Elsevier

Health & Place

Volume 15, Issue 1, March 2009, Pages 69-78
Health & Place

Urban sanitation and health in the developing world: Reminiscing the nineteenth century industrial nations

https://doi.org/10.1016/j.healthplace.2008.02.003Get rights and content

Abstract

The dichotomy in development trajectories of urbanisation, industrialisation and economic change, and the associated environmental health challenges, between the industrialised nations and the developing world, could offer useful lessons, especially for the latter. This paper examines points of convergence in the underlying factors and theories, underpinning urbanisation, sanitation and health in the 19th century industrialised nations and the developing world and explores the major reasons why many low income countries have not managed to redress their urban sanitation and health problems. It concludes that any meaningful developments in low income countries may require strategies, policies and actions, which emphasise local realities over and above global concerns and priorities.

Introduction

Analysis across space and time highlights the points of convergence and divergence in the development trajectories of urbanisation, industrialisation and economic growth, and associated urban sanitation and health challenges between the industrialised nations and the developing world (Sclar et al., 2005). The transfer of the benefits of modern medicine from the industrialised countries, mainly the development of vaccines, saw the eradication of diseases such as smallpox, and others like polio and guinea worm, on track of being eliminated in the developing world; this significantly helped to reduce their mortality levels (Cohen, 2004; Hinman, 1998). The paradox is that, in spite of increased globalisation, about a century and half following the public health and sanitary revolution, sanitation and related health problems remain a serious concern in many developing countries. It is worth discussing the extent to which the urban sanitation and health problems of many developing world countries are reminiscent of the 19th century industrialised nations. ‘Lesson drawing’ can enable us to understand why certain policies and strategies might work or fail in different time periods or settings (Nedley, 2004; Greener, 2001). Illuminating this dichotomy is not to suggest uniformity in the urban sanitary and health experiences of either the industrialised countries or the contemporary developing nations. Differences would always exist even within nations and regions and the risk of the “ecological fallacy”, which increases “as the scale of analysis becomes wider” (Curtis and Taket, 1996, p. 75), is often associated with drawing out commonalities. Hence any generic reference to ‘the developing world’ in this paper is not implying that the problems are about the same in most developing world cities. The focus is on those urban centres in Africa, Asia and the Caribbean which are relatively small and characterised by weak industrial base and economies, yet experiencing rapid urban growth: “the smaller and less prosperous cities in lower income countries or in the lower income regions of middle-income countries” in which “environmental health problems are likely to be the most serious and to affect the highest proportion of the population” (Satterthwaite, 1997b, p. 217). Even so, there are a few exceptional cases of rapidly growing developing world cities with better managed urban environmental problems, for example Curtiba and Pôrto Alegre in Brazil, and Ilo in Peru, than others which have not been growing so fast (Hardoy et al., 2001; Satterthwaite, 1997a).

The ambivalent character of cities as symbolising civilisation and wealth, while serving as “centres of degradation and exploitation” (McGranahan et al., 2001, p. 41), has received adequate scholarly attention (see also UNFPA, 2007; Moore et al., 2003; von Schirnding, 2002; Hardoy et al., 2001; Langeweg et al., 2000; McMichael, 2000). Szreter has argued that economic development had a negative influence on public health during the industrial revolution (in the form of disruption, deprivation, disease and death, the ‘four Ds’) using Britain as a case study—a paradigm which he suggests could be applicable to some developing countries. He, however, acknowledges that a combination of factors, including economic, social and political, was invaluable to the sanitary revolution (Szreter, 2003, Szreter, 1997). The 19th century industrial revolution was accompanied by high levels of urbanisation, degrading sanitary conditions and unprecedented levels of morbidity and mortality, which affected mostly the working class population (Evans, 2004; McMichael, 2000; Melosi, 2000). To some extent these developments would appear to be replicated in many cities in Africa, Asia and the Caribbean.

Although the ‘speed and scale’ of urbanisation in low to middle income countries, especially in Asia and Africa, have been relatively high (UNFPA, 2007) the rate of urbanisation in the developing world is not unique. The overall urban growth rate has in fact been on the decline and lower than projected figures over the past two decades; but it is the actual increase in the share numbers of the urban population (or the proportion of national population that is urban) in the developing world that is of serious concern (UNFPA, 2007; Cohen, 2004). More importantly, with the exception of a few better performing economies, urbanisation in the developing world has not been accompanied by a remarkable economic or industrial growth. It is not urbanisation per se, but the phenomenon of ever increasing number (and proportion) of urban residents living in abject poverty in South and East Asia, Latin America and sub-Saharan Africa (UNFPA, 2007), along with the growing wealth inequalities (Cohen, 2004), that presents a contrasting picture to the 19th century industrialised nations. The disadvantages, which the urban poor in these countries suffer, are largely in the areas of sanitation and health (UNFPA, 2007).

Following the public health and sanitary revolution more than a hundred years ago in the developed countries, access to piped water supply, flush latrines and solid waste disposal facilities have for long been taken for granted as diseases like cholera, diarrhoea, malaria and typhoid became a problem of the past. Yet these problems appear to be intractable in many low income countries, even in the face of increased globalisation; and sanitation, in particular, continues to receive much less attention at national and international levels (Mason, 2002). Apart from a mix of driving forces underpinning the urban environmental health problems, in general, there are major theories, which, although they often border on polemics, are critical to our understanding of the dichotomy in the experiences of the developed world and the developing countries.

Section snippets

The convergences

Similarities in urban sanitation and health in the developing countries and the 19th century industrialised nations exist mainly in the form of:

  • urbanisation and socioeconomic disparities as key determinants;

  • inadequate provision of sanitary and environmental amenities;

  • social exclusion and inequalities, amid public health inadequacies; and

  • the associated morbidity-communicable diseases.

The divergences

In spite of the apparent parallels, given the scale, lack of financial and technological resources, and institutional or political capacity necessary to deal with the problem, the urban environmental health problems in the developing world cities today are clearly unprecedented (WHO, 1991). The divergences can be examined in the form of strategies to redress urban sanitation and health problems, the development trajectories, the epidemiological transition and change in environmental health

The challenges for the developing world

Policy weaknesses are critical among the reasons why many low income countries fail to redress their urban sanitation and health problems. It has been observed that even though “policy analysis is an established discipline in the industrialised world … its application to developing countries has been limited” and “the health sector in particular appears to have been neglected” (Walt and Gilson, 1994, p. 353). With specific reference to the UK welfare health system Mohan has argued that the

Conclusions—implications of the dichotomy and recommendations

Only in terms of key determining factors (urbanisation, polarisation and wealth inequalities) and outcomes (deplorable sanitary and housing conditions and communicable and infectious diseases) are urban sanitation and health problems in the majority of low income countries reminiscent to those of 19th century developed countries. Urban development throughout history has been made possible by ensuring that clean water and a method for disposing of waste are a key part of urban infrastructure. In

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