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Kumars Khosh-Chashm

The countries of the Eastern Mediterranean Region are experiencing rapid urbanization. Cities and local authorities have limited resources and cannot provide essential services. Also, many rural communities suffer from a lack of proper environmental facilities. The traditional approaches, where cities and local authorities are expected to provide and maintain all services, are failing. "Healthy Cities" and "Healthy Villages" concepts provide a unique opportunity for people and authorities to build a partnership to overcome their problems. This paper examines the problems of rapid urbanization, explains the "Healthy Cities" and "Healthy Villages" concepts and shows why they provide an effective strategy for overcoming the problems in urban and rural areas of the Region.

Introduction

Healthy cities are clean and have good health and environmental services. They are safe, and people can live in them comfortably with their own social bonds, beliefs, customs and lifestyles. As Dr H. A. Gezairy, the Regional Director of WHO's Eastern Mediterranean Region (EMR), has stated [1]:

It is not surprising that people are emotionally involved with their native place. A city or village is not a mere geographical location; it is not simply a collection of buildings, shops and streets: it is the embodiment of its inhabitants' social and physical environment, the mark of their particular architectural forms and past expressions, a place of human bonding, culture and spiritual heritage. These are very deep roots that tie people to their "home town" and feed their civic pride as well as their sense of civic responsibility. These strong bonds are the main resources to draw upon in order to mobilize the collective actions that are needed to overcome urban problems.

The Eastern Mediterranean Region is facing rapid urbanization, and this has caused severe health and environmental problems in its cities. With this and the above in mind, the WHO/EMRO Healthy City and Healthy Village programmes have been developed to strengthen cities and local authorities and enable them to tackle health and environment problems.

This paper examines the problem of rapid urbanization and tries to demonstrate why the "Healthy City" and "Healthy Village" concepts provide an effective strategy to overcome the problems in all areas, urban and rural, of the Region.

Urbanization in the Region

Rapid population growth, which has led to accelerated urbanization, has contributed to the deterioration of the health and environmental status of many cities in the Eastern Mediterranean Region [2]. Countries in the EMR have varied urban growth rates. As Fig. 1 suggests, for the least-developed countries of the Region the rate of urban population increase is comparatively low. In contrast, in the richer countries the increase is very high [3]. Both total and urban population growth rates in the Region are high. Of the 24 countries in the world with an average annual population growth rate of 3.5% or more, 12 are in the EMR. Average growth rates as high as 7.5% have been reported for one of the Region's cities-Giza, on the outskirts of Cairo [2].

Many cities and national authorities do not have sufficient funds and suffer from institutional weaknesses. Consequently, the cities cannot provide a timely response to population pressure and rapid urban growth. The result is an unplanned and haphazard urban sprawl with defective and insufficient services. Another problem is that people are not involved in the planning and management of their towns. They expect the municipal authorities to do everything and provide proper services and control city expansion. The problem of rapid urbanization is not only unplanned physical growth, it can have an adverse social, cultural, and even spiritual impact on people's lives.

Health and environmental status of cities

The health status of people in cities depends on their economic level. The urban poor are most affected by the health hazards of urban life. They suffer from communicable diseases, malnutrition, high maternal and infant mortality, poor housing and often, a lack of access to health care services. In the meantime the urban rich are affected by diet-related problems such as obesity and their sedentary lifestyle -"diseases of affluence" such as diabetes and cardiovascular disease become more prevalent. Also in cities, both rich and poor are subject to stress and psychosocial problems [2,4].

In many cities in the Region, squatter settlements and shanty towns have grown rapidly, and green areas and agricultural lands around cities have eroded or have been destroyed. Many cities suffer from congestion, air and industrial pollution, and inadequate sewage and solid waste management systems. In some, the cost of water supply and sanitation has escalated to be among the highest in the world. Most cities suffer from shortages of adequate housing, because urban land and housing prices have risen above the affordable income range of the average person [2].

