Viewpoint

TWPR, 17 (4) 1995

DAVID SATTERTHWAITE

Viewpoint The underestimation of urban poverty and of its health consequences

I ntroduction One of the great puzzles for those working on urban issues in the South is reconciling the regional and global statistics that are in the statistical annexes published by the World Bank, UNDP and other United Nations agencies with the local realities in which one works or reads about through the work of other researchers. Detailed local or city studies on, for instance, the proportion of people served with piped water or health care usually seem at odds with the national and global statistics listed at the end of such influential publications as the annual World Development Report from the World Bank and the Human Development Report of UNDP. One always assumed that what was found in the local studies was simply unrepresentative of conditions at the national, continental or global level. But the number of such discrepancies began to mount during my work with staff from UNCHS (Habitat) and with a large network of researchers from both the North and the South, when preparing a new edition of The Global Report on Human Settlements (UNCHS, 1996) for Habitat II (the second UN conference to be held in Istanbul in March 1996). There are so many local and city studies that seem at odds with national and global statistics that perhaps the validity of the global statistics should be questioned. Of particular relevance to Habitat II are the global estimates for urban poverty and for the inadequate provision for water, sanitation and health care to urban populations. If the most widely quoted estimates of the scale of urban poverty in the South are correct, the proportion of the urban population 'living in poverty' must have been reduced considerably during the late 1970s and the 1980s. Similarly, if the global figures for the number of urban dwellers lacking piped water, sanitation and health care are correct, by the early 1990s most of the urban population are adequately

David Satterthwaite is Director of the Human Settlements Programme, International Institute for Environment and Development, 3 Endsleigh Street, London WeIH ODD.

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Copyright (c) 2006 ProQuest Information and Learning Company Copyright (c) Liverpool University Press

iv DAVID SAITERTHWAITE served. This would imply that as plans are finalised for Habitat II, there is much to celebrate, 20 years after the first UN Conference on Human Settlements in 1976.

The scale of urban poverty A report in 1989 suggested that 130 million of the poorest people in the South lived in urban areas (Leonard, 1989). Since 1.4 billion people then lived in urban areas in the South (UN, 1995), this implies that more than 90 per cent of its urban population were then not among the 'poorest poor'. A World Bank estimate for 1988 suggested that there were 330 million 'poor' people in urban areas of the South (World Bank, 1991), which implies that less than a quarter of the South's urban population were living in poverty. Many studies on urban poverty within nations or within particular cities suggest that much more than a quarter of their populations have incomes too low to allow them to meet basic needs; in most, between a third and a half of the population is below the poverty line, and in some more than a half (see, for instance, Tabatabai and Fouad, 1993). A study of the magnitude of poverty in Latin America that measured the scale of poverty using country-specific rather than universal poverty lines and that made allowances for the higher cost of living in citiescompared with rural areas and small towns also suggested that the World Bank estimates for this region were much too low (Feres and Leon, 1990). But what is perhaps more relevant is the extent to which official poverty lines themselves underestimate the scale of urban poverty and misrepresent its nature (see, for instance, Chambers, 1994; Wratten, 1995). One aspect of this underestimate can be seen in the mismatch between what might be termed 'income poverty' and 'housing poverty' (Pugh, 1995). In most countries in the South, the proportion of urban dwellers living in very poor housing is substantially higher than the proportion said to live in 'absolute poverty' by official statistics. An estimate made in 1990 suggested that at least 600 million urban dwellers in Africa, Asia and Latin America live in housing that is so overcrowded and of such poor quality, with such inadequate provision for water, sanitation, drainage and rubbish collection, that their lives and their health are continually at risk (Caimcross, Hardoyand Satterthwaite, 1990). This estimate was subsequently endorsed by the World Health Organization (WHO, 1992). If these people are considered to be living in poverty, it greatly increases the proportion of the urban population considered poor. There is also the noteworthy difference between countries in the North and most in the South. In the North, while many people with low incomes may live in poor and overcrowded housing, most has piped water, toilets connected to sewers, drains and bathrooms. In most urban areas of the South the reverse is true, with far more people 'living in poverty' than having incomes that fall below the official poverty line. 1 This in part reflects the low priority given by governments and aid agencies to I One important exception to this can be found in Latin America among some of the middle classes who suffered a serious drop in income during the 19808. Their housing conditions often remained adequate but their income fell below the poverty line (Minujin, 1995).


