
countries also call for immediate attention, not only the departments, since a fundamental shift of values,
because of epidemiological and technical considerations strategy, and approach is involved. In most cases,
but also for humanitarian reasons. The fact that one- reorganization is not the first step required, but rather
third of the 1979 investment of the World Bank in but rather should evolve when there is already some
water and sanitation was directed to relieving urban record of initial achievement. Various alternatives were
poverty, using the “site-and service” or “slum upgrading’’ discussed in a recent WHO document [52]. On the whole
approach, supports this conclusion. Unfortunately, it seems better not to set up new public health care units
such new investment often cannot keep pace with vertically organized, but to build them into the plans and
deteriorating conditions, and sometimes speculation and operating systems that shape activity across the entire
manipulation prevent the improvements from benefiting department. Collaboration and communication depend
those for whom they were originally intended [49]. fundamentally on personal qualities and personal
contacts. They also depend on there being a sufficient
Traditions practices congruence of objectives among all those concerned.
The use of traditional practices and practitioners is not Such reorganization is now in progress at the
limited to rural areas. To a lesser extent it is also observed Municipal Health Department of Manila [53]. It consists
in urban areas, but there seem to be differences within of several steps, including drastically shortened lines of
the population - for example, between immigrants of the communication between the department and its operating
first and second generations. The urban Health Sector staff in the field; new roles for the public health nurses
Assessment of Cairo emphasized that clients may use a expected to work more closely with community leaders;
variety of health care facilities and depend on self-care, coordination of field services under the supervision of
10 Health services and environmental factors

a team leader; strengthening of the city information and children in the most deprived districts [31]. The
system and its ability to assess needs dynamically, to programme includes supplementary feeding, promotion
monitor progress, and to evaluate the effect of health of childcare and day-care centres, training of day-care
interventions; improved training programmes for the instructors, development of small-scale poultry farming,
basic and continuing education of community health market gardening, and integrated slum rehabilitation.
workers; and, finally, greater involvement in meeting Several national and international organizations
the basic needs of the client population (food, water, participate under the co-ordination of the Ministry of
sanitation, housing, employment) through intersectoral Labour and Social Affairs. Women’s organizations play a
collaboration. fundamental role. Progress is being made in spite of the
constraints experienced, such as shortages of personnel,
Convergent multisectoral action equipment, educational material, and finances, and a
steep rise in prices after 1978.
Epidemiology has long debated the multifactorial causes
Hyderabad is one of the 14 cities in which the Indian
of disease and the relationship between socio-economic
government has undertaken experimental urban
factors and health. McKeown brilliantly demonstrated
community projects after a decision in 1966 to shift from
the link between socio-economic development and
slum eradication to slum improvement. Hyderabad has
health effects by a now wellknown analysis of mortality
experienced a rapid population increase and is now the
statistics for England and Wales from 1838-1841 to the
fifth largest city in India, with an estimated population of
1970s [54]. Similar observations have been made using
2.5 million, of whom 500,000 live in slums. The project
United States statistics [55]. McKeown’s effort clarifies,
is a comprehensive one and includes environmental
among other things, the likely respective influences on
sanitation, construction of self help houses and water
health status of socio-economic development and of
improvements, family welfare, immunization, health
conventional health service activities. The result is to
and first-aid classes, family planning, cooking and home
recognize the importance of socio-economic changes on
marketing demonstration, supplementary feeding,
the basis of facts and to strengthen the theoretical basis
special nutrition and midday-meal programmes,
for multisectoral intervention in health.
recreational and cultural activities and youth
The appeal and feasibility of the multisectoral programmes, crèches, primary and night schools,
approach, and the confidence that it commands, vocational training, and economic activities such as bank
particularly at community level, are demonstrated by loans and sewing cooperatives. Special emphasis is placed
the number, variety, and continuing proliferation of such on the participation of women, on income-earning
projects. In both rural and urban areas an attempt is activities for women, and on the inclusion of women in
being made to look at health problems not through the the project staff. In spite of the usual problems related to
distorting effect of disciplinary or sectoral considerations management and the scarcity of personnel, the project is
but on the basis of their true determinants, their relative expanding and is being replicated in other states.
