Arch Pediatr Adolesc Med. 2010 Mar;164(3):243-9.

Association between child immunization and availability of health infrastructure in slums in India.

Ghei K, Agarwal S, Subramanyam MA, Subramanian SV.

Department of Society, Human Development, and Health, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115, USA.

Comment in:
Arch Pediatr Adolesc Med. 2010 Mar;164(3):294-6.

OBJECTIVE: To examine the association between presence of an urban health center (UHC) in proximity to a slum and immunization status of slum children in a city in India.

DESIGN: Cross-sectional study.

SETTING: Slums of Agra, India.

PARTICIPANTS: Data were obtained from a baseline survey conducted by the US Agency for International Development Environmental Health Project in 2005 in slums in Agra. The study population consisted of 1728 children aged 10 to 23 months. Information about children’s immunization was obtained from interviews with mothers aged 15 to 44 years. Main Exposure Availability and proximity to a UHC that provides immunization services.

MAIN OUTCOME MEASURES: Immunization status of children, which was measured as “complete” if the child had received 1 dose of BCG vaccine, 3 doses each of diphtheria, pertussis, and tetanus and oral polio vaccines, and 1 dose of measles vaccine; “partial” if any 1 or more vaccines were missing; and “not” if no vaccine was received. Adjusted relative risk ratios compared children receiving complete or partial immunization with those not immunized.

RESULTS: Adjusted models showed that presence of a UHC within 2 km of a slum was associated with more than twice the likelihood of children being completely (relative risk ratio, 2.03; 95% confidence interval, 1.12-3.66) or partially (relative risk ratio, 2.33; 95% confidence interval, 1.55-3.50) immunized.

CONCLUSIONS: We found that presence of a UHC was positively associated with immunization status of children in slums. These results suggest a need for greater public attention to expand coverage of slums through UHCs.

PLoS Negl Trop Dis. 2010 Mar 16;4(3):e631.

Informal Urban Settlements and Cholera Risk in Dar es Salaam, Tanzania.

Penrose K, de Castro MC, Werema J, Ryan ET.

Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America.

BACKGROUND: As a result of poor economic opportunities and an increasing shortage of affordable housing, much of the spatial growth in many of the world’s fastest-growing cities is a result of the expansion of informal settlements where residents live without security of tenure and with limited access to basic infrastructure. Although inadequate water and sanitation facilities, crowding and other poor living conditions can have a significant impact on the spread of infectious diseases, analyses relating these diseases to ongoing global urbanization, especially at the neighborhood and household level in informal settlements, have been infrequent. To begin to address this deficiency, we analyzed urban environmental data and the burden of cholera in Dar es Salaam, Tanzania.

METHODOLOGY/PRINCIPAL FINDINGS: Cholera incidence was examined in relation to the percentage of a ward’s residents who were informal, the percentage of a ward’s informal residents without an improved water source, the percentage of a ward’s informal residents without improved sanitation, distance to the nearest cholera treatment facility, population density, median asset index score in informal areas, and presence or absence of major roads. We found that cholera incidence was most closely associated with informal housing, population density, and the income level of informal residents. Using data available in this study, our model would suggest nearly a one percent increase in cholera incidence for every percentage point increase in informal residents, approximately a two percent increase in cholera incidence for every increase in population density of 1000 people per km(2) in Dar es Salaam in 2006, and close to a fifty percent decrease in cholera incidence in wards where informal residents had minimally improved income levels, as measured by ownership of a radio or CD player on average, in comparison to wards where informal residents did not own any items about which they were asked. In this study, the range of access to improved sanitation and improved water sources was quite narrow at the ward level, limiting our ability to discern relationships between these variables and cholera incidence. Analysis at the individual household level for these variables would be of interest.

CONCLUSIONS/SIGNIFICANCE: Our results suggest that ongoing global urbanization coupled with urban poverty will be associated with increased risks for certain infectious diseases, such as cholera, underscoring the need for improved infrastructure and planning as the world’s urban population continues to expand.

NEW DELHI (AlertNet) – There’s no escaping urban India’s growth.

In the capital, hundreds of migrants arrive daily at railway and bus stations, densely populated slums burgeon at the seams and building complexes, shopping malls and industrial plants are sprouting up in every direction.

But as industrialisation takes effect and growing numbers of rural populations move to towns and cities like New Delhi, experts say the inability to provide clean and safe drinking water – especially to the urban poor – has reached crisis point.