Urban health services have a strong curative instead of a preventive bias. Environmental health services suffer from severe institutional and human resources shortcomings. Problems are more acute in the secondary cities where municipal authorities lack funds and machinery to run services [2].

The above picture does not reflect of the status in all cities of the Region, however. In countries such as the United Arab Emirates, Bahrain, Saudi Arabia, Kuwait, Qatar and Cyprus the municipal services work properly and are in excellent condition. Similarly, some cities in Jordan, Tunisia and the Islamic Republic of Iran enjoy effective municipal management.

Objectives

Basic objective

The basic objective of the Healthy City programme in the EMR is to improve the health of urban dwellers, especially in poor areas, giving priority to the upgrading of health services and environmental conditions in the cities [1].

Secondary objectives

1. Increased awareness of health and environmental issues in urban development efforts.
2. Political mobilization and community participation to prepare and implement municipal (city-wide or local) health and environment actions and projects, ideally and whenever feasible, through the development of a systematic city health and environment plan.
3. Increased capacity of the municipal government to manage urban problems using participatory approaches [5,6].

Healthy City approaches

Healthy City action does not replace, take over or interfere with ongoing health and environmental activities undertaken by different government and municipal agencies. On the contrary, it tries to generate local and community support to help ongoing activities. Furthermore, Healthy City action aims to connect and coordinate related activities to achieve better practical coordination.

Healthy City approaches and actions have six characteristics in common.

1. They are based upon a commitment to health and the environment.
2. They stimulate political decision-making to support health and the environment.
3. They generate intersectoral action.
4. They emphasize community participation.
5. They work through innovation.
6. Projects are "setting specific", i.e., school, workplace, neighbourhood. They aim to improve the overall health and environmental conditions of such settings in an integrated fashion [6].

The focus of the Healthy City concept is the development of healthy public policies, which may be defined as those which attach importance to health as a goal of development. All agencies concerned with energy, food, agriculture, macroeconomic planning, industry, education, housing and other areas, should examine the health implications of their policies and programmes, and adjust them to better promote health and a healthy environment. It is important for governments to formulate urban environmental policies and plans at all levels and integrate environmental considerations into all urban development planning efforts. Policies for land use, traffic and transportation that support health and the environment provide a vital context to support individual projects in these areas [7].

Healthy City progress in the EMR

The Healthy City action in the EMR started in 1988, following the Healthy City Programme in Europe. The basic strategy of Healthy City in the EMR was framed during a major conference in Cairo in November 1990. Since the Cairo conference, the Healthy City concept and action have progressed rapidly. Extensive projects and activities have been launched in many cities in Iran, Tunisia, Pakistan and most recently in Cyprus [8].

In collaboration with the Arab Urban Development Institute (AUDI), Dubai Municipality, the Health Committee of the Gulf Cooperation Council (GCC) and the WHO Regional Office for the Eastern Mediterranean (EMRO), the first Healthy City conference in the GCC countries was held from 26 to 28 November 1994 in Dubai. The Conference recommended that WHO and AUDI should collaborate closely for further development of the Healthy City programme in these countries [9]. Plans are under way to start the programme in Kuwait, Oman, Saudi Arabia and the United Arab Emirates. Furthermore, WHO staff have been active in Morocco and the Republic of Yemen in the formulation of proposals to start Healthy City programmes.

The second WHO/EMRO Healthy City Conference was convened in Hammamet, Tunisia, from 21 to 25 June 1994. The Conf-erence, which was attended by participants from 12 countries, recommended that WHO/EMRO should expand activities and provide more material and resources for the programme. Projects and proposals have been prepared, and action has been taken to secure funds for the expansion of the programme [10].

Organization of Healthy City projects and activities

A Healthy City action starts with three or four interested individuals who approach the municipal and government authorities and the international agencies. This group in collaboration with the municipality and the health and environment sectors establishes a "partnership task force". This task force appoints at least one full-time coordinator who will be in charge of the day-to-day activities of the project.