importance, and their chronological relationship. In fact,
The Sang Kancil project was started in 1979 in
the primary health care philosophy and strategy evolved
Kuala Lumpur, Malaysia, to meet the numerous health
relatively recent initiatives along these lines [56, 57].
problems caused by the large squatter population,
In the case of an urban population in general and of which has risen dramatically during the last 10 years
the urban poor in particular, the linkages between social, [58, 59]. A 1978 census of the squatters recorded 48,709
environmental, and economic conditions, individual and households distributed among 148 squatter settlements
community behaviour, health status, and general well- and comprising a population of at least 234,000 (out
being are so intricate and all-pervading that no lasting of a total of about 1 million in the city). A consultative
solution to the prevailing problems can be envisaged that seminar in 1978 concluded that there was a high risk of
does not give due weight to all the elements in proportion communicable diseases in the squatter communities, with
to their importance. fewer than 30% of the children being immunized and a
Forty per cent of the urban population of Ethiopia live high prevalence of worm infections; that the care of poor
in Addis Ababa. About 80% to 90% of the city population children should be closely linked to that of their mothers;
are below the poverty line and live in crowded, low-grade that there were high rates of emotional problems, truancy,
settlements deprived of essential services. An urban and drug addiction among schoolchildren; and that a
upgrading programme, based on surveys carried out with high proportion of working mothers had to leave their
the participation of the University in 1977, was initiated children with neighbours, with other children, or alone.
in Addis Ababa, with its main emphasis on mothers After extensive consultation, the Sang Kancil project
Alessandro Rossi-Espagnet 11

opted to focus on preschool education, maternal and Rocinha is one of the largest but not one of the worst
child care, and income-generating activities. Community favelas of Rio de Janeiro [61]. It is rather heterogeneous,
centres were constructed in two areas with the intention with some semi-legalized areas and, especially on the
of having 20 such centres by 1985. Two kinds of personnel steep slopes, areas where the population lives under
have been trained: nurse-practitioners and community precarious conditions of extreme indigence. The most
preschool teachers. Income-generating activities were striking feature is the accumulation of human waste and
the most difficult to develop but were considered a garbage, with all the consequences of insect and rodent
very important component, because the relationship infestation and disease prevalence. The area has a history
between income and health was well understood. A first of community organization, with some local services
step was the establishment of a “mini-factory” where being supported by community groups. Components of
squatter women learned needlecraft and tailoring, and the programme are water supply and sanitation, informal
manufactured batik garments and soft toys and were education and community schools, day care, and primary
thus able to increase their income by 25%. health care. Progress is being made in all components.
A project in poor areas (called young towns) of the A notable degree of community participation has been
southern zone of metropolitan Lima, Peru, was initiated achieved, and the programme has demonstrated that
in 1978 to cover 45 neighbourhoods with a population community resources and public support can produce
of about 550,000 [60, 61]. Its objective is integrated favourable results. The work is being extended to other
health care for children and families at the primary level, favelas using the methods developed in Rocinha.
through co-ordinated action by services and institutions Other examples are available from the Mathare Valley
and through the participation of organized communities. in Kenya; Rosso, Mauritania; Maxquene, Mozambique;
The conditions in which the people of the young towns and various districts in Dar es Salaam, Dakar, and
live are extreme, characterized by underemployment, elsewhere.
malnutrition, occupational difficulties, little access All these projects play an important part in changing
to basic services, and so on. Fifty-four per cent of the attitudes and priorities, provided several specific
population have no stable employment, and almost 60% requirements are met: They must be planned with a long-
suffer from malnutrition, being unable to obtain more term perspective (e.g., a 10-year horizon). There has to
than 80% of their caloric needs. Malnutrition is due to a be considerable initial investment of staff, time, and skills
lack of food, not to irrational selection. Infant mortality to bring the projects to the point of take-off. There must
is quite high, and medical services for the young are also be a real involvement by the communities served,
insufficient. Because there is no garbage collection, almost who must understand and support the project. Political
6,000 tons are dumped each month at the periphery of leaders must be able to assess for themselves the nature
the settlements, producting unhealthy conditions. Only and impact of the projects. Finally, the start-up projects
7% of the population have access to drinking water and should, from the beginning, be first steps in a strategy for
sewage services in the home. Conditions for women large-scale action to provide good coverage for all those
are particularly bad, largely because of the traditional who have previously been ignored.