v improving housing and living conditions, especially piped water and sanitation and measures to ensure that sufficient land is available for new housing. But it also partly reflects the fact that poverty lines are generally based on income levels and that 'minimum income levels' are determined without making sufficient allowance for the cost of what might be termed 'minimum adequate quality' housing. The concept of measuring poverty by setting an income level below which an individual or household is 'poor' was developed in the North and transferred with little modification to the South. Although it is common to see comments like 'so many million people living in poverty', it is almost always through their income levels, not their living conditions, that governments and international agencies define them as poor. The concept ofincome-based poverty lines was thus transferred from societies in which only a small proportion of the population lived in housing with inadequate water and sanitation to societies in which this was not the case. The concept was also transferred from societies in which most or all the populations had access to free education and health care to those in which many low-income urban dwellers had no access to free health care and increasingly had to pay considerable sums for education. Yet the definition of poverty lines in the South-in theory set at the income level that is meant to ensure individuals or households can meet their basic needs-rarely includes the income needed by urban households to keep children at school and to pay for health care. In many countries, the same poverty line is set for rural and urban areas, no allowance made for the generally higher cost of living in towns. Yet the cost of housing is generally much higher in large cities, especially for those working in low-wage or casual jobs in central districts, where housing costs are particularly high. Alternatively, they may live in cheaper sites on the periphery but have to pay high bus or train fares to get to and from work-but it is very rare for poverty lines to include any consideration of the cost of transport. This suggests that the number of urban households with incomes too low to allow them to meet their daily needs, to afford housing with adequate water and sanitation, to afford health care and to cover the costs of sending their children to school is much larger than the number officially recorded as 'living below the poverty line.' THE UNDERESTIMATION OF URBAN POVERTY

The number of urban dwellers inadequately served by water supplies Official United Nations statistics suggest that by the early 1990s more than 80 per cent of the urban population in Africa, Asia and Latin America were 'adequately served' with piped water. But these statistics considerably overstate the number for two reasons. The first is the lack of an agreed definition of what is 'adequate' and the latitude given to governments in making the judgment. The second is the tendency for governments greatly to exaggerate the proportion of their people with piped water supplies. United Nations agencies such as the World Health Organization, being inter-governmental, are obliged to publish the water supply statistics supplied by their member governments. Staff from the World Health Organization know better than anyone else the inaccuracies in the statistics they publish, but they cannot publicly question them. People are considered adequately served with water of they have 'access to an


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adequate amount of safe drinking water located within a convenient distance from the user's dwelling' (WHOIUNICEF, 1993, 13). Each of the words in italics is defined within the particular countries, not by the international agencies responsible for monitoring and evaluating progress (ibid.). A considerable proportion of those who are said to have 'safe' water do not have drinking water at a convenient distance. Water is very heavy to carry any distance. A family of five or six needs about 300 litres of water a day to meet all its needs, the equivalent of 30 or more full buckets. Governments often claim that if a household is within 100 metres of a public standpipe, then it is adequately served. Fetching and carrying water from a source just 20-30 metres from a house is an onerous and time-eonsuming task, if sufficient water is to be obtained for all basic domestic tasks. Eye and ear infections, skin diseases, scabies, lice and fleas are very difficult to control without sufficient supplies of water to permit regular washing and laundry (Caimcross, 1990). Readily available water is needed to prepare food, cook, wash up and clean the house. The amount of water a family uses will be influenced greatly by the distance that water has to be carried to the home, so the convenience of a water source can be as important for health as its quality (ibid.). Governments tend to describe all those with public standpipes or boreholes with a handpump nearby as 'being adequately served'. But there is often only one tap or pump for dozens or even hundreds of households. In low-income settlements in cities, especially tne more peripheral illegal settlements, if there is piped water at all, there are usually hundreds of water users for each tap. A survey conducted in Dakar in the late 1980s found one area of the city (Pikine) with 1513 people to a tap and many other areas with 500 or more (Ngom, 1989). Long queues at a public tap (especially if water is only available for a few hours a day, as is often the case) and time spent making repeated trips back to the house take up time that could be used earning an income or completing other domestic tasks. In addition, many public water standpipes in urban areas are poorly maintained. It is surprising to discover how many countries claim that between 80 and 99 per cent of their urban populations have adequate water supplies when detailed studies from these same countries suggest much lower percentages. For instance, official statistics for India suggest that 87 per cent of its urban population have adequate safe water, while those for Pakistan suggest a coverage of some 80 per cent (WHOIUNICEF, 1993); Burundi, Ethiopia and Ghana are among a number of African countries claiming more than 90 per cent (ibid.). Even a cursory examination of conditions in lowincome, urban settlements in these countries suggests that these figures are grossly inflated. Thus, the proportion of the urban population in Africa, Asia and Latin America that is said to have access to safe water supplies is certainly much larger than the actual proportion that has a regular, sufficient and convenient supply of good quality water at an affordable cost.

