Comment: Urbanisation is a challenge for public health

Historically, Malé city has been an engine of economic growth, a centre of culture, and a generator of ideas. But while human potential is infinite, resources are finite.

Urbanisation creates problems, but healthy cities can solve them. A billion people now live in the world’s urban slums. The urban population of Asia is expected to double between 2000 and 2030. The health sector needs to take the lead in calling attention to the enormous implications of this growth in cities for the health of the people who live and work in them.

On 7 April 2010, World Health Day, WHO will focus on the themes of Urbanisation and Health.

With the possibility that over the next 30 years all population growth will be in urban areas, urbanisation becomes a real challenge for public health.

Urbanisation is associated with many health challenges related to water, environment, violence and injury, noncommunicable diseases (NCDs) and their risk factors like tobacco use, unhealthy diets, physical inactivity, harmful use of alcohol as well as the risks associated with disease outbreaks.

In poorly planned cities, the urban poor are the ones who will suffer the burden of these and other health problems, including an increased risk for violence and for some communicable diseases such as tuberculosis and HIV/AIDS.

In 2008, the Human Rights Commission of Maldives (HRCM) carried on a “Rapid Assessment of the Housing Situation in the Maldives”.

In interviews in Malé, the study described issues such as exorbitant rent levels, housing space, size, overcrowding, unaffordable access to clean drinking water, and many other problems like unhealthy living conditions, social problems as a result of overcrowding.

Many of the respondents indicated that these problems were the key causes of rising social issues such as gang warfare and drug abuse.

Furthermore, several social problems are also faced within the household including child abuse, psychological impact in growing up in areas of overcrowding, breakdown of many families due to the hardship faced by them stimulating a ripple effect of social disorder for the families, particularly the children caught in the situation.

The assessment highlighted that the sources of such housing stress are many, but it is mainly attributed by the raising demand for housing as a result of increased migration of Maldivians and foreigners to the capital. There are over 30,000 international migrant laborers now living in Malé under more crowded situations.

In the rapid assessment, local residents reported as many as 30 men sharing 3m x 3m flats without running water or sanitation facilities. These workers have to queue at public water taps to access clean water and often have to sleep in shifts as not all of them are able to fit into the space they occupy at the same time.

Among nationals, they felt that public services in Malé and to a lesser extent in Hithadhoo, Thulusdhoo and Kulhudhufushi were significantly better than the services they could receive at home or urban centers closer to them, being hospitals, secondary schools and higher education the most commonly mentioned services.

Other important factors for individual and family migration included the availability of employment opportunities and higher wages in Malé and better prospects for developing one’s own business from the capital.

As we can see, it is important to note that the major drivers, or social determinants, of health in urban settings are beyond the health sector, including physical infrastructure, access to social and health services, local governance, and the distribution of income and educational opportunities.

The solution? Proper urban planning can promote healthy behaviours and safety through investment in active transport, designing areas to promote physical activity and passing regulatory controls on tobacco and food safety. Improving urban living conditions in the areas of housing, water and sanitation will go a long way to mitigating health risks. Building inclusive cities that are accessible and age-friendly will benefit all urban residents.

Such actions do not necessarily require additional funding, but commitment to redirect resources to priority interventions, thereby achieving greater efficiency.

The Rapid Assessment of the Housing Situation in Maldives conducted by the HRCM, concluded providing a series of recommendations, which together are designed to kick-start a broader process leading to continuously improving housing conditions in the Maldives.

Dr Jorge Mario Luna is the WHO Representative to the Maldives.