attitude that women should not study or work outside
Non-health activities sectorally implemented may
the home.
also have a substantial effect on health [62]. The link with
Because of the size of the settlements and the high education is well known and important. It is associated
proportion of the total metropolitan population living with lower fertility levels [63, 64] and increases the
there, these socio-economic and physical conditions efficiency of family planning programmes. Education
present a major policy problem for the country and the of low-income women will help them to appreciate the
government. The project activities consist of mother and benefits of breast-feeding, of a balanced uncontaminated
child care, including nutrition and oral health; water and diet for their children, and of personal hygiene. School
environmental sanitation; early stimulation and non- feeding programmes are not only an incentive to the
formalized initial education of children; basic education enrolment of children in schools but also a means to
and training of women in matters such as making better health, increased attendance at school, and the
clothes and shoes, food processing, carpentry, and other ability and motivation to learn [65, 66]. There exists an
skills; and training block monitors, health promoters, important web of interrelationships between education,
and midwives. The project is based on a thorough health, nutrition, and family planning in which women
analysis and relies on local community organizations. It play a fundamental role. Of particular importance
initially covered 46 young towns and is being expanded is the concept of basic education, which differs from
to other areas. conventional primary education in that it attempts to
12 Health services and environmental factors

satisfy the minimum needs of specifically identified Community organization and self-reliate
groups, not only children but also youths, adult men
The extremely high rates of population growth; the
and women, and selected rural and urban groups. The
multiplicity, nature, and scale of the needs; the apathy,
effects of improved water supply, sewerage, and solid-
hostility, and neglect often exhibited by governments;
waste disposal have been discussed extensively. Mention
and the insufficiency of the resources engaged all suggest
should also be made of housing, the transportation
that it will never be possible to grapple with the problems
system (which influences access to health and family
of the poor in slums and squatter settlements without
planning centres), the development of urban agriculture
the initiative and the active participation of the people
(as in Lusaka), job availability, and income in its two-way
themselves. In many instances little will be done for them
relationship with health, nutrition, fertility, and (once
unless they call for action, and in almost every case no
again) education.
lasting benefit will ensue without their active support,
Convergent action by different programmes and understanding, and participation. But will they respond?
sectors entails an effort in intra- and inter-sectoral In rural areas, community organization is a historical
articulation. The point is not so much to contrast the phenomenon, based on solid cultural foundations.
vertical and the horizontal approaches as two conceptually It remains reasonably efficient and largely taken for
different modes of service delivery, but to decide for what granted. All this is lost with the influx to the cities, at
purposes or at which stage each is better suited or more just the time when a reference point for protection and
cost-effective, and when one should naturally evolve into direction is most needed. Having once been lost, the
the other. It is a matter of awareness and co-ordination: delicate connective tissue of social organization has
awareness of how to mobilize the most appropriate somehow to be reconstructed so that people can find
resources to cope with a given problem (irrespective of themselves again: on the one hand, to discover and
disciplinary considerations, organizational location, or realize the potential of the community and, on the other,
managerial responsibility) and ability to coordinate them to attract the attention of politicians, governments, and
all, so that those who can make a useful contribution are other powerful organizations. Yet the conditions to
involved, gaps are not left, the work is done efficiently, redevelop social organization are difficult to establish. in
and the objectives are met. the new slums and squatter settlements little is generally
In urban health development, where the improvement done to guide rural migrants when they arrive or to help
of the environment, behavioural changes, and the them through the transition from rural to urban life and
satisfaction of basic needs have such fundamental through the various “rings” of the city to a point where
importance, the application of knowledge about the they can feel that they belong in anything more than a
close links between health and development can bear superficial and temporary sense [681.