The other main functions of the task force include:

leadership and political support for the development of projects

development of a Healthy City work plan, projects and activities

support for approval of Healthy City projects and municipal health and environment plans

resource mobilization

encouraging community groups to become involved.

The members of the partnership task force could be city councillors responsible for social services, senior managers of the Primary Health Care system, representatives of community groups, the mayor, concerned university departments, representatives from business, industry, labour and professional bodies, NGOs and religious leaders [7,11].

Mobilization of Healthy City activities

The partnership task force, either through the development of a Municipal Health and Environmental Plan (MHEP) or based on a set of specific pressing priority problems, develops Healthy City projects and work plans.

Expected Healthy City outputs

Improved environmental health services and conditions in the city. These include water supply, sewerage, solid wastes, pollution control, green areas, housing, etc.

A strong promotional process, which focuses on health and environment, is developed.

The role of women and the needs of children are promoted.

Health and environment institutions in the city are strengthened.

Networking and information exchange is established.

NGOs, universities and interest groups are involved.

Resources are mobilized.

A closer link and contact between environmental health programmes, urban primary health care, nutrition, care of the elderly, accident prevention, women and child health, mental health, etc., are established.

Healthy Village

Healthy Village as a concept was first proposed by WHO/EMRO in 1989, in a Technical Consultation on Urban Environmental Health, which was held in the WHO Regional Office in Alexandria, Egypt [12]. Healthy Village is a holistic approach intended to address the critical environmental health problems in rural areas.

Environmental status of rural areas

In the past one or two decades in rural areas, environmental health activities have focused almost entirely on water supply and sanitation. In spite of major efforts during the International Drinking Water Supply and Sanitation Decade (IDWSSD) 1980-1990, many rural populations in a number of countries in the Region still do not have adequate access to sufficient and safe water. Rural sanitation coverage is low; it is believed that the lack of latrines and open defecation around villages contribute heavily to infant mortality and morbidity.

The health of rural populations, and especially of children, is adversely affected by lack of solid waste collection and disposal, improper housing of animals, sullage and stagnant waters, dust, lack of sufficient water for bathing and washing and the unhygienic conditions of local food markets. Unhygienic food preparation, food storage and water storage are also factors in the poor health status of rural populations.

These problems are further compounded by poorly constructed houses, which allow growth and infestation of pests, including rodents. Such houses do not provide proper insulation against heat and cold, and in the colder countries of the Region, lack of proper heating and ventilation has a major impact on prevalence of upper respiratory diseases in rural areas.

Biomass fuels (wood, crop residues, manure, coal, etc.) are extensively used in some countries of the Region. These fuels are mostly burned under primitive, inefficient conditions producing a heavy load of indoor pollution, which is harmful to health. The most important known adverse effects are various forms of respiratory diseases. In the Eastern Mediterranean Region up to 70 million people may be using biomass fuels and may suffer from their adverse health effects.

The improper use, handling, and storing of pesticides for agricultural and vector control also brings harm to the health of agricultural workers and their families [13].

Healthy Village approaches

The Healthy Village concept has been developed to address the above environmental and other related health and social issues in an integrated fashion. In view of the importance of the interrelation between economy and health, the Healthy Village concept has further evolved to include employment and income generation. Similar to the Healthy City approaches, Healthy Village actions try to facilitate and not duplicate and interfere with ongoing development activities.

Healthy Village approaches have the following characteristics in common.

They aim to promote and mobilize health and environmental measures and considerations at the village and the local levels.

They aim to facilitate collaboration between health and other sectors at the local level.

They aim to raise community awareness and standards of health and hygiene education.

They place a high priority on improving environmental services (water supply, sanitation, village cleanliness, etc.).

They aim to stimulate and strengthen local-level decision-making, community initiatives and participation, and resource mobilization.

They encourage and promote the use of appropriate technology and local know-how [14].