“Higher demand for water, increased pollution by humans and industry and the mismanagement of water is most of all impacting the poorest people in the country’s towns and cities,” said Sushmita Sengupta of a Delhi-based think-tank, the Centre for Science and Environment (CSE).

“Cities are already water-stressed and with increasing urbanisation, we need to learn to stop wasting vital resources.”

According to India’s last census in 2001, around 286 million – 28 percent of population – live in towns and cities.

This is projected to reach around 575 million people in 2030, which will mean around 40 percent of India’s total population will be urban.

Yet no major cities and towns have a 24×7 water supply. Most households receive water twice daily – in the morning and evening – with many middleclass families relying on water storage tanks.

Water cuts that last days are becoming increasingly common in the scorching summer months, and water protests and reports of violence over water scarcity are on the rise in urban centres.

 SLUMMING IT

For over 40 million slum dwellers across India, many of whom cannot afford to pay for private tankers to supply water, the basic amenities of clean water and toilets remain elusive, say aid workers.

New Delhi is one of the fastest growing and most densely populated cities in India, with about 1,000 migrants arriving every day – most heading to slum colonies scattered around the city in search of a better life.

An estimated 4 million people live in slums – almost 30 percent of the capital’s population.

Yet many have to defecate in the open and have no choice but to drink and bathe in contaminated water.

In southwest Delhi’s Mangla Puri slums, women fill buckets up from the only two working pipes that serve the 2,000 residents of this over-crowded, densely populated colony.

They wait patiently as a tiny trickle passes through a plastic pipe into their containers. “We are tired of living like this,” said Satinder Singh Raghav, a 25-year-old driver.

“The past four days, we didn’t have any water and when we do get it, it is very little.”

Residents – most of whom live in families of around six in tiny one-room cheek-by-jowl concrete units – say they cannot afford to buy water and resort to knocking on doors in the nearby affluent enclaves begging for the vital resource.

Sanitation standards in Mangla Puri are also poor. The two open water pipes sit alongside massive piles of rotting garbage and open drains filled with sewage, plastic and other rubbish. Piles of human waste from the few public toilets available are dumped out in the open less than 50 metres from the slum dwellings and there is an unbearable stench as pigs roll around in puddles of sewage.

Aid workers say poor sanitation contaminates scarce ground water.

“One of the reasons for contamination of groundwater is human waste which is percolating into the same water that people are drinking,” said Indira Khurana, WaterAid’s director of policy and partnerships.

Although access to clean drinking water has improved in many parts of the country, the World Bank estimates that 21 percent of communicable diseases in India are still related to unsafe water. Globally, unsafe water kills hundreds of thousands of people every year.

Poor drinking water and hygiene practices are resulting in mass cases of diarrhea across the country, which cause more than 1,600 deaths daily, the World Bank adds.

Experts say groundwater is also polluted with chemicals from industry and agriculture such as fertilisers, as well as high concentrations of fluoride and arsenic.

 POLLUTION AND WASTAGE

Contamination is not limited to groundwater. Surface water sources like rivers, lakes and streams which supply many towns and cities are also severely contaminated.

Environmentalists say most of these water sources are turning into sewers where municipalities are dumping billions of tonnes of untreated sewage, not only killing vital water supplies but also threatening the lives of the poor who drink and bathe in the water.

New Delhi alone produces 3.6 billion tonnes of sewage every day but due to poor management less than half is effectively treated. The remaining untreated waste is dumped into the Yamuna river – which accounts for 86 percent of Delhi’s water supply.

According to the Central Pollution Control Board, around 70 percent of the pollution in the Yamuna is human excrement. The rest is industrial effluents and agricultural run-off. Environmentalists say while India has over 300 sewage treatment plants, most are under-utilised and positioned too far from sewage drainage points.

Treated waste is often mixed with untreated sewage and thrown back into rivers. India’s drainage system is decrepit and in serious need of repair, with more than half of the country’s drains virtually redundant.

“There is a massive amount of wastage of water due to poor management… We need to focus on policies like rainwater harvesting as well as decentralising waste management,” said CSE’s Sengupta.

Environmentalists argue that climate change will exacerbate the water crisis as vital monsoon rains become erratic.

A July 2009 report by the Australian government warned that in the coming years, climate change could drastically weaken monsoon rains on the subcontinent, on which more than a billion people rely for agriculture and water supplies.