important and long-lasting fruit. Thus, it is through In contrast to the relatively stable and homogeneous
multisectoral action and intersectoral articulation that rural village, migrants find themselves in a society that is
the evolution from “medical services,” dominantly culturally and linguistically very heterogeneous, transient
curative and disease-oriented, to “health systems,” and mobile, opportunistic and restless, too preoccupied
emphasizing health promotion and disease prevention, with individual survival to be concerned with solving
can be concretely realized. collective problems or with finding mechanisms to face
The background document for the technical them, and collectively unaware of the ways of life in the
discussions of the 1986 World Health Assembly [67] new environment. At the same time, they find themselves
states that it is in the slums of cities in emerging nations caught up in a continuous, often unconscious, battle
that a well-conceived health development policy can against the ignorance, prejudice, and hostility of the
prove itself by “giving the poor access to resources more fortunate. While these features of the urban society
and economic opportunities, raising educational are divisive, some people nevertheless feel united by
levels, ensuring availability and distribution of food, inhabiting the same place, by sharing poverty, and by
improving the status of women and providing the basic enduring a number of pressing common problems to
infrastructure and other public amenities.” which some solution must be found. It is neighbourhood
Unfortunately, because health planning continues to awareness, with different names in different places, that
be influenced by the perception that health is mainly provides the basis for the social organization of the
the result of medical services, it cannot be said that urban poor and thus for some improvement in their
a comprehensive intersectoral policy has emerged in living conditions.
most cases. Contrary to the long-established assumption that
low-income urban populations typically lack social
Alessandro Rossi-Espagnet 13

organization and are apathetic, their initiative and In some cases the initiative comes entirely from the
resourcefulness are increasingly recognized by planners community, which creates and maintains the organization
and other government officials. There is of course an and infrastructure to bring about the improvement it has
implicit danger that an overemphasis on community defined. Sometimes unbearable conditions, or the threat
action may be used as a pretext for withholding of slum clearance and eviction, lead to an open clash
government support, but, in practice, experience has with the government: such was the case of the Hong
shown that neither the exclusively community-managed Kong boat people and the Tondo residents in Manila.
self-help programme nor the paternalistic government- This type of reaction, although often effective, does not
sponsored and imposed community programme is create an atmosphere of trust between slum people and
viable. Success is more likely to occur when a partnership the authorities; nor, in general, are the results conducive
between community and government is established, to large-scale replication.
entailing recognition of what self-help can do, respect There have been some community initiatives, however,
for the individual, and willingness of the government to if not yet many, that are not based on confrontation,
cooperate with popular action [69]. although admittedly the stakes may not have been as high
A UNICEF review based on information from 70 as in the preceding examples. One example is the creation
countries and case studies prepared on 9 of them, community kitchens in the Kamanves slum in Miraj,
concluded that the community-based approach is viable India, which was initially part of a comprehensive effort
and has been increasingly adopted. It enables services to to improve the nutritional status of the population and
reach further out to the poorest families; to be designed later was developed well beyond its original objectives.
in explicit response to needs that people have themselves After a discussion of local problems in the community,
articulated, and thus to be better understood and a group of residents formed a committee that, after
supported; to be more valued and better maintained by consultation with the Director of Community Health,
the community; and to be less expensive while permitting started to work with the staff of the local hospital in a
broader coverage. Social action is not only a result but series of activities involving all community residents. An
also a way of achieving social cohesion. organization was established, a management committee
There are different methods of implementing this was elected, and fees were collected from all members.
partnership, and the examples do not lend themselves The first initiative was a morning feeding programme for
easily to any simple classification. But viability seems children, later expanded to cover very poor adults at a
to be enhanced if the involvement of the community cost of 0.06 rupee per person. The kitchen, which was
originates from a clear understanding of the problems initially out in the open, was later provided with a shelter.
being faced, or from initiatives taken from within the Children attending were given a medical examination.
community. The programme expanded to conclude training and
income-generating activities. The health education
Developments that result from a true dialogue
programme was a most important one and led, among
between government and communities, where the
other things, to high immunization rates for diphtheria-
respective contributions are mutually acknowledged, are
pertussis-tetanus, polio, tuberculosis, and smallpox.