Th« mmaber of urban dwellers with i1UUlequate sanitation Official statisticssuggest that at least a third of the South's urban population have no proper sanitationand that an even greater number lack adequate menas to dispose of


vii waste water (Sinnatamby, 1990; WHOIUNICEF, 1993). But based on three criteria, a much larger proportion lack adequate provision for sa:utation: THE UNDERESTIMATION OF URBAN POVERTY

1 A toilet to which people have easy access. Tens of millions of urban dwellers have access only to shared toilets; so many people use them that access is difficult or even at times impossible. 2 A sanitation system that minimises the possibility of human contact with human excreta. Most systems do not, and most latrines have neither running water nor a basin for washing after defecation. 3 A sanitation system that is easy to maintain and to keep clean. Most do not fulfill this criterion.

Drawing on WHOIUNICEF figures (1993), it can be estimated that more than three-fifths of urban populations in the South are not connected to a public sewerage system. Where there are sewers, these are typically located in the richer residential, government and commercial areas. Many major cities and smaller urban centres have no sewers at all. And while there are alternatives to conventional sewers that can be as effective and convenient, such as septic tanks (if emptied regularly) and small-bore sewers, these only serve a small proportion of the urban populations (ibid.). Official statistics exaggerate the proportion of urban populations with adequate sanitation for reasons similar to those given for water. When reporting to United Nations agencies, governments make their own definitions of what is considered a 'sanitary facility', the distance that is considered convenient between a dwelling and its facility and what constitutes 'access' (WHO/UNICEF, 1993). People judged to have 'access to sanitation' often have only a communal pit latrine shared with dozens of households. The use of such latrines may constitute a much greater health hazard than defecation in the open. This is not to say that communal toilets are never a solution. Communal toilets can be maintained to a high standard of hygiene. The Indian NGO SPARe, the National Slum Dwellers Federation and Mahila Milan have shown how the upgrading of many densely populated, low-income areas requires communal toilets and washing facilities, as house plot sizes are so small that individual facilities cannot be included within them (Patel and Hoffmann, 1993). The provision of communal facilities is also a defence against middle-class encroachment into the upgraded areas (ibid). Although the toilet blocks being developed by these three institutions include careful provision for adequate maintenance, it is generally rare for communal toilets to be so maintained. And overall, a considerable proportion of those judged by official government statistics (which then form the basis for the statistics of international agencies) to have adequate provision for sanitation do not enjoy such provision. For instance, in Accra, Ghana, there was a close relation between the prevalence of diarrhoea in children under six and the sharing of toilets (Songsore and McGranahan, 1993). Among the countries claiming that 80 per cent or more of their urban populations were served with sanitation in 1991 are Equatorial Guinea (95 per cent), Sierra Leone (92 per cent), the Sudan (89 per cent) and Jamaica (100 per cent) (WHOI UNICEF, 1993). These figures do not accord with detailed reports on levels of


