Are our cities killing us? African cities, urban development and non-communicable diseases by Ebele Mogo
(Based on a stakeholder meeting with the Young Planners' Forum of the Nigerian Institute of Town Planners)
2008 was a milestone since the beginning of civilization when the greater majority of the human race became urban dwellers. Urban growth rates continue to rise globally, with the highest rates occurring in the developing world. While urban centres provide opportunities for individual socioeconomic advancement, information, culture and knowledge, urban centres are simultaneously centres for intra-urban poverty, crime, unemployment, homelessness and slum proliferation, insecurity, violence among other social vices and problems that have negative impacts on health outcomes.
This coexistence of the best and worst socioeconomic conditions within the same city leads to polarization in health outcomes within the city where the best health outcomes and facilities are available for the richer urban dwellers while squalid living conditions, human insecurities and diseases arising from sub-optimal diets, lifestyles, stress, pollution, and occupational risk hit poorer urban dwellers the hardest.There are therefore justified concerns about the ability of thriving urban centres around Africa to deal with the demands of urbanization. Due to the original audience for which this paper was prepared, this paper emphasizes the Lagos megacity region, however so much is applicable to megacities across the continent.
Urban development and the social determinants of health
The urban physical and psycho-social environment mediates health through providing access to the infrastructure necessary for health and wellbeing such as income, nutrition, water and sanitation, waste management, education, housing and place of residence. Most notable is the nutrition transition taking place in rapidly urbanizing low and middle countries including Nigeria. Due to the importation of Westernized sensibilities there is a shift from cultural food traditions toward increased consumption of energy-dense foods, and increased intake of fats, food sweeteners, sodas, meats and highly processed foods.
The proliferation of food chains with their well advertised, easily available food options in urban centres has also contributed to the rapid rise of preventable non-communicable challenges such as obesity, and diseases such as diabetes. With the increase in sedentary work, poor access to public spaces, the mechanization of previously labourious life tasks, and the increase in sedentary leisure activities people in urban centres tend to adopt less physically active lifestyles thus putting themselves at higher risk for preventable chronic conditions. The change in the urban landscape due to urban sprawl also contributes to unsafe roads and transportation infrastructure, the degradation of water and air resources, a wasteful 'car' centres approach to city planning, all combining to reduce the tendency for healthy lifestyle activities such as walking and cycling in the city.
The sedentary occupations most common in urban areas are often associated with diabetes and cardiovascular disease due to lower physical activity coupled with workplace stress of ergonomic, psychosocial and physical natures. While workers in the informal sector may be more likely to have less sedentary lifestyles, poor nutrition, housing, working and living conditions increase their non-communicable disease risk.
Cities in Nigeria also face severe levels of urban air pollution which are higher than those of their developed world counterparts due to deficiencies in power production which are then augmented through the use of carbon-monoxide producing generators. In addition to the pollution generated by industries, energy production and vehicles, this goes on to increase urban dwellers' risk for chronic cardio-respiratory diseases and cancer, which is on the rise in developing countries.
Housing and the built environment on non-communicable disease risk.
The built environment also impacts on the non-communicable disease risk of urban dwellers. Many poor urban residents suffer from a depressive mental state due to the chronic stress situations they find themselves in due to the harsh social and physical conditions of their built environment and their loss of personal control. Poor quality housing which is very rampant in rapidly urbanizing low and middle income country cities such as Lagos Nigeria often have the attendant problems of overcrowding, insufficient lighting, noise and air pollution and poor sanitation which lead to increased stress levels.These chronic stressors alter the psychosocial landscape of the individual and serve as high risk factors for hypertension and cardiovascular problems.