difficult to cite. The community development in Rocinha,
Rio de Janeiro, already mentioned, may be such an One purpose of the community organization
example. Residents formed a health group, a sanitation is to enable slum dwellers to gain organizational
group, and a school group and worked together with the and managerial skills, including the confidence to
Municipal Secretariat for Social Development first at choose who should participate, to work with and use
a survey and later at joint planning of the programme government and non-governmental organizations, and
based on the survey. The resulting activities included to build mechanisms that demand responsibility and
child and adult education, sanitation, and health accountability from the resource holders as well as from
services. The main sewer system was established through comunity beneficiaries. Nylon-a periurban slum area
a mutual-help process, and secondary connections near the airport of Douala, Cameroon, that was estimated
were built by the community. Community agents have to have reached a population of more than 100,000 by
been trained to monitor the growth of children under 1980 and yet, until a few years ago, was marked on city
five years old and to form women’s health education maps as an uninhabited zone where the population had
groups. The programme and its methodology have been no legal existence- provides a good example of how the
institutionalized, and the possibility of expansion to process can develop so that community goals can be
other areas is being considered. met by the residents. Initially, in order to fight water
and industrial pollution and growing vandalism, the
14 Health services and environmental factors

three ethnic groups living in Nylon decided to join in a legislation, administrative bottlenecks, and the inability
common effort to improve their condition. The area was of government officials to communicate with the
divided into lots, blocks, sectors, and subdivisions, and community and to understand the dynamics of an urban
“animators” were assigned to each unit, accountable to slum. Similarly, NGOs may define health programmes in
the corresponding person at the next higher level. The terms of their own perceptions, pursue short-term goals,
leaders then sought municipal assistance, organized a and occasionally (and this also applies to governments)
seminar on the urban environment Which attracted create dependent attitudes (“What’s there for me this
public attention to their problems!, and established time?”) that are not conducive to community initiative,
a training programme for the animators. Official organization, and action.
recognition was gained from the Ministry of Social Before ending this section, three additional
Affairs. A community centre was constructed, and later remarks should be made. The first is to emphasize the
a topographical survey was carried out and a master fundamental role of women in community organization
plan for development drawn up. Electricity was installed and action. Women are principal actors and vital target
and, with foreign aid, the construction of a market place groups in community involvement. They are close to the
began. Community activities in Nylon gave rise to the children, the most vulnerable group among the urban
concept of a “transitional urban economy,” which is poor and at the most critical moments of their lives;
neither traditional nor modern and is characterized they decide on contraception, breast-feeding, and the
by predominantly unemployed people working in the quality and quantity of children’s food; they may make
informal sector, simple methods of production, and all the difference in the prevention of disease, and are
a complex network of ties with the modern sector, likely to have to decide what to do and where to take
whose by-products and waste materials are exploited to children when they are sick; they keep the urban garden
the maximum. Food self-sufficiency was considered a ( when there is space for it) and raise small animals;
prerequisite of the transitional urban economy, and so economically, they are the ones who have to make ends
any available land was intensely cultivated, poultry was meet in the household; they are the responsible persons
raised, and an experiment was initiated with a small in most single-parent households and the ones to go to
food-producing industry. for complementary income; they benefit from, but also
Many other examples could be mentioned, and run, the community crèches and day-care centres for
some have been included in preceding sections. They pre-school children. They are, no doubt, those in whom
are all the result of community development, forming education money is best invested.
a fascinatingly diverse story in which the entry points Second is to underline the ability of communities in
and motivators are endlessly varied. The key stimulus many countries (this applies to urban and rural areas alike)
can be community crisis, a health intervention, a to operate in terms not of stereotyped socioeconomic
government programme, the interest of a specific group development plans of compartmentalized bureaucratic
such as women, an existing community structure, or a units but of community needs, basic causes, and
charismatic leader. convergent actions that can synergistically meet those
Failures occur also and are not unexpected. Indeed, needs. Indeed, the community level is where intra- and
the circumstances of the urban poor, some of which inter-sectoral coordination becomes natural and real.