The government must invest more in infrastructure and management, experts add.

“The water demand (in India) will exceed supply by 40 percent by 2030 if it’s just a business-as-usual scenario and if the government does not spend adequately on infrastructure,” said Bharat Sharma of the International Water Management Institute.

“You have little incentive to use the water efficiently.” (Additional reporting by Matthias Williams)

Source – http://in.reuters.com/article/topNews/idINIndia-47117720100322?sp=true

WHO – Megacities and urban health. December 2009.

Full-text: http://www.who.or.jp/2009/reports/Megacities_Report_DEC09.pdf (pdf, 275KB)

Megacities are cities of 10 million or more inhabitants. There are more than 20 megacities in the world and they are highly diverse. They concentrate national and global economic and political power as well as scientific, political and media attention. When analysing health in megacities, it is difficult to separate the effect of size from other variables. However, cities of similar size do not necessarily suffer from the same problems, and at the same time common issues can be found among cities of very different dimensions. Nevertheless, starting with an analysis of their common characteristics, we identify nine challenges that megacities face which have particular health impact: transportation, governance, water and sanitation, safety, food security, water and sanitation, health care, emergency preparedness, and environmental issues. Each challenge is analysed in terms of its relationship with urban health. They are highly influenced by the complexity of megacities in terms of population size, geographical extension, social inequalities, and usually multiple and fragmented metropolitan governments. We conclude that given the variation among megacities and the extent of commonalities between megacities and other lower population settings, the relevance of the megacity as a category in urban health is limited. Yet the identification of these challenges, and the different ways in which they are being handled, is useful for shedding light on determinants of health and potential intersectoral interventions in a range of urban settings well beyond this group of cities.

India and China have together lifted at least 125 million out of slums between 1990 and 2010, and improved the lives of slum dwellers more than any other country, a new UN report has said.

India has lifted 59.7 million people out of slum conditions since 2000. Slum prevalence fell from 41.5 per cent in 1990 to 28.1 per cent in 2010. This is a relative decrease of 32 per cent, the study found, according to the report called State of the World’s Cities 2010/2011.

“Lessening poverty and improving conditions in slums are part of India’s urban development policy,” the report said, pointing out four main reasons for it.

First, building the skills of the urban poor in their chosen businesses, and by providing them micro-credit. Second, providing basic services and development within slum settlements, thus improving living conditions.

Third, providing security of tenure to poor families living in unauthorised settlements, improving their access to serviced low-cost housing and subsidised housing finance. Fourth, encouraging the poor to take part in decision-making and community development efforts.

China has made the greatest progress on this front with improvements to the daily conditions of 65.3 million urban residents, the report said.

Proportionally, China’s urban population living in slums fell from 37.3 per cent in 2000 to some 28 per cent in 2010, a relative decrease of 25 per cent.

“Despite growing inequality due to the country’s rapid economic advance, China has improved living conditions by embracing economic reforms and implementing modernisation policies that have used urbanisation to drive national growth,” the report said.

Overall, the report finds that 227 million people in the world have moved out of slum conditions since 2000. At the same time, the study also stresses that 55 million new slum dwellers have been added to the global urban population since 2000.

“However, this achievement is not uniformly distributed across regions,” said Anna Tibaijuka, head of the UN Human Settlements Programme.

“Success is highly skewed towards the more advanced emerging economies, while poorer countries have not done as well,” she said.

Overall, the UN report finds that the number of people living in slums has risen from 777 million in 2000 to 830 million in 2010, and warns that unless urgent steps are taken the number could rise to 900 million in 2020.

Source – http://www.business-standard.com/india/news/indiachina-lift-millions-outslums-un/88943/on

Access to safe drinking water improving; sanitation needs greater efforts

Link - Progress on Sanitation and Drinking-Water –2010 Update Report

15 MARCH 2010 | GENEVA | NEW YORK — With 87% of the world’s population or approximately 5.9 billion people using safe drinking-water sources, the world is on track to meet or even exceed the drinking-water target of the Millennium Development Goals (MDGs), according to the new WHO/UNICEF Joint Monitoring Programme (JMP) report Progress on Sanitation and Drinking-Water –2010 Update Report, released today.

More needs to be done for sanitation 

However, with almost 39% of the world’s population or over 2.6 billion people living without improved sanitation facilities, the report also points out that much more needs to be done to come close to the sanitation MDG target. If the current trend continues unchanged, the international community will miss the 2015 sanitation MDG by almost one billion people.

