Tuesday, September 2, 2014
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The Health Challenge in Emerging-Market Cities

OXFORD – Emerging markets – Brazil, China, India, Indonesia, Mexico, Russia, Turkey, and some 15 other countries in Africa, Asia, Europe, and Latin America – account for a rapidly growing share of the world’s population and economy. But their governments now face one of the major challenges of the twenty-first century: creating public-health solutions that match the speed and scale of urbanization.

The four largest emerging markets account for more than 40% of the world’s population and have a collective GDP of nearly $9 trillion. It is expected that their economies will overtake those of the G-7 by 2030, and that, by 2050, Brazil, China, India, Mexico, and Russia will, with the US, be the worlds’ dominant economies.

Today, however, these countries’ cities must contend with economic and social issues that are more acute, more urgent, and of a vastly larger scale than those that confronted European and American cities in the nineteenth and twentieth centuries.

A principal challenge is managing the consequences of the explosive growth of urban populations. More than half of the world’s population now lives in cities. In my own country, Pakistan, Karachi is growing at a rate of 1,000 people per day.

Massive migration to urban areas, high unemployment, low incomes, poor housing and sanitation, inadequate infrastructure, and social deprivation are shared symptoms of economic hubs where population growth has not been reconciled with cohesive approaches to public-health policy. As government, business, and academic leaders agreed at a recent meeting held under the auspices of the Emerging Markets Symposium, the promise of emerging-market countries will not be realized if their cities, and consequently their economies, are sick.

A seminal 1995 report on human development by my compatriot, Mahbub ul Haq, stressed the differences between human security viewed as personal security and viewed as national security. He used human-development indicators rather than aggregate national indicators to measure economic and social progress. His fundamental proposition was that development is about people.

Nothing is more fundamental to human security than health, which permits human choice, enables human freedom, and underpins human development. We often focus on health care and emphasize the roles of medicine and physicians. But health is also about wellness, the security of life, and the capacity to work and learn. As the economist and philosopher Amartya Sen has put it, “health is a precondition for functional effectiveness across a whole range of human activities.”

Even as the disease burden in emerging-market cities shifts from infectious to chronic illnesses, urban populations remain vulnerable to epidemic disease, childhood diseases born of malnutrition, HIV/AIDS, malaria, tuberculosis, and mental disorders rooted in unemployment and poverty. They are also vulnerable to death and injury from natural disasters and traffic accidents – and to the health consequences of social disorder and breakdown.

The speed of urban growth and the resulting concentration of poverty have overwhelmed the capacity of some national and municipal governments to provide services – sustainable and affordable housing, clean water and sanitation, and education – essential to urban public health. But the concentration of people and economic activity in emerging-market cities and megacities does offer invaluable opportunities of scale for building health-related infrastructure and delivering health-care services.

Several steps should be taken. Emerging-market governments must address critical issues arising from weak coordination within, and between, national and municipal governments on health and health-care policies and programs. They should consider reforms that include giving city governments the authority, resources, and responsibility that they need to address health and health-care outcomes.

Anticipatory city planning, based on realistic demographic forecasts, patient registers, and health-information systems, as well as participation in urban health-knowledge networks, needs to be implemented. Proven systems and reforms should be shared between emerging-market cities, and successful new innovations and ideas should be adapted to local conditions.

This includes new and affordable technologies, such as low-cost mobile telephony for use by community-health workers. In Pakistan, for example, there are 60 million mobile phone subscribers in a population of 160 million. Mobile telephones can help deliver affordable urban health care by serving as diagnostic tools for taking pictures, and by their usefulness for writing prescriptions and monitoring the condition of patients in low-income areas.

In short, urban public health needs to be reinvented. The health of emerging-market cities – and countries – demands no less.

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