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DAVID SATIERTHWAITE provision in the major cities in these countries. For instance, if 100 per cent of Jamaica's urban population is adequately served, how is this reconciled with a recent report for Kingston, Jamaica's largest city, that suggests that only 18 per cent of the population are connected to sewers, that 27 per cent have so~-awayp~t~: that 47 per cent use pit latrines and that 8 per cent say they have no sanitary facilities at all? A significant percentage of the population (especially those in low-income communities) defecate in open lots, abandoned buildings or into plastic bags that are then thrown into gullies. The sewerage system in the central city area is old and in need of repair. There are also frequent blockages as solid waste is disposed of down the manholes (Robotham, 1994). Many studies of illegal settlements and of other settlements with a predominance of low-income groups have pointed to the lack of health care or the very poor quality of any free services. Yet official statistics often claim that 100 per cent of the urban population is covered. Zambia, Pakistan and Egypt are among the countries claiming that 100 per cent of their urban populations have access to health care; Nigeria, Sierra Leone and Niger claim that between 86 and 90 per cent have access (UNDP, 1994). Again, it is difficult to believe that such a high proportion of their urban populations have access to adequate health care.

The health burden of poor quality housing The scale of the health burden imposed on people living in poor housing has probably been greatly underestimated. The inadequate provision of water, sanitation and drainage and the poor quality, overcrowded dwellings bring an enormous health burden. For instance, the incidence of diarrhoeal diseases in 1990 was about 200 times higher in sub-Saharan Africa than in the North (World Bank, 1993). Disease burdens from tuberculosis, most respiratory infections (including pneumonia, one of the largest causes of death worldwide) and intestinal worms are generally much increased by overcrowding (WHO, 1992). So too is the health burden from accidents in the home. Many accidental injuries arise from poor quality, overcrowded housing-not surprisingly considering that there are often four or more persons in each small room in shelters made of flammable materials and that there is little chance of providing occupants (especially children) with protection from open fires or stoves. But very few studies have examined the health burden faced by lowincome urban dwellers. One that did revealed a tremendous health burden faced by low-income groups in terms of work days lost to illness and injury and the dire economic consequences this brought in terms of increased debt and increased undernutrition for all family members (Pryer, 1989; 1993). Yet most of these health costs could have been prevented or much reduced (ibid.). Not only are adults and children in low-income urban households sick more often; the possibilities of a rapid recovery are much worse. It is difficult to imagine how parents within low-income households cope with the much greater incidence and severity of illness and injury-for instance with sick children when they lack such basic items as spare clothing and bedding for when a child's bedding or clothing become soiled, when there is no readily available water (preferably warm) for washing clothes and personal hygiene, and when there are no emergency health


THE UNDERESTIMATION OF URBAN POVERTY ix services on hand. It becomes even more difficult when no adult can afford to take time off work to nurse sick or injured children and when any purchase of medicines or payment to a health clinic means a serious loss of income or assets. In effect the

households in which adults are least able to take time off to nurse sick f~y

members and to pay for health care are often those households whose members are ill most often. In most instances, most or all of the burden of coping with sick or injured children falls on mothers or older girl siblings (Satterthwaite, Hart, Levy et aI., forthcoming). One reason why the health issues associated with poor housing have been generally ignored is simply that housing professionals have ignored them. Here, too, the inappropriate transfer of Northern experience to the South has often been an inappropriate legacy, since professionals concerned with the quality of housing in the North rarely have to cope with houses lacking piped water, sanitation and drainage. Most of the professionals and post-graduate courses that train housing and urban specialists for work in the South give little or no consideration to the health issues related to housing and urban development. Another reason is that the growing interest in environmental problems in cities of the South is also biased by Northern perceptions. For instance, because air pollution is such a significant problem in many cities in the North and also, perhaps, because it is relatively easy to measure, it is often given more attention in cities in the South than the inadequate provision of water, sanitation, drainage and health care. Yet it is these inadequacies that underpin most ill health, premature deaths and physical disability, not ambient air pollution (Hardoy, Mitlin and Satterthwaite, 1992; WHO, 1992). Ambient air pollution also receives more attention than indoor air pollution-although in most cities in the lower-income countries, the latter has a much more serious health impact in homes because of overcrowded dwellings with open fires or poorly vented stoves (ibid.). Insufficient recognition is given to the difficulty that a high proportion of parents face when trying to provide themselves and their children with a safe and healthy environment when housing conditions are poor, livelihoods are precarious, working hours are long, health services are lacking, and educational resources are limitedeven when some improvement has been made to water supply and, less commonly, to sanitation. This is especially the case when such improvements are mostly not to a standard and convenience that is the norm in the North and in most middle- and upper-income households in the same city. In addition, in an effort to reduce costs, both governments and international agencies often support the installation in lowincome neighbourhoods of water, sanitation and drainage systems that the households or the wider community has to manage and maintain. But there has been no trend towards asking middle- and upper-income groups to help manage their water supply networks, sewers and drains.