Improvements 

The good news is that open defecation – the riskiest sanitation practice of all – is on the decline worldwide, with a global decrease from 25% in 1990 to 17% in 2008, representing a decrease of 168 million people practicing open defecation since 1990. However, this practice is still widely spread in Southern Asia, where an estimated 44% of the population defecate in the open.

Joint Monitoring Programme report 

The JMP report presents the current status and trends in 209 countries or territories towards reaching the drinking-water and sanitation MDG target, along with an assessment as to what these trends reveal.

“We all recognize the vital importance of water and sanitation to human health and well-being and their role as an engine of development. The question now lies in how to accelerate progress towards achieving the MDG targets and most importantly how to leap a step further to ultimately achieve the vision of universal access”, said Dr Maria Neira, WHO’s Director for the Department of Public Health and Environment.

This report provides the clearest picture to date of the current use of improved sanitation facilities and improved sources of drinking-water throughout the world. The report is aimed to be used by policy-makers, donors, governmental and nongovernmental agencies to decide what needs to be done and where to focus their efforts to achieve these goals.

“We need to not only focus on reaching the water and sanitation MDG targets but also on achieving them with equity, ensuring that the most vulnerable groups and those hard to reach share in the successes achieved elsewhere,” said Dr Tessa Wardlaw, UNICEF’s Chief of Statistics and Monitoring.

Rural areas lagging
 
Despite the world’s population being almost equally divided between urban and rural dwellers, the vast majority without access to water and sanitation live in rural areas. Seven out of ten people without basic sanitation are rural inhabitants and more than eight out of ten people without access to improved drinking-water sources live in rural areas.

Disparity between rich and poor
 
A similar disparity is found between the poor and non-poor. A comparison between the richest and poorest 20% of the population in sub-Saharan Africa reveals that the richest are more than twice as likely to use an improved drinking-water source and almost five times more likely to use improved sanitation facilities. Although there is insufficient data at present, country data available confirms similar disparities elsewhere.

“With only five more years to go until 2015, a major leap in efforts and investments in sanitation is needed today in order to have an impact by the time we carry out our end-of-MDG evaluation,” said Robert Bos, Coordinator, Water, Sanitation, Hygiene and Health at WHO.

Unsafe water, sanitation and hygiene claim the lives of an estimated 1.5 million children under the age of five each year. Lack of access to water, sanitation and hygiene affects the health, security, livelihood and quality of life for children, impacting women and girls first and most. They are much more likely than men and boys to be the ones burdened with collecting drinking-water.

About the JMP
 
“With almost 884 million people living without access to safe drinking-water and approximately three times that number lacking basic sanitation we must act now as one global community to ensure water and sanitation for all,” said Ms Clarissa Brocklehurst, UNICEF Chief of the Water, Sanitation and Hygiene (WASH).

The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation is the official UN mechanism tasked with monitoring progress towards MDG Target 7c on drinking water supply and sanitation. The report includes information from household surveys and censuses completed during the period 1985–2008. A record number of nearly 300 datasets were added to the global database for this year’s report. Importantly, the newer data have not yet registered the impact of the International Year of Sanitation (2008), which it is hoped will make a significant difference to the rate of progress towards the MDG sanitation target.

Density and disasters: economics of urban hazard risk, Dec. 2009. Policy Research Working Paper.

Link: Full-text (pdf, 1.54MB)

S. Lall
Today, 370 million people live in cities in earthquake prone areas and 310 million in cities with high probability of tropical cyclones. By 2050, these numbers are likely to more than double. Mortality risk therefore is highly concentrated in many of the world’s cities and economic risk even more so. This paper discusses what sets hazard risk in urban areas apart, provides estimates of valuation of hazard risk, and discusses implications for individual mitigation and public policy. The main conclusions are that urban agglomeration economies change the cost-benefit calculation of hazard mitigation, that good hazard management is first and foremost good general urban management, and that the public sector must perform better in generating and disseminating credible information on hazard risk in cities.

The short-term impact of higher food prices on poverty in Uganda, 2010.
Policy Research Working Paper.

