Module 2: What are Health Inequities?

Health inequities are “avoidable inequalities in health between groups of people within countries and between counties...Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs.”(1) Inequities result from circumstances stemming from socioeconomic status, living conditions and other social, geographical, and environmental determinants that can be improved upon by human actions.  In other words, they are neither naturally predetermined nor inevitable.  For example, it is an inequity when a child living in a Nairobi slum is more likely than a child living elsewhere in the city to die before the age of five.  Another example would be the fact that male life expectancy in Glasgow ranges from 54 to 82 years, depending on the neighborhood in which the man resides.  These statistics are not due to laws of nature, nor are they unchangeable.  Inequities typically arise when social issues such as household wealth, education, and housing location overshadow biological differences like age and gender.  Though biological and predetermined differences do cause inequalities, they are not considered inequities, as they are not caused by social or systematic factors, and are thus not inherently “unfair.”  For instance, the fact that color blindness is more prevalent in men than in women is not an inequity, but merely an inequality based on chromosomal differences between the sexes.(2)      

Inequities Should Be Addressed

The goal of addressing inequities is to achieve the opposite outcome: health equity.  Ideally, everyone should have the opportunity to reach their full health potential regardless of their socioeconomic circumstances.  Achieving health equity is an issue of human rights and international frameworks.  The “right to health” is included in discourse of health partnerships and policies worldwide.  Furthermore, inequities can act as rallying points for public demands for change, and resulting policies toward health equity often reduce political resistance.  In this way, an inequity can act as a “social accountant,” a reliable way to monitor a city’s ability to meet its residents’ demands.

Working to diminish health inequities improves cities in various ways, such as drawing in residents and investors, and decreasing crime.  Furthermore, taking action to create equity among vulnerable and disadvantaged groups often incorporates “urban planning” projects that “[improve] transport systems, housing and green spaces . . . and better [prepare] cities for natural disasters.”(3)

Disaggregation is Key to Uncovering Health Inequities

The drawback of using averages to measure poverty in cities is that averages can “mask wide socioeconomic differentials.”(4)  For instance, a city’s average household income would not reflect the pockets of extreme poverty or wealth in that area.  Thus, health policies are inefficient when based on averages alone.  Averages hide inequities that can be addressed by focusing policies on particular areas and groups of people.  However, the creation of such policies requires extensive research into these specific communities.(5)

Poor Groups are Exponentially Disadvantaged

Despite having the most severe health issues, the urban poor are often the most neglected by health officials primarily because many poor urban dwellers live in informal or illegal settlements or are homeless.  Governments and NGOs also focus much of their attention on rural areas, leaving the urban poor to fend for themselves.  Meanwhile, the urban poor are overshadowed by the urban rich and cannot afford the health care that wealthy individuals can access; though health care might be technically available to the poor, it is not realistically accessible.  In this way, the urban poor “fall through the cracks.”(6)

Groups living in urban poverty suffer from multidimensional vulnerability, causing these communities to experience health problems at exponentially higher rates than those of wealthier groups.  Trudy Harpham of London South Bank University summarized the major unique characteristics of urban poverty and their associated negative health externalities as follows:

• “Commoditization (reliance on the cash economy): poorer nutritional status due to lack of food from subsistence farming, reduced care of infants and children due to distant work places

• Overcrowded living conditions (slums): infectious diseases, accidents

• Environmental hazard (stemming from density and hazardous location of settlements, and exposure to multiple pollutants): respiratory diseases, diarrhea

• Social fragmentation (lack of community and inter-household mechanisms for social security, relative to those in rural areas): mental ill health

• Crime and violence: homicide, injuries, mental ill health

• Traffic accidents: injuries and death

• Natural disasters: injuries and death”(7)

On top of these damaging consequences, urban poor groups can experience increased vulnerability due to irregular employment, low access to fair credit and sanitation services, insecure land tenure, denial of healthcare (especially to migrants), high prevalence of illness (diarrhea, fever, cough), alcoholism, substance abuse, gender inequity, poor education, and lack of organized community efforts.(8) Many people experience a multitude of these issues, which build upon each other and exacerbate the consequences of poverty.

