Today’s cities are expanding, often right before our eyes. You’ve probably seen it yourself — the new apartment building across the street or perhaps the expanding informal settlement downtown. We know it’s happening at a staggering rate. Over the next 35 years, 70 percent of the planet will live in cities and towns — up from 50 percent just four years ago. New apartments and new townhouses are being built, but sadly there seems to be no change in living conditions for far too many.
If current trends continue, 2050 will see 3 billion people living in overcrowded, unsanitary and structurally unsound housing — and that’s a conservative estimate from U.N.-Habitat and the World Bank’s Cities Alliance. In the “global south,” where most urbanization is occurring, an estimated 40 percent of people will be living in conditions that most of us would consider unsuitable. But are we powerlessly destined for this bleak apocalyptic implosion — as depicted in Mike Davis’ 2006 publication “Planet of Slums” — or can this seemingly insurmountable housing challenge spawn a new thinking? Densification, environmental heath, prosperity: Can development practitioners get to a place where we link these three?
Before I answer, let’s dispel a few common myths about slums.
1. Slums are a drain on a city/country’s resources. Yes, slums no doubt consume some very basic resources such as infrastructure improvements but let’s not forget that in sub-Saharan Africa, the informal sector from these communities account for a combined 42 percent of gross domestic product.
2. Privatization solves the slum improvement crisis. I, for one, worry about the overuse of the term “solution.” I think “strategy” — in the form of trying, observing and ultimately evaluating the impact of an intervention — is a more digestible term. Far too often, private housing developers are incentivized through government subsidies to adequately house the poor using “market-based solutions.” Examples like Mumbai, Nairobi and Rio show that developers are interested in rehousing residents since they can take over the land (in a prime location) and sell it at a higher market value. When such motives are prioritized and governments provide facilitating subsidies, the result is most often community backlash and the return of residents to original locations.
3. Treating poor housing conditions and/or relocating residents will eradicate or significantly decrease the burden of disease. If this were the case, I think the millions that have been forcibly evicted or transferred to more suitable housing would have all since seen long-term reductions in disease — clearly not the case. While programs that improve housing conditions for the poorest have the potential to deliver real health gains, the opportunities for meaningful impact have yet to be maximized. This has stunted the methodology needed to achieve real gains. It has also meant that the assessment criteria for measuring success have become fundamentally flawed.
So what are these opportunities, methodologies and more robust assessments? Not surprisingly, they all first require a fundamental shift in the paradigm about how governments and ultimately aid agencies, local companies and communities view the dual challenge of health and living conditions. My own survey of more than 136 central government ministries in the “global north and south” has yet to unearth a centralized department or ministry operating nationally with a joint portfolio of health and housing. While at a glance, these portfolios appear diametrically opposed and deserving of their own budgets, mandates and outcomes — the current setup is akin to viewing a 21st century challenge through a 19th century lens.
Governments in such environments need to wake up to the realities in which they govern. The approach of countries (United States included) spending upward of 15 percent of GDP on health care delivery is — as the Global Fund to Fight AIDS, Tuberculosis and Malaria and others have declared — unsustainable. Health care delivery can be wasteful in situations where children are being treated for diarrhea-related illnesses resulting from at-risk living environments. One World Bank study in Mexico showed that children in homes with dirt floors are 45 percent more susceptible to parasitic diseases. Government ministries ought to do more in advancing the understanding of this interconnectivity.
Several precedents already exist in support of it — the Human Development Index and the more recent Multidimensional Poverty Index shine light on the impact borne by poor living standards and poor health. Close scrutiny reveals that five of the six MPI components listed as measure of living standards — floors, cooking fuel, electricity, sanitation and water — are all directly related to treating or spreading the deadliest disease burdens faced by most countries in the “global south.” A failure to seize the opportunity to understand and combine the health and housing sectors has meant that so many across the globe are not maximizing the resources afforded to them.
This takes me to methodology. It is here that key failures can be seen as deliberate or hugely shortsighted. Most practitioners broadly recognize that improving living conditions yields direct and unintended benefits for residents. To achieve specific health gains, however, the approach needs to be SMART: specific, measurable, achievable, reliable and time-based — and I would add attractive. In the field of design, nuances and specificity already implicit in the design process can help us achieve the kind of measurable health gains we are seeking.
Current methodologies for housing improvement, or more popularly slum upgrading, use what I and former colleagues at the World Bank call a “developer-driven” model to impact: success is measured simply by the number of houses built, roofs replaced, families relocated or additional rooms built. This sets the scene for a rapidly deployed impact-hungry stakeholder assessment which most often sees or measures value as the real, the tangible, the built, when in fact, a better approach uses what is built to measure longer-term gains. Reductions in diarrhea-related deaths are linked to unsuitable sanitation and household plumbing; respiratory-related deaths are linked to poorly designed cooking areas.
Designing projects that put these links at the heart of implementation requires time, site-specific approaches and a sympathetic set of country officials and community members. I spend my days working in this interstitial space between delivering housing improvements and achieving health gains. My vision and that of our organization is that our resource-limited future will drive innovative approaches in also appropriating housing improvement as a key delivery strategy for achieving health gains among the poor.
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