are listed at the beginning of this section, seem to make Finally, a tribute should be paid to the initiative and
success much more surprising than failure. Paradoxically, resourcefulness of marginal urban communities, whose
the people in old established slums often experience qualities are indeed being increasingly recognized by
more difficulty in working together for the common planners and other government officials. Frankenhoff
well-being than those in new slums and squatter areas. notes, “It is essential to facilitate the involvement of
The main constraints rest with the poor themselves, who the untapped resources of marginal communities into
rarely have the social amalgam, confidence, skill, and the process of urban development.” There are political,
experience to galvanize their own community, deal with social, and economic arguments in favour of this option.
government officials and NGOs, and, if the need arises, The political argument is that increasing the stability
challenge other people’s conservative, selfish, and hostile of these slum communities in terms of jobs, housing,
attitudes and actions. education, and health will contribute to national political
Government collaboration with communities may stability. The social argument is that the community that
be hampered by excessively scientific and technical is helped to build itself will produce social benefits for
approaches, poor mechanisms for social planning, the nation. The economic argument is that the slum
insistence on too high standards, inappropriate community can generate significant consumer demands
Alessandro Rossi-Espagnet 15

as well as capital formation. Houses, sewers, sidewalks, 8. Kerejan H. N’da K. Approches des problèmes alimentaires
schools, and clinics can be built by such a community et nutritionnels d’une mégalopolis africaine. Med Afr Noire
with a minimum of assistance. 1981 ;28(7):479-482.
9. Data Banik ND. Feeding habits and weaning practices in
infants and preschool children in slum areas in New Delhi.
Conclusions Arch Child Health 1979;2113):51-57.
Urban health development with a main focus on the poor 10. Data Banik ND. Some observations on feeding
must be pursued with continuity and determination programmes, nutrition and growth of preschool children in
in the developing countries. Responsibility must be urban community. Indian J Pediatr 1977;441353): 139-149.
decentralized to increase relevance. Services must be 11. de la Luz Alvarez M, Mikacic D, Ottenberger A, Salazar
improved through the establishment of the necessary ME. Características de familias urbanas con lactantes
managerial processes. The infrastructure must be desnutridos. Arch Latinoam Nutr 1979;29(2):220-232.
strengthened, expanded, and, where it is totally lacking, 12. Sigulem DM, Tudisco ES. Aleitamento natural en diferentes
created. The referral system must be reorganized and classes de renda no município de São Paulo. Arch Latinoam
the patient workload redistributed. All relevant sectors Nutr 1980;30(3):400-416.
of socio-economic development must be mobilized and 13. Survey 1963-1965. Colombia: National Nutrition Institute.
organized into functional networks to contribute to 14. Vinocur P. Clasificación funcional de poblaciones
clearly defined health objectives. Communities must be desnutridas en Costa Rica. Bol Informativo SIN
involved, but the mistake must be avoided of only calling 1980;2(February).
on the poor, as if other, more privileged strata of society 15. Secretaría general del Consejo Nacional de Planificación
were to be exempted from contributing extraordinary Económica, e Instituto de Nutrición de Centroamérica
resources that instead are expected of the poor. y Panama (INCAP). Regionalización de problemas
nutricionales en Guatemala. Final report (unpublished).
The urban turnaround observed in industrialized Guatemala, 1980.
cities, it was pointed out at the 1984 conference on 16. Ministerio de Salud Pública y Asistencia Social de El
population in Mexico City, is for the time being unlikely Salvador, e Instituto de Nutrición de Centromérica y
to occur in most developing countries. Here, therefore, Panama (INCAP). Clasificación funcional de problemas
the problems will stay and grow, and must be faced. nutricionales en El Salvador. Final report. Guatemala, 1977.
Several international organizations have led the way, and 17. Ministry of Public Health. Bulletin de la santé publique,
we all must follow and do things that will concretely help nouvelle serie tome 3, no. 54. In: Basta SS. ed. Nutrition
the poor. and health in low income urban areas of the third world.
Ecol. Food Nutr. 1977;6:113-124.
References 18. Nelson J. Mandl PE. Peri-urban malnutrition, a neglected
problem. Assignment Children 1978;43:25.