Healthy Village activities

The Healthy Village concept may include the following.

Forming a village committee, made up of villagers, to oversee activities and mobilize the community and facilitate their participation and contribution.

Forming a compatible committee at the district or provincial/governorate level, represented by the district or provincial local authorities and agencies, to support village-level activities.

Conducting diagnostic surveys with full community involvement to identify the priority problems and available resources.

Raising community awareness and conducting health and hygiene education.

Improving the water supply and sanitation systems, solid refuse collection and disposal, and food safety.

Evaluating housing conditions and providing advice for the improvement of houses.

Training the locals in "do-it-yourself" house building that takes into account appropriate health and environmental considerations.

Surveying the economy and identifying/creating employment opportunities through local-level income generation activities.

Trying to maintain the natural ecology of the village and beautifying the surroundings by planting trees and flowers, draining stagnant or septic waters, maintaining roads and pathways, etc. [14].

In the Islamic Republic of Iran, before the concept of the Healthy Village was put forward by WHO/EMRO in 1989, a dynamic and extensive rural environment programme, covering all the country, had been in existence since the mid 1980s. Under this programme, which is now known as the Healthy Village, remarkable progress has been achieved. The programme, which is executed by the Environmental Health Directorate General in the Ministry of Health and Medical Education, works within the Primary Health Care (PHC) system. The operation of the programme at the village level rests mainly on the PHC worker, known as the behvarz. But the main technical support is provided by the engineers and technicians at the Ministry of Health [15]. The Iranian programme can serve as an example for other countries.

In Egypt a successful project with UNDP funding has been completed. The project was concerned with water supply and sanitation, information and appropriate village-level environmental technology. The next phase of the project, which is more comprehensive, has been approved and started operation. This phase, in addition to the components of the previous phase, contains housing, income generation and employment [14,16] elements. The Healthy Village concept has been adopted in Oman, and activities have been initiated in two wilayats.

Evaluation

Evaluation is an integral and ongoing part of the Healthy Village and Healthy City programmes. Reports are provided every six months to inform all participants of current activities. Two types of tools are used for the evaluation process: "process type indicators" and "outcome measures". While the emphasis is on the process type indicators as measures of project implementation and effect, outcome measures are nonetheless encouraged in all projects.

Process type indicators monitor activities such as the development of a plan, the formation of a task force, the formulation of a project, etc. Outcome measures often take a longer-term perspective, but some measures might change during the activities' span. Such measures might include the rate of water supply coverage, sanitation coverage, hospital bed coverage, etc. [7].

The Role of WHO/EMRO

Since the start of the Healthy City programme, WHO/EMRO has assisted in promotion of the concept among governments and municipalities. It has also provided limited resources and facilities for mobilization of city level projects and country action [8]. WHO/EMRO works through Healthy City coordinators and ministries of health and provides the following support:

development of promotional material and technical guidelines

provision of limited support for country and city level meetings

provision of consultancy support and development of technical projects and programmes

development of project proposals and support for securing external assistance

holding of intercountry meetings and conferences

establishment of a regional network and facilitating twinning of cities and contacts with other regions

dissemination of information, technical manuals, papers, publications, etc. [5].

Conclusions

Cities and national authorities have to work with limited financial and material resources and are thus unable to provide adequate services and health and environmental safeguards in cities and villages. A new approach is needed: people must collaborate closely with the authorities in helping to upgrade life in both urban and rural settings. The Healthy City and Healthy Village programmes aim to improve environmental and health conditions by raising public awareness and by mobilizing community activity, thus providing an excellent opportunity for people and local authorities to come closer together. Hence communities can strengthen their capacity to deliver effective environmental and health services. A priority objective is to develop the role of local governments in public health and to encourage them to implement a "Health for All" policy at the city and village levels.

Through Healthy City and Healthy Village programmes, local people can solve their basic needs based on the level of resources that can be mobilized while respecting their culture and the requirements of health and environmental protection.