Conclusions If many of the national statistics on the proportion of urban populations lacking health care, water and sanitation are so faulty, this probably invalidates the many relevant comparisons made between rural and urban populations-although rural


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DAVID SATIERTHWAITE statistics may be as exaggerated as those for urban populations. Many other national or global figures also seem at fault-for instance, many of the urban statistics quoted

in the 1994 editions of the Human Deoelopment Report (UNDP, 1994) and the WarId DtfJelopment Report (World Bank, 1994) are not based on recent census data that is available but on estimates and projections based on older data. This in turn leads to a considerable exaggeration of the rate at which many countries are urbanising and of the rate at which the populations of most of the world's largest cities are growing. The new Global Report, drawing on recent census data, shows that the world will be less urbanised and far less dominated by 'megacities' by the year 2000 than has been assumed by most people to date (UNCHS, 1996). The need to give water supply, sanitation, drainage and health care a higher priority was also stressed in 1975 in the lead up to the first UN Conference on Human Settlements. Governments also committed themselves to a higher priority for water and sanitation at Habitat I in 1976. There is also no lack of innovative examples from the South that show how the problems described above can be tackled. An increasing number of governments recognise the limitations and inaccuracies of income-based poverty lines and are now using new measures of deprivation which seek to identify those with 'unsatisfied basic needs', and these include those living in poor housing with inadequate water supplies and sanitation (Minujin, 1995). It is also notable how many of the innovative projects that reached low-income groups with improved housing and basic services came from local NGOs or municipal authorities in the South, many implemented with no support from aid agencies. These include models for housing finance schemes for those whose incomes are too low or uncertain to allow them to obtain finance from the private sector; these often achieve better levels of repayment than those achieved by banks (ACHRIHIC, 1994). They include new ways through which governments work with low-income groups and their community organisations to improve housing conditions and health (see, for instance, Espinosa and Rivera, 1994; Guerrero 1995). In Latin America there also seems to be a new generation of mayors who are associated with the return to or reinforcement of local democracy and who are trying new approaches, showing a much greater concern for low-income groups and avoiding long-established paternalist approaches. The hope is that the small but increasing number of examples documented are not the exceptions to a rule but representative of a larger trend both in Latin America and elsewhere. The enormous failure to provide water, sanitation and health care and the huge health burden these impose on urban populations seem unmanageable when aggregated. But if these problems in each city and municipality can be addressed by more competent and accountable local authorities working with citizen groups, NGOs and other local participants, the problem appears more manageable. For most national governments this implies considerable changes in policy. It also implies fundamental changes in the approaches of most development assistance agencies, who currently give a very low priority to water supply, sanitation and primary health care and who channel very little support to municipal authorities, community-based organisations and NGOs (Satterthwaite, 1995). Yet it is the actions of these local actors over the next 20 years that will determine whether the City Summit in 1996 has any real impact.