1. Austin JE. Confronting urban malnutrition, the design 19. Jeliffe EFP. The impact of the food industry on the
of urban malnutrition programmes. World Bank staff nutritional status of infants and preschool children in
occasional paper no. 29. Baltimore, Md., USA: Johns developing countries, priorities in child nutrition in
Hopkins University Press, 1980. developing countries. Vol. II. Boston: Harvard University
2. Council, Food and Agriculture Organization of the United School of Public Health, 1980;265.
Nations. The state of food and agriculture 1984. Document 20. Prasada Rao TM, Gowrinath Sastry J. Vijayarghansan
CL 86/2. Rome: FAG, 1984. K. Nutritional status of children in urban slums around
3. Rossi-Espagnet A. Primary health care in urban areas: Hyderabad City. Indian J Med Res 1974;62(10):1492-1498.
reaching the urban poor in developing countries. State-of- 21. Paramit S. Experiences in the field of urban primary health
the-art report by UNICEF and WHO. Geneva: WHO, 1984. care in Jakarta. Report of UNICEF-WHO meeting on
4. United Nations Department of International Economic primary health care in urban areas. Geneva: WHO, 1983.
and Social Affairs. Patterns of urban and rural population 22. Brink EW, El-Sayed AH, Dakroury AM, et al. The
growth. New York: United Nations, 1980. Egyptian national nutrition survey, 1978. Bull WHO
5. United Nations Department of Economic and Social 1983;61(51: 853-860.
Affairs. Migration, population growth and employment in 23. Khanjanasthiti P. Wray JD. Early protein-calorie
metropolitan areas of selected developing countries. New malnutrition in slum areas of Bangkok Municipality, 1970-
York: United Nations, 1985. 1971. J Med Anoe (Thailand) 1974;57(7):357-366.
6. UNICEF-WHO. Interregional consultation on primary 24. Pmcleberg F. Efecto de la nutrición medio ambiente sobre
health care in urban areas. Geneva: UNICEF/WHO, 1986. el desarrollo psico-motor en el niño. Cuadernos Medico-
7. Basta SS. Nutrition and health in low income urban areas of Sociales 1968;9(5).
the third world. Ecol Food Nutr 1977;6:113-124.
16 Health services and environmental factors

25. Lambert J. Population growth, nutrition and food supply. 45. United Nations. Habitat, global review of human settlement.
ESCAP monograph: population of Papua New Guinea 1979. New York: United Nations, 1976.
26. Hart JT. The inverse care law. Lancet 1971;1:405-412. 46. United Nations. World Housing Survey. New York: United
27. Knowx PL, Bohland J, Shumsky NL. The urban transition Nations, 1974.
and the evolution of the medical care delivery system in 47. Morell S. Morell D. Six slums in Bangkok. Bangkok:
America. Soc Sci Med 1983;17:37-43. UNICEF, 1972.
28. Smith DL, Cole-King S, Tarimo E. Primary health care: a 48. White MB, White HO. The power of the people: community
look at its meaning. Unpublished. Geneva: WHO Division action in Korea. Urban Industrial Mission, East Asian
of Strengthening of Health Services, 1982. Christian Conference. 1973.
29. Dennis T. Rethinking community medicine. London: Unit 49. De Gyenat W. Atención primaria de salud en zones
for the Study of Health Policy, 1979. urbanas y rurales de los poises en desarrollo semejanzas y
30. England R. Water decade: legislation prevents progress. diferencias. Bol Sanit Panam 1983;94(5):441-460.
Consulting Engineer. 1981; October. 50. Hassouna WA. Studying urban health care: the case of the
31. UNICEF-WHO. Report of the UNICEF/WHO meeting on Cairo health assessment study. Paper prepared for the joint
primary health care in urban areas. Appendix 4. Geneva: UNICEF/WHO meeting on primary health care in urban
UNICEF/WHO, 1983. areas, Geneva. 1983.
32. Ministry of Health. Legislação federal do sector saud 4. 51. Remesh A, Hyma B. Traditional Indian medicine in practice
Interministerial order no. 001/78. Brasilia: Ministry of in an Indian metropolitan city. Sac Sci Med 1981;150: 69-81.
Health, 1978. 52. WHO-DANIDA. Strengthening ministries of health for
33. UNICEF. Urban basic services: reaching children and primary health care. Report of a joint WHO/DANIDA
women of the urban poor. Report by the Executive Director. work. shop. 1982.