Both Healthy City and Healthy Village approaches, as has been shown, bring about effective intersectoral collaboration at the city and local levels. This is critically important since city and village health and environmental problems have a multifaceted nature and require close collaboration and coordination between all the players, from the national authorities and nongovernmental organizations up to the individuals themselves.

The goal for better health for all requires making the whole environment-the physical environment, and the social and economic environment-supportive to health rather than damaging to it. Healthy City and Healthy Village programmes are holistic and take into consideration the settings, such as the home, workplace, neighbourhood, schools, marketplaces, etc., where people live and work. This is where the Healthy City and Healthy Village concepts are most effective.

"Healthy public policies" at the municipal and business levels provide a framework for healthy lives and momentum for continual improvement. Healthy City and Healthy Village programmes measure not only the "health burden" of development activities (e.g., looking at the deleterious effects of industrial development, mining or farming) but also recognize "health opportunities" presented by development programmes. These development activities, such as housing or industrial development, can enhance the health status of the population if health promotion and development measures are incorporated into their planning and implementation [7].

References

1. Report of the Intercountry Healthy Cities Conference, Cairo, Egypt. Alexandria, Egypt, World Health Organization Regional Office for the Eastern Mediterranean, 1991 (document WH-EM/ES/414).
2. The importance of urbanization on health. Alexandria, Egypt, WHO/EMRO, 1992 (Technical Discussions; EM/RC 39/Tech.DISC./1).
3. World population prospects. New York, United Nations, 1990.
4. Tabibzadeh I, Rossi-Espagnet A, Maxwell R. Spotlight on the cities. Geneva, World Health Organization, 1989.
5. Healthy Cities initiatives and programme. Draft brochure. Alexandria, Egypt, WHO/EMRO, 1994.
6. Draft guidelines for development of the Healthy City project and activities in the Eastern Mediterranean Region. WHO/EMRO, 1994.
7. Goldstein G. Integrated health and environment management in cities, the role of healthy cities project. Paper prepared for the second EMR Healthy Cities Conference, Hammamet, Tunisia, 21-25 June 1994. Geneva, World Health Organization, 1994.
8. The Work of WHO in the Eastern Mediterranean Region. Annual Report of the Regional Director 1994. Alexandria, Egypt, WHO/EMRO, 1994.
9. Conclusions and recommendations of the first Healthy City Conference in the Gulf Countries, 26-29 November 1994, Dubai, United Arab Emirates. Arab Urban Development Institute in collaboration with WHO/EMRO and Municipality of Dubai.
10. Report of the second WHO/EMRO Healthy Cities Conference, Hammamet, Tunisia. Alexandria, Egypt, WHO/EMRO, 1994 (document WHO-EM/PEH/466/E/L/07.94/115).
11. Twenty steps for developing a healthy cities project. World Health Organization, Regional Office for Europe, 1992.
12. Report of Informal Consultation on Urbanization and Environmental Health in relation to the Healthy City Concept, Alexandria. Alexandria, Egypt, WHO/EMRO, 1990 (document EM/ES/405-E).
13. Environmental health in rural and urban development and housing. A collaborative framework and strategy for WHO technical cooperation in the Eastern Mediterranean Region. Alexandria, Egypt, World Health Organization Regional Office for the Eastern Mediterranean, 1990.
14. Employment and sanitation in Healthy Villages, Egypt. UNDP/WHO Project Document.
15. Healthy Village in Iran. A 20-minute video film by the Ministry of Health and Medical Education, Islamic Republic of Iran.
16. Reports on Design and Construction, and Operation and Maintenance and Performance Monitoring of M.T. Mazah and El Nazlah Ponds, Drinking Water Supply and Sanitation Sector Support Project in Egypt. Alexandria, Egypt, WHO/EMRO, 1992 (UNDP: EGY/82/002; WHO: EGY/CWS/001).