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Poor in the city

  • Published at 07:33 am June 5th, 2018
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Our slums are a public health catastrophe / NASHIRUL ISLAM

The importance of an evidence-based approach to addressing the problems of urban poverty

Urbanisation is a seemingly inevitable consequence of modernization and economic development. The Industrial Revolution in England brought about urbanization on a scale that had never been witnessed before in human history -- in 1801 only 17% of the population in England lived in cities. 

By 1891, 72% of the population lived in urban centres.

Income inequality was particularly stark and visible in these new urban centres of the Western world, a fact of life captured vividly in the novels of writers like Charles Dickens. Within these great engines of global commerce and trade, destitute slums existed alongside the grand mansions of industrialists.

Many countries in the developing world are now undergoing a similar transition. When Bangladesh achieved independence in 1971, the majority of the population lived in the countryside. 

As the country has developed economically, more and more people have moved to the cities. A 2008 article titled “Population Challenges for Bangladesh in the Coming Decades” published by icddr,b estimates that half of Bangladesh’s population will live in cities by 2050, and that slums were growing at a rate of 7% every year. 

More than 35% of urban residents in Bangladesh live in slums. Some are fleeing the negative consequences of climate change, while others are seeking better economic opportunities. 

Rapid urbanization has brought about a new range of problems for the urban poor, and a new pattern of inequality that the country is not prepared to deal with. The national health infrastructure established after independence was designed to serve the needs of a largely rural population. In the rapidly urbanizing landscape of 21st century Bangladesh, this infrastructure is unable to serve the needs of slum-dwellers and the urban poor.

A 2015 paper titled “Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh” from icddr,b analyzed the utilization of health services in slum settlements in Dhaka, one of the most densely populated cities in the world. 

The study finds that there is a clear lack of formal health care provision in these areas. 80% of health care providers were privately operated and were usually either pharmacies or non-formal/traditional doctors. Only 37% of the private sector health staff in these areas had formal medical qualification. 

Formal health care provision is lacking and limited to a few NGOs. These NGO-run formal health care providers were also usually only open until 5-6pm, further restricting their utilization.

This lack of access to formal health care has had a devastating impact on the health of the urban poor. Child mortality for slum residents has reached 95 deaths per 1,000 live births, compared to 55 and 66 per 1,000 for the urban non-poor and rural inhabitants respectively. 

A 2018 paper from icddr,b studied nutrition and growth in 265 slum children from birth to 24 months of age. The results from the study are shocking -- 48% of the children were stunted by two years of age, even though stunting overall has decreased nationwide.

There is also evidence that urban slum residents suffer from a higher rate of non-communicable diseases (NCDs), like hypertension and diabetes, than the general population. 

A 2017 study found a very high prevalence of risk factors for NCDs -- smoking, insufficient fruit and vegetable intake, and low physical activity were all alarmingly prevalent in this sub-population. Combined with the lack of formal health care provision, the rise in NCDs will inevitably cause a lot of hardship for families in these communities.

While there are no simple answers to problems of this scale, icddr,b researchers are actively trying to find innovative and cost-effective solutions to ease the pain of the urban poor in Dhaka. 

One recent success story is a randomized trial evaluating a behaviour change intervention to promote better toilet maintenance and cleanliness carried out by the Environmental Interventions Unit at icddr,b. 

Sanitation is notoriously bad in urban slums, with large numbers of families having to share limited toilet facilities. 

The six-month intervention combined the provision of simple tools like solid waste bins and behaviour change materials (such as signs showing proper toilet use). The intervention was successful, resulting in visibly cleaner toilets.

The success of the intervention demonstrates the value of taking an evidence-based approach to the problem of urban poverty in the Global South. 

The data generated by public health research will be vital for effective policy-making, while the innovative pilot projects and trials conducted by institutions like icddr,b could one day be scaled up to nationwide policies. 

Zain Omar Ali is a former consultant at icddr,b.