Due to inadequate housing in Nigerian cities in the face of rapid urbanization and population growth, slums and shanty towns continue to proliferate. These slums could be as little as a clutter of shacks or as large as regions like Ajegunle and Mushin. Rural-urban migrants who move to the city to seek better opportunities often have to build make-shift shelters on vacant pieces of land. These cheap but insecure shelters expose the residents to great risk due to poor infrastructure, poor road networks, poor drainage and susceptibility to environmental problems like flooding and ocean surge, noise, atmospheric and water pollution. The greater majority of these slums are overcrowded, lack basic amenities, have high rates of crime, and high rates of disease and epidemic. In conditions of low social security such as this with high levels of chronic stress and pollution, residents are exposed to chronic respiratory problems and cardiovascular risks.
Most proffered 'solutions' to these social ills have often failed to take equity into consideration. The typical response has been to demolish these slums, only to see these evictions fuel the growth or expansion of new or older slums. The insecure social status of these slum dwellers from their lack of social records, lack of formal employment, poverty and lack of stable employment makes it hard for them to benefit from means of upward mobility such as the provision of mortgages, typically reserved for the working class. As a result, the 'solutions' proposed to the housing crisis have often been biased toward the more financially stable and would only widen the gap and subsequent health risks between the rich and the poor.
Planning for reduced NCD-risk in Nigeria and the way forward
Urban planning affects the built environment which impacts on the social determinants of health and the state of life in the environment. If urbanization continues without increased proactivity in the planning of cities, there will be an increased burden of non-communicable diseases with negative socioeconomic impacts globally. City planning is an urgent necessity as urban living becomes the way of life of the majority thus mounting more pressure on urban resources.
Social problems like slum proliferation and the chronic health problems associated with these settings can only be solved through adequate planning. City planning and the interconnectivity of buildings, road networks, access to water, sanitation, power supply, food security and patterns of goods consumption present urban planners with a serious responsibility to design a city where health is possible. Proper policies in planning the urban can create the right environmental intervention and strategies to make fighting non-communicable diseases sustainable in the city.
Making the healthy choice the easy choice.
Through designing efficient transport systems that make provision for active lifestyles of pedestrians and cyclists, physical activity levels and air quality in the city can be improved, thereby reducing chronic disease risk and lives lost from respiratory problems and heart diseases.
Safety is a key issue in making the active choice the easy choice. By putting the necessary urban authorities in place to ensure well-lit, signposted and safe roads, people will be encouraged to walk or cycle without being afraid for their lives and safety.
Interventions in the design of the environment such as simply making provision for safe green spaces or other neighbourhood amenities such as recreational facilities will increase the likelihood of physical activity. Such community spaces also provide opportunity for reduced stress and an increased sense of community thereby reducing the risk of noncommunicable diseases.Within buildings, simple changes in design such as the use of art, music, colour and improved lighting in stairways to encourage the use of the stairs may effect significant reductions in the risk of cardiovascular diseases.
Urban planning can also address the problem of poor nutrition associated with rapid urbanization and the changing food culture by modifying the networks that guide the flow of food and services into the city. For example, improving access of urban dwellers, especially the urban poor to vegetables, fruits and fresh produce can serve to improve the nutritional status of the city dwellers. Urban planning can promote this through the use of policy, design and infrastructure. The spaces in the city can be used beneficially; to promote healthy eating, and increase the awareness of the importance of physical activity among the residents instead of advertising highly processed foods and inactive lifestyles. Children, who are often targeted for unhealthy advertisements and commercial messages could be protected through the use of zoning and land-use regulations stipulating the use of advertisement spaces and restricting the number and proximity of fast food restaurants in settings where children and young people meet, play and learn.
Healthy urban planning can also provide incentives and infrastructural provisions for fresh local produce to be supplied to the urban areas at cheaper costs and through encouraging local citizens to grow their own local gardens. Local markets also encourage urban residents to engage in physical activity.
The big picture
Urban planning can save lives when integrated with such practices as participatory urban governance, leadership, collaboration and integration, the use of evaluation and assessment tools, knowledge management and the use of the law in healthy urban planning.At the heart of this is an attitude shift toward a proper understanding of the roots and rightful place of urban planning as central to health.