One low-income urban group, the informal sector, is especially neglected in terms of health.  The informal sector consists of the self-employed, individuals working for firms with less than five employees, and family business workers without specified wages.  In West Africa in particular, almost three-quarters of workers are part of the informal sector.  While these groups are off government radar, they are vulnerable to dangerous working conditions, which can include “scavenging, balancing on precarious scaffolding, [… or] weaving in between traffic.”(9)

Varying Neighborhoods Within Cities

Geography matters in terms of certain inequities.  Some neighborhoods have access to fresh food from markets, while others must choose from fast food or street carts.  While some areas have quality housing and clean spaces, others are polluted, crowded, and poorly constructed.  Different areas have varying amounts of health and social services, and crime and disorder can cluster into the more vulnerable pockets of cities.  Some of the greatest inequities between city neighborhoods are found in the world’s wealthiest cities. In poorer neighborhoods of New York City, for example, life expectancy is eight years shorter than in the city’s most affluent areas.

This is supported by studies demonstrating that the poorest neighborhoods (in economic terms) are those in which residents are the least likely to have access to health care, on top of the fact that they are already living in the most vulnerable environments.(10) Disaggregated data in this case can help distinguish between different shortcomings of specific neighborhoods and can encourage policymakers to focus in on the exact needs of neighborhoods.  This is not to say, however, that policies should be established based on geography alone.  For example, not all urban poor live in slums or disadvantaged areas, and not all slum dwellers are poor.  In fact, in Mumbai, a city with astronomical housing rates, “‘slumlike’ housing does not always connote extreme poverty or disadvantage.”(11) Successful policies would have to combine considerations of economic status with other variables related to neighborhood setting.(12)

Urban Slum Inequities

Slum dwellers experience some of the worse health conditions in the world.  Slums are areas of poorly built, overcrowded tenements or shacks with unsanitary water and low-quality living conditions.  Moreover, they are extremely unregulated.  In India, almost half of the country’s slums are not officially recognized by municipalities, corporations, local bodies, or development authorities, and are therefore not included in policy or aid considerations.(13) Residents of these informal areas tend to have the worst health outcomes.  In Bangladesh, twice as many infant deaths occur in urban slums than in urban areas generally.(14) Similarly, studies from Nairobi, Kenya show that people born in slums have unusually high mortality rates and, “[c]hildren born in the slums to women who were pregnant at the time of migration have the highest risk of dying;” this indicates that “delivery in the slums has long-term health consequences for children."(15) In another study of slums in La Paz, Bolivia, people living in slums had worse health outcomes than people living elsewhere in the city.  Compared to those not living in slums, women of La Paz slums were less aware of HIV/AIDS, other sexually transmitted diseases, and associated preventative measures, and they also had less access to (and consequently, less frequent use of) condoms.  The children of the city’s slums suffer past infancy as well.  Due to minimal access to health facilities and treatment, children in slums are less likely to be immunized, and therefore face higher mortality rates than their cohorts in non-slum areas.(16) Slums continue to produce alarming health outcomes, with extreme deficiencies in nutrition, sanitation, safe water, and access to health services.  The following modules cover these issues more in depth.

Footnotes

(1) World Health Organization (WHO). (2008). Social determinants of health: key concepts. Geneva: World Health Organization.

(2) Ibid.

(3) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT).  Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(4) Montgomery, M. “Urban Poverty and Health in Developing Countries.”  Population Bulletin 64 (June 2009): 2-15. 

(5) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT).  Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.  

(6) Shetty, P. "Health Care for Urban Poor Falls Through the Gap.”The Lancet 377 (February 2011): 627-628. 

(7) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116. 

(8) Agarwal, S. “Growing Health Needs of the Urban Poor: Challenges and Program Experiences from India.” UHRC. Power Point. https://www.yumpu.com/en/document/view/11318160/growing-health-needs-of-the-urban-poor-challenges-and-program-.

(9) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.  Accessed on 2 June 2011.

(10) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT).  Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010. Accessed on 13 June 2011. 

(11) Shetty, Priya. "Health Care for Urban Poor Falls Through the Gap.”The Lancet 377 (February 2011): 627-628. 

(12) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT).  Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(13) Agarwal, Siddharth. “Growing Health Needs of the Urban Poor: Challenges and Program Experiences from India.” UHRC. Power Point.

(14) Wright, Albert M. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007. 

(15) Bocquier, Philippe, et. al., “Do Migrant Children Face Greater Health Hazards in Slum Settlements?  Evidence from Nairobi, Kenya.” Journal of Urban Health (November 2010): 1-16.

(16) United Nations Human Settlements Programme (UN-HABITAT). Urban Health Inequities: La Paz, Bolivia.