OVER 55 per cent of the world population lives in cities. With fast-growing urbanisation, this figure is set to rise to 68pc by 2050. Pakistan is one of the most populous countries, with increasing migration towards its cities. Yet, urban policy has failed to keep pace with the growing demand for public services in health, transport, education, etc. There is much talk of better transport and education provision in urban areas, but healthcare has not figured very much even in discussions on urban planning.

Urban policy can enhance health outcomes for town and city dwellers if the promotion and protection of public health are positioned at the heart of city and town planning.

Ironically, it is in urban areas where health inequalities and degraded healthcare infrastructure are starkly exposed. Alongside rich and shiny neighbourhoods are slums, where poor housing and sanitation and appalling waste management systems have an adverse impact on lives. Similarly, underfunded enclaves in urban areas are deprived of public parks and spacious housing units, which aggravates the already poor health outcomes in these areas. The lack of access to proper health infrastructure and economic opportunities in poor and unplanned areas worsens matters. The story of rosy health and ill health in urban settings is the story of unequal access to healthcare in a city’s rich and poor areas.

The World Health Organisation (WHO) emphasises better air quality, water and sanitation, a smoke-free environment, safe and healthily planned areas as well as the management of vector-borne disease and preparedness for health emergencies in urban areas. But cities lack most of these, thanks to rising population numbers (and thus greater competition for already stretched resources), an underdeveloped infrastructure and poor housing and sanitation systems. Bad air quality and pollution exacerbate these problems. Some estimates say that as much as 90pc of the population in the urban areas inhales polluted air, resulting in respiratory diseases. The smog in Lahore is a case in point.

Public health must be at the heart of planning.

Urban areas face numerous health threats. First is the growing burden of non-communicable illnesses, such as heart disease, diabetes and asthma, made worse by unhealthy living and poor working conditions. Diabetes is associated with obesity and physical inactivity, which is brought on, among other factors, by the dearth of green walking spaces. Unhealthy lifestyles complicate the management of this disease.

Road injuries and interpersonal violence due to poverty and social tension are also a health threat, though perhaps not generally viewed as such. Road injuries are linked to badly designed transport systems and weakly implemented vehicle and motorway regulations.

Moreover, the threat of vector-borne diseases such as dengue now looms large in urban areas. This is linked to both urbanisation and crowded living conditions. Almost 40pc of urban dwellers lack access to sanitation and safe drinking water. As has been observed, the spread of Covid-19 was swiftest in congested and overcrowded urban areas. The epic migration of migrant labour in India, from the slums of large urban centres to rural homes, was reflective of health-related effects in the slums.

Urban areas, while consuming over two-thirds of the world’s energy, are also large emitters of greenhouse gases. Their inhabitants are most vulnerable to climate change as these areas tend to experience higher temperatures as compared to rural areas due to declining green cover. In the US, certain historically deprived and un­­derdeveloped areas inhabited by Lati­nos and African Americans and im­­migrant populati­o­­ns experience hi­­gher temperatures — this is described as thermal inequities. The latter are accentuated in the winter months, when residents of poor areas and poverty-stricken households with elderly people cannot find enough money to heat homes. The result is death among the elderly.

In view of the above, urgent action is needed to find ways of incorporating public health in urban planning. Urban planners and health leaders should devise housing, transport, waste management, water and sanitation systems with an eye on how these affect the health of city dwellers.

The WHO has long been engaged in healthy cities initiatives; the World Bank is planning a similar venture. In Europe, many cities have joined hands for promoting healthy initiatives to improve health and living conditions. Pakistan’s policymakers can learn from urban planners in these and other countries and view living conditions through a health lens. With a little forward planning, urban health can be hugely improved.

The writer, a public health consultant, is the author of Patient Pakistan: Reforming and Fixing Healthcare.
drarifazad@gmail.com
Twitter: arifazad5

Published in Dawn, February 15th, 2023