K. Simler.

Link to: Full-text (pdf, 866KB)

World prices for staple foods increased between 2006 and 2008, and accelerated sharply in 2008. Initial analysis indicated that the adverse effects of higher food prices in Uganda were likely to be small because of the diversity of its staple foods, high level of food self-sufficiency, and weak links with world markets. This paper extends the previous analyses, disaggregating by regions and individual food items, using more recent price data, and estimating the impact on consumption poverty. The analysis finds that poor households in Uganda tend to be net buyers of food staples, and therefore suffer welfare losses when food prices increase. This is most pronounced in urban areas, but holds true for most rural households as well. The diversity of staple foods has not been an effective buffer because of price increases across a range of staple foods. The paper estimates that both the incidence and depth of poverty have increased — at least in the short run — as a result of higher food prices in 2008, increasing by 2.6 and 2.2 percentage points, respectively. The increase in poverty is highest in the Northern region, which is already the poorest in Uganda. The need for mitigating social protection measures appears to be greater than previously recognized. Not only are the negative impacts larger, but they are also much more widespread geographically. This suggests the need for continued close monitoring of the situation, including monitoring the adequacy of existing safety nets and feeding programs.

Environ Health Perspect. 2010 Mar 1.

Childhood Lead Exposure After the Phase-out of Leaded Gasoline: An Ecological Study of School-Age Children in Kampala, Uganda.

Graber LK, Asher D, Anandaraja N, Bopp RF, Merrill K, Cullen MR, Luboga S, Trasande L.  Yale University School of Medicine.

Background: Tetraethyl lead was phased out of gasoline in Uganda in 2005. Recent mitigation of an important source of lead exposure suggests examination and re-evaluation of the prevalence of childhood lead poisoning in this country. Ongoing concerns persist about exposure from the Kiteezi landfill in Kampala, the country’s capital.

Objectives: To determine blood lead (BLL) distributions among Kampala schoolchildren, and identify risk factors for elevated blood lead levels (EBLL; >/=10 microg/dL). 

Analytical Approach: Using a stratified, cross-sectional design, we obtained blood samples, questionnaire data, and soil and dust samples from the homes and schools of 163 4-8 year old children, representing communities with different risks of exposure.

Results: The mean BLL was 7.15 microg/dL; 20.5% were found to have EBLL. Multivariable analysis found participants whose families owned fewer household items, ate canned food, or used the community water supply as their primary water source to have higher BLL and likelihood of EBLL. Distance <.5 mi from the landfill was the factor most strongly associated with increments in BLL (5.51 microg/dL, p<.0001) and likelihood of EBLL (OR=4.71,  p=.0093). Dust/soil lead was not significantly predictive of BLL/EBLL.

Conclusions: Lead poisoning remains highly prevalent among school-aged children in Kampala. Confirmatory studies are needed, but further efforts are indicated to limit lead exposure from the landfill, whether through water contamination or through another mechanism. While African nations are to be lauded for the removal of lead from gasoline, this study serves as a reminder that other sources of exposure to this potent neurotoxicant merit ongoing attention.

Vaccine-preventable diseases are responsible for severe rates of morbidity and mortality in Africa. Despite the availability of appropriate vaccines for routine use on infants, vaccine-preventable diseases are highly endemic throughout sub-Saharan Africa. Widespread disparities in the coverage of immunization programmes persist between and within rural and urban areas, regions and communities in Nigeria.

This study assessed the individual- and community-level explanatory factors associated with child immunization differentials between migrant and non-migrant groups.

Methods: The proportion of children that received each of the eight vaccines in the routine immunization schedule in Nigeria was estimated. Multilevel multivariable regression analysis was performed on a nationally representative sample of 6029 children from 2735 mothers aged 15-49 years and nested within 365 communities. Odds ratios with 95% confidence intervals were used to express measures of association between the characteristics.

Results: The pattern of full immunization clusters within families and communities. Findings provide support for the traditional migration hypotheses, and show that individual-level characteristics, such as, migrant disruption (migration itself), selectivity (demographic and socio-economic characteristics), and adaptation (health care utilization), as well as community-level characteristics (region of residence, and proportion of mothers who had hospital delivery) are important in explaining the differentials in full immunization among the children.

Conclusions: Migration is an important determinant of child immunization uptake. This study stresses the need for community-level efforts at increasing female education, measures aimed at alleviating poverty for residents in urban and remote rural areas, and improving the equitable distribution of maternal and child health services.

Author: Diddy Antai Credits/Source: BMC Public Health 2010, 10:116