Occasional papers series no. 3. New York: UNICEF, 1984. 53. A descriptive study of the Manila health care delivery
34. UNICEF-WHO. Summaries of country experiences. system by the study team of the Manila Health Department.
Interregional consultation on primary health care in urban Unpublished. Manila: Manila Health Department, 1983.
areas. Geneva: UNICEF/WHO, 1986. 54. McKeown T. The role of medicine: dream, mirage or
35. UNICEF. Urban examples: starting up with basic services. nemesis. Oxford: Basil Blackwell, 1979.
New York: UNICEF, 1986. 55. McKinley BJ, McKinley MS. The questionable contributions
36. UNICEF-WHO. Report of a joint consultation on primary of medical measures to the decline of mortality in the
health care in urban areas. Geneva: UNICEF/WHO, 1984. United States in the twentieth century. Milbank Mem Fund
1977:55(3):405-428.
37. World Health Organization. Collaboration with non-
governmental organizations in implementing the global 56. Djukanovic V, Mach EP. Alternative approaches to meeting
strategy for health for all. Report of the technical discussions basic health needs in developing countries. A joint
of the 38th World Health Assembly. Geneva: WHO, 1985. UNICEF/WHO study. Geneva: WHO, 1975.
38. The role of hospitals in primary health care. Report of 57. Newell WK. Health by the people. Geneva: WHO, 1975.
a conference sponsored by the Aga Khan Foundation 58. Khairuddin Yusof. “Sang Kancil”: care for urban squatters
and WHO, Geneva, and cosponsored by the Canadian in Malaysia. World Health Forum 1982;3(3):278-281.
International Development Agency and the Age Khan 59. Diaz R. Restructuring services to reach the urban poor in
Foundation, Canada. 1981. Kuala Lumpur. Assignment Children 1982;57-58: 135- 156.
39. World hospitals. Q J Int Hosp Fed 1982;18(3):12-15. 60. Herrera Davila J. Atención integral al niño y su familia en
40. Escobar MJA. System of referral: progress report 1978-1979. los pueblos jovenes del cono sur de Lima Metropolitans.
Unpublished. Call: Universidad del Valle, Health Division, Paper prepared for the International Seminar/Workshop
Departments of Social Medicine and Pediatrics, 1979. on Urban Primary Health Care, Popayan, Colombia, 1982.
41. Rossi-Espagnet A. Health and urban poor. World Health 61. United Nations-ECOSOC. Urban basic services: reaching
1983;July:2. children and women of the urban poor, Addendum: a
42. Etherton D. Water and sanitation in slums and shanty summary of nine case studies. New York: UN, 1982.
towns. New York: UNICEF, 1980. 62. Linn JF. Cities in the developing world, policies for their
43. Teller CH. The population dynamics of urbanization and equitable and efficient growth. World Bank research
some implications for the health sector. Paper prepared for publication. Oxford: Oxford University Press, 1983.
the PAHO/AMRO Regional Technical Consultation on the 63. Boulier BL. Population policy and income distribution.
development of health services and primary health care in In: Frank, Jr CR, Webb RC, ads. Income distribution and
urban areas and big cities, Washington, DC, Nov. 1981. growth in the less developed countries. Washington, DC:
44. Ismartono Y. It’s the government’s job to collect the garbage. Brookings Institute, 1977.
UNICEF News 1983;1(15):12-14.
Alessandro Rossi-Espagnet 17

64. Anker R. An analysis of fertility differentials in developing 68. Toffler A. Interview with Constantinos Doxiadis. In: Future
countries. Rev Econ Statistics 1978;60(1):58-69. shock. New York: Bantam Books, 1979:389.
65. World Bank. Health sector policy paper. Washington, 69. United Nations. Urban slums and squatter settlements in the
DC: World Bank, 1975. third world: note by the Secretary General. Paper prepared
66. World Bank. Health sector policy paper. Washington, for the Regional Preparatory Conference for Habitat,
DC: World Bank, 1980. United Nations Conference on Human Settlements. A/
CONF.70/RPC/9. 1975.
67. World Health Organizaion. Technical discussions. In:
39th World Health Assembly. Geneva: WHO, 1986.