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An Analysis of Health and Wellbeing in a Rapidly Urbanising Environment:
The Urban Hanoi
COPD – Chronic Obstructive Pulmonary Disease
LMIC – Low-middle-income Country
NCDs – Non-communicable Diseases
O3 – Ground-level Ozone
TB – Tuberculosis
WHO – World Health Organization
Urbanisation and the Global Perspective
Cities make up a crucial part of the societal fabric of countries(1). They provide opportunities for employment, education, cultural enhancement, hope for a better life, improved health outcomes, and contribute to national and regional economies worldwide(1). Over half of the world’s human population now reside in urban cities(1, 2), with that proportion predicted to continue rising(2). The percentage of the global population living in urban areas increased from 32% in 1955 to 38% in 1975 and 45% in 1995(1). From 1995 thru 2005, the urban population in low-middle-income countries(LMIC) grew by approximately 1.2million people per week (165,000 people per day)(3). By 2030, the World Health Organization(WHO) estimates that 60% of the world’s population will become city dwellers, with those projections increasing to about 70% by 2050(3). “The world is rapidly urbanizing with significant changes in our living standards, lifestyles, social behaviour and health,” says Dr Jacob Kumaresan, director of the WHO Centre for Health Development, Japan(3).
Rapid Urbanisation in South East Asia
South-East Asia is progressively urbanizing(4, 5). In 1950, 16% of its population lived in urban areas, which increased to 42% by 2010, an incline of about 250 million people, with the percentage of urban dwellers in the region anticipated to reach 50% by 2025(4, 5). The urban population growth rate within South-East Asia is approximately 2.2% per year, with the growth rate among the least urbanized countries in the region being much higher (Timor-Leste 5%; Lao 4.8%; Cambodia 3.2%)(5). By 2050, all countries in the region will have a majority of their population living in urban areas(5).
Urbanisation and economic development in general mutually reinforce one another, with the most urbanized countries being the most economically developed(4, 5). The same holds true in South-East Asia(4, 5). The most economically advanced countries in the region (Singapore, Malaysia and Brunei) report urbanisation levels over 65% with the least economically developed countries (Cambodia, Myanmar, Timor-Leste and Vietnam) reporting urbanisation levels less than 34%(5). The increase in urban inhabitants occurs in correlation with the region’s economic growth, with urban cities connecting to global markets and becoming major economic centres(5).
Urbanisation: The Vietnamese Context
Vietnam is presently facing one of the world’s most accelerated urban transitions(6). In the past three decades, Vietnam has emerged from one of the poorest countries in the world to the third fastest developing economy in South-East Asia and the fourth worldwide(7). Over the next decade, its cities and towns are anticipated to grow at a rate of 7% per year, increasing the nations urban population from one-third to one-half(6). The capital city Hanoi is one of the key sites for this urban transition(6). While the aspect of this transition has improved individual living standards, much of the changes also pose negative impacts on overall quality of life, particularly for poor and vulnerable populations like children and the elderly(7).
The Vietnamese government recognize that growth in Hanoi and cities alike is vital to the national shift from agriculture to manufacturing services, to increase the nation’s gross domestic product and improve the lifestyle and well-being of the country’s population(6). However, the rapid growth in populations and activities in and around cities places immense pressure on the local leaders to maintain the escalating demands for infrastructure, housing, social services, public facilities and environmental controls(6). So, while there is consensus on the benefits of urbanisation, concerns on the burdens resulting from the urban progression and the importance of anticipating and addressing them are also raised by foreign academics and decision-makers(6).
The process of Urbanisation in Vietnam
In Vietnam, the process of urbanisation can be divided into two categories, planned urbanisation (i.e. city centres) and spontaneous urbanisation (i.e. slums)(6). While urbanisation is very important for large cities like Hanoi and Ho Chi Minh, the central state has embarked on a large-scale urbanisation plan since 2000, to foster economic growth(6). This has led to the transformation of agricultural land into ‘urban’ land for industrial and housing development and the re-establishment of slum areas, displacing slum dwellers into public housing(6). Whether planned or spontaneous, urbanisation has vast consequences for the local communities (i.e. displaced farmers, slum dwellers or new migrants)(6). In all cases, communities are faced with various challenges; finding new livelihood (employment, housing, access to food), competing for scarce resources from rural to urban dwellings, adapting to changing environments, infrastructure development and regulatory frameworks(6).
