Urban Health

Urban Health
Dr.Kedar Karki
AREAS OF CONCERN

Cities are a center of immigration, both from rural areas (as evidenced by the population shift of the last century) and from other countries. Port cities (which may not be coastal in this age of airport travel) experience a constant influx of people from other cultures and climates. This may add to the health challenge in a number of ways. For example, during the period following the end of the Vietnam War in which a large number of refugees from Southeast Asia were arriving in the United States, many health care providers had to learn about an entirely new range of parasitic diseases that were endemic in these people's countries of origin. Beyond specific diseases, immigrants bring different expectations of the health care system, and a different understanding of the range of interventions appropriate to various disease states. Some immigrant health practices have moved toward the mainstream, as in the increasing use of acupuncture, once seen as an odd practice of the Chinese immigrant community. And the increasingly popular herbal remedies are an echo of the role the botanica plays in Hispanic cultures.

HOUSING
Assurance of safe housing has long been an issue for urban areas, and the history of the city is one of many cycles of housing development and reform. Failure to plan for housing infrastructure (water and sewer systems, electricity) when the population is moving into an urban area can result in extensive, substandard housing for those at lower income levels. This can be found in the barrios, favelas, and other overnight city extensions found around many cities in the developing world. Substandard urban housing more often takes the form of older buildings in central city neighborhoods that have not been maintained and are not well-served by public or private services of any kind. Health hazards in such settings include exposure to lead-based paint, cockroach feces (implicated in the increase in asthma), temperature extremes, or unsafe windows and stairs.

In addition to issues of inadequate housing, the combination of a limited supply of affordable housing and low-income levels leaves some individuals and families with no place to call home. The homeless concentrate in urban areas. This may be in part due to the cost of housing in some urban areas, forcing people out of safe housing and into the streets. For example, the economic boom of the 1990s in New York City led to a tightened housing market; those serving the homeless reported a marked increase in families with children finding themselves without a permanent place to live. This has important implications for health care, as homelessness may be associated with a lack of a way to pay for care, and the struggle for safe shelter may obscure early indications of need for care and thus more serious illness problems later on. Housing policy that does not offer ready assistance may also consider a person as having a home as long as there is some extended family member with room on the sofa or living room floor. While such an arrangement may work for a short time under emergency circumstances, the loss of privacy and crowding that results adds another dimension of stress to the risks of mental and physical ill health.

As would be true in rural as well as urban areas, control of indoor temperature is a significant issue. Experiences during periods of extreme heat during the 1990s have led to an increasing awareness of the risks, especially for the elderly or infirm in urban areas, when the temperature remains over 95 or 100 degrees Fahrenheit for several days. Windows may be locked shut for fear of intruders and fans or air conditioning may be seen as an expensive luxury. Neighborhoods attentive to the needs of the housebound during a severe winter (are they frozen in without adequate food? have we made adjustments in the cost of heating so that freezing is unlikely?) have not understood that there were perils at the other end of the thermometer. In areas in which housing is multilevel, and especially where it is high-rise, the isolation of individuals may mean that neighbors do not know who is alone and unable to make appropriate adjustments to either hot or cool weather, and excess media attention to crime and violence may distort views of personal safety and mitigate against cooperation.

FOOD AND WATER
Urban areas offer inhabitants little opportunity to obtain food other than through purchase. The larger the urbanized area, the further foods have to travel to reach stores and eventually households. This also makes "fresh" a relative term: the produce delivered straight from the field to the store is going to be much fresher when the journey is one hour than when it is one day. On the other hand, large concentrations of people make it economically reasonable to regularly import food from all over the globe, making formerly seasonal fruits and vegetables available year-round.

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Delivery of fresh water to residents was often one of the first public health activities taken up by municipal authorities in the eighteenth century. Using simple surface impoundment, wooden piping, and gravity, water that was not contaminated by urban sewerage and waste products could be made available to central pumps and to individual residences. Over time, the systems have become more elaborate, and contamination concerns have expanded to include not only the infectious diseases of the past and present, but a wide range of potentially damaging chemical agents associated with modern industrial life. For urban areas, concern about water is not only related to use for human consumption, it is a significant part of safety, given the role that water plays in control of fire. The concentration of housing and industry in urban areas has made fire safety an urban concern since the colonial era. Benjamin Franklin is cited as the father of the modern fire insurance and fire fighting systems in the United States. Urban areas devote an extensive portion of zoning and construction regulation to assuring that heating, cooking, and industrial fires, and electrical transmission systems, are such that the probability of fire is minimized. WASTE DISPOSAL
The concentration of populations in urban areas also means an increased accumulation of waste products. Removal of human waste and garbage is a major commitment in any city, whether the mechanism chosen is completely public or funded by a mixture of public and private resources. The treatment of human waste is costly, and new requirements that protect both people and the environment from contaminants has meant a steady investment in upgrading treatment facilities and building new ones. Treatment plants running at or near capacity in systems in which storm runoff drains into the common sewers may overflow or be bypassed during rainy seasons, causing downstream problems.

Trash and garbage that accumulate in urban areas must be disposed of safely. The old-fashioned garbage incinerator is no longer feasible, due to both volume of material and the air pollution caused by burning. Landfill disposal requires moving the material outside the urban boundary, and safety requirements for landfills have become increasingly stringent. While many areas do not want any waste disposal nearby, the acceptance and processing of urban waste has been welcomed by some economically suffering rural areas. Trash from East Coast urban areas may be moved long distances by land or sea for final disposal. The volume of waste is directly related to the degree of attention paid to recycling of materials. Paper, glass, metal, and plastics all can be returned to use with proper treatment, but efforts to fully recycle met with varying degrees of success. Some urban areas have come very late to full recycling efforts, but most now offer curbside or individual pickup of separated recyclable materials.

At the same time as communities search for more ways to dispose of waste, attention to the siting of waste disposal has increased due to the awareness that racial and ethnic minorities have found themselves disproportionately exposed to these sites. Whether this is because landfills are deliberately located in minority communities, or their proximity is the indirect result of lower income levels and lower property values adjacent to environmental hazards, the practice has fueled both rage and concern, and government action has been taken to address the problem. This issue of environmental justice could be easily expanded to other land-use issues in urban areas, since neighborhoods with lower income levels and greater concentrations of minority populations generally have less open space for parks and playing fields, and the ones they have are often in poor condition. Lack of safe park space leaves low-income urban children playing in the street or other unsafe areas, increasing chances of injury.

HEALTH AND HEALTH SERVICES
Urban hospital systems have provided a critical link in access to health care. Many have a long history of service that dates to the waves of immigration and the epidemics of communicable diseases during the nineteenth and early twentieth centuries. Those that are publicly owned have been particularly important because of their continuity of presence, visibility, and obligation to serve all within the jurisdiction. One example of the continuing evolution of such systems is the shift from a combination of inpatient care, specialty clinics, and emergency rooms to community partnerships featuring community-oriented primary care.