THE UNDERESTIMATION OF URBAN POVERTY REFERENCES ACHRIHIC (1994), 'Finance and resource mobilization for low income housing and neighbourhood development: a worshop report', Pagtambayayong Foundation Inc., Philippines. CAIRNCROSS, S. (1990), 'Water supply and the urban poor' in J. E. Hardoy et ale (eds.), The Poor Die Young: Housing and Health in Third World Cities, London, Earthscan, 109-26. CAIRNCROSS, S., HARDOY, J. E. and SATfERTHWAITE, D. (1990), 'The urban context' in J. E. Hardoy et ale (eds.), The Poor Die Young: Housing and Health in Third World Cities, London, Earthscan, 1-24. CHAMBERS, R. (1994), 'Poverty and livelihoods: whose reality counts?' (overview paper prepared for the Stockholm Roundtable on Global Change), 22-24 July. ESPINOSA, L. and RIVERA, O. A. (1994), 'UNICEF's urban basic services programme in illegal settlements in Guatemala City', Environment and Urbanization, 6, 9-29. FERES, J. C. and LEON, A. (1990), 'The magnitude of poverty in Latin America' , CEPAL Review, no. 41, 133-51. GUERRERO V. R. (1995), 'Innovative programs for the urban poor in Cali, Colombia' in B. Bradford and M. A. Gwynne (eds.), Down to Earth: Community Perspectives on H ealth, Development and the Environment, West Hartford, Kumarian Press, 17-22. HARDOY, J. E., MITLIN, D. and SATTERTHWAITE, D. (1992), Environmental Problems in Third World Cities, London, Earthscan. LEONARD, H. J. (1989), 'Environment and the poor: development strategies for a common agenda' in H. J. Leonard (ed.), Environment and the Poor: Development Strategies for a Common Agenda" Overseas Development Council, New Brunswick, Transaction Books. MINDJIN, A. (1995), 'Squeezed: the middle class in Latin America', Environment and Urbanization, 7, 153-66. NGOM, T. (1989), 'Appropriate standards for infrastructure in Dakar' in R. E. Stren and R. R. White (eds.), African Cities in Crisis, Boulder, CO, Westview Press, 176-202. PATEL, S. and HOFFMANN, H. (1993), 'Homeless International, SPARC Toilet Block Construction, Interim Report', Homeless International. PRYER, J. (1989), 'When breadwinners fall ill: preliminary findings from a case study in


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Bangladesh' in 'Vulnerability: how the poor cope' , IDS Bulletin, 20, 49-57. PRYER, J. (1993), 'The impact of adult illhealth on household income and nutrition in Khulna, Bangladesht, E nvinmmmt tmd UrhlDlization, 5, 35-49. PUGH, C. (1995), 'The role of the World Bank in housing') in B. Aldrich and R. Sandhu (eds.), Housing the Poor: Policy and Practice in Developing Countries, London, Zed Books. ROBOTHAM, D. (1994), 'Redefining urban health policy: the Jamaica case' (paper presented at the Urban Health Conference), London School of Hygiene and Tropical Medicine, 6-8 December. SATTERTHWAITE, D. (1995), 'The scale and nature of international donor assistance to housing, basic services and other human-settlements related projects' (paper presented at the UNUIWIDER Conference on 'Human Settlements in the Changing Global Political and Economic Processes'), Helsinki, August. SATTERTHWAITE, D., HART, R., LEVY, C., MITLIN, D., ROSS, D., SMIT, J. and STEPHENS, C. (forthcoming), The Environment for Children, London and New York, Earthscan and UNICEF. SINNATAMBY, G. (1990), 'Low cost sanitation' in J. E. Hardoy et ale (eds.), The Poor Die Young: Housing and Health in Third World Cities, London Earthscan, 127-67. SONGSORE, J. and McGRANAHAN, G. (1993), 'Environment, wealth and health: towards an analysis of intra-urban differentials within Greater Accra Metropolitan Area, Ghana', Environment and Urbanization,S, 10-24. TABATABAI, H. with FOUAD, M. (1993), The Incidence of Poverty in Developing Countries: An ILO Compendium of Data, A World Employment Programme Study, Geneva, International Labour Office. UN (1995), World Urbanization Prospects: The 1994 Revision, New York, United Nations, Population Division. UNCHS (HABITAT) (1996), An Urbanizing World: Global Report on Human Settlements 1996, Oxford, Oxford University Press. UNDP (1994), Human Deoelopmou Report 1994, Oxford, Oxford University Press. WHO (1992), Our Planet, Our Health (report of the WHO Commission on Health and Environment), Geneva, World Health Organization. WHOIUNICEF (1993), Water Supply and

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ACKNOWLEDGEMENTS During much of 1994 and 1995 the author worked with UNCUS (Habitat) and a large network of scholars and practitioners in both the North and the South to prepare a global review of conditions and trends within the world's settlements. This is to be published in 1996 by UNCHS as An Urbanizing World: the Global Report onHuman Settlements. This paper draws from the preparatory process for this report although the views expressed do not necessarily represent the views of UNCHS or of any other UN agency. It also draws on the author's previous work with Jorge Hardoy and Sandy Caimcross and with WHO on the links between housing and health and his work with UNICEF on the environmental problems faced by children and their parents which was undertaken with Roger Hart, Caren Levy, Diana Mitlin, David Ross, Iac Smit and Carolyn Stephens.