Current Urban Development Trends in Hanoi
In the 1990s, Hanoi went through a transition, transforming from a city of walking and cycling to motorized transport(7). Concurrently, the city evolved from a place where people lived and worked in the same space, to a city where homes are separate from workplaces(7). Over time, the city’s skyline is swiftly shifting from a city of low buildings to one of high rises(7). The previous urban fabric with which residents identify with is vastly being replaced by a ‘modern city’, one unfamiliar to its citizens(7). Peri-urban spaces, better defined as spaces of transition are now a common sight in visualizing and understanding urbanisation in Vietnam and its socioeconomic and political transitions(6). These peri-urban spaces function as a bridge between the traditional rural environment that once dominated the economic and socio-cultural fabric of the country to the new megacity and global market that it aspires to be(6). So this raises the following questions, how are populations impacted by these rapid social, environmental, cultural and economic transformations affecting their everyday lives?
Health and Wellbeing in the Changing Urban Environment
Cities are an important determinant of the future sustainability of human health and wellbeing(2). According to the WHO, although “urban living continues to offer many opportunities, including potential access to better health care, today’s urban environments can concentrate health risks and introduce new hazards”(3). The health risks linked to urban milieu are diverse(2). Many cities now face various health threats like infectious diseases that stem from crowded populations in substandard housing conditions(2); severe and chronic diseases associated with industrial pollution(2); an increase in non-communicable diseases(NCDs) (COPD, diabetes, cancers) from unhealthy urban lifestyles (physical inactivity, unhealthy diet, tobacco and alcohol use)(2, 3); injuries from motorcycle and vehicle accidents; violence, crime(2); and environmental and climate change(2).
Urbanisation and NCDs
NCDs cause millions of deaths globally, with most casualties occurring in LMIC(8). With the rapid urbanisation in Vietnam, it suffers the double burden of current incidences of communicable diseases and an increase of NCDs(8). Between 1970 – 2013, Vietnamese ministry of health reported a decrease in the percentage of communicable diseases by 56% while NCDs increased by 64% in the same time period, concurrent with the urban development boom in Vietnam(8). With the incline of NCDs, it has put a strain on the healthcare system. A study testing urban commune health stations capacity to respond to NCDs in Hanoi, found them to be unequipped to respond to the rising prevalence of NCDs, due to the limited workforce, budget, little to no NCD services and treatments at the commune health stations(8). Urban commune health stations are the closest healthcare service to the communities in Vietnam but also the lowest level in the health system(8), making it difficult to adequately combat NCDs in urban Hanoi.
The Spread of Diseases: Rural to Urban Migration
Rapid urbanisation has substantial implications on population health. The rising movement of individuals from rural to urban regions alters the epidemiological disease profile of a country as new diseases form and old ones re-emerge(9). This has been the case of tuberculosis(TB), malaria and HIV/AIDS(3). Urbanisation has also led to changes in diet and exercise habits, increasing the prevalence of obesity, diabetes and cardiovascular disease(2, 3, 9). While many migrants tend to be young and in healthy conditions, when they arrive in cities, they are often subjected to poor and overcrowding conditions, increasing their incidence of diseases like typhoid fever, malaria and respiratory diseases(9). In recent years, TB has presented high infection rates in major cities, with 83% of TB infected individuals living in cities(3).
High rates of sexually transmitted diseases, including HIV/AIDS, are now prevalent in migrants(9). As they are highly mobile, they often spread the virus when they return back to the rural, village or countryside, where health services are inadequate to combat infections as they are in the cities(9). Much migrant health issue result from unfamiliarity with and lack of access to existing health services(9). In Vietnam, migrants workers health coverage in their rural hometowns do not function when they migrate to urban cities like Hanoi. As a result, the high medical costs in cities make them reluctant to go to the hospital and seek medical attention when needed(9).
Urbanisation has also impacted vulnerable populations in cities. Children are particularly susceptible to disease when they live in an environment that is overpopulated, in poor hygiene, with high noise pollution, and lack space for recreation and study(9). The strong and undesirable impacts of urbanisation also affect the elderly their independent mobility, access and utilisation of quiet spaces for socializing and leisure(7). These groups bear not only the unfavourable physical environment but also the stressors associated and from other factors like the violence, such an environment creates(9).
Crowded urban cities, combined with poor sanitary surroundings and insufficient waste disposal bred conditions for the spread of infections and becomes a risk factor for diarrheal and parasitic diseases(9). Given the outcome urbanisation can have on health, it is essential that health considerations play a vital role in urban planning and policy making, as the negative burdens are placed on the poor, migrants, and marginalised.
Air Pollution in Urban Hanoi
A common negative feature of congested urban areas is air pollution. Common air pollutants include particulate matter (PM10 and PM2.5), ground-level ozone (O3), and carbon monoxide (10, 11). The poor air quality is commonly attributed to solid particles, dust or allergens suspended in the air, industrial plants and refinery wastes, motor vehicle emission, wood burning and bushfires(10, 11). Due to the vast population in urban cities, air pollution has been known to result in cardiovascular and respiratory diseases (i.e. asthma, lung cancer)(10). When exposed to poor air conditions for a prolonged period, city dwellers can experience harmful health effects like loss of lung capacity, become more susceptible to various respiratory ailments, and a shortened life span(10).
The WHO reports that urban air pollution kills approximately 1.2 million people annually, mainly due to cardiovascular and respiratory diseases(3). In LMIC, motor vehicles, generators and household fuel combustions are major contributors to urban pollution(3). In Hanoi, there has been a correlation of high O3 to hospital admission for respiratory diseases(12). Among all air pollutants, O3 is the most prominent, exceeding the limits in many parts of the world, including South-East Asia(12). Acute exposure to high levels of O3 can elicit chest pain, throat irritation, cough and wheezing, with regular exposure resulting in poor lung function and growth(12). The rapid urbanisation and economic expansion in Vietnam have been associated with high levels of O3 in the country with the main contributor in Hanoi being vehicles, crop burning in suburban areas, fossil fuel power plants(12).
Accidents and Injuries
The rapid motorization of Hanoi has become dominated by motorcycles as the main source of transport(6, 7). It enables one to commute faster, do business, work and generate income(7). Since its initial introduction to Vietnam, the motorbike has become a symbol of personal mobility, an asset and one of the most convenient means of transportation in a Hanoi, a city where its urban framework is dominated by narrow alleys(6). Motorbike ownership in Hanoi has reached high rates, with 80% of households owning a motorbike and 40% of households owning at least two motorbikes(6).
The encumbered and weak traffic network in Hanoi is bearing increasing infrastructural pressure(6). The road system and structure represent less than 7% of the land area, compared to 15% in most European cities and 11% in China’s large cities(6). As a result, the streets of Hanoi have become overcrowded and at rush hour traffic can come to a standstill(7). Over the last 10 years, travel speed and time in downtown Hanoi have worsened by traffic congestion and longer travel distances(6). The slow progression in road development, disorderly driving style, lenient traffic law enforcement and rising traffic congestion has resulted in an increase in transport cost, air and noise pollution and accidents(6). Road traffic injuries are the ninth leading cause of death globally, with most road traffic death occurring in low-middle-income countries(3). About 50% of casualties in road traffic accidents are among pedestrians, cyclist and motorbike users(3). In Vietnam, road traffic accident kills approximately 14,000 people (aged 15 – 29 years) per year, with motorcyclist accounting for over 50% of the fatalities(13).
Lack of Public Space
Hanoi is well-known as one of the most overcrowded cities in the world(6). In 2008, the human densities in the urban regions averaged 272 persons per hectare and reached up to 404 persons in the city centres, compared to 370 persons in Hong Kong, 86 in Paris and 62 in London(6). Such high human densities put pressure on the city to provide public spaces for people to engage, interact socially, exercise, escape the traffic, pollution and enjoy the environment and green space(6). Hanoi can hardly meet the demands of its residents for public space. Recreational areas especially are inadequate to serve the urban communities(6). Urban parks account for just 0.3% of the city’s land, representing just less than 1 m2 per person(6). Present parks are unevenly distributed across the city and are inaccessible for youths and the elderly(6). About 50% of Hanoi’s citizens are not within walking distance to a park from their homes, while current public spaces offer few recreational options to users(6). Instead, urban public spaces in Hanoi, are mostly designed with lakes and flowerbeds which hardly meet the populations growing demand for spaces to socialize and for recreational activities(6).
The lack of formal spaces and easily accessible urban public parks have been compensated by informal adaptive use of sidewalks and street spaces in Hanoi for an array of activities including domestic, social, and recreational uses(6). However, the most regulated informal spaces in Hanoi is not a permanent solution and is not match to the safety and accessibility of public parks and recreation centres where citizens are free from traffic, air pollution, and can interact with the community(6).
Physical Inactivity and Diet
The removal of public spaces where people can exercise and the transition from active transportation (walking and cycling) to passive (motorbikes) had declined population physical activity impacting population health(7). Urban environments often incite physical inactivity and an unhealthy diet(3). Engaging in physical activity is discouraged by urban factors like over-crowding, heavy traffic, poor air quality, lack of safe recreational spaces(7). Moderate levels of physical activity are essential to public health as it reduces risk factors for chronic diseases and obesity by 50 per cent(7). A common phrase in Hanoi is “people here don’t like to walk”(7), however, a more appropriate phrase is the city is not designed or conducive for physical activity. While physical activity is essential for health and well-being, it is far easier in a supportive environment(3).
In addition to physical inactivity, poor diet is another way urbanisation impacts population health, a double burden many faces in urban dwellings(10). Urban cities like offer access to quick, easy and cheap food that often unhealthy containing large amounts of sodium and sugar(10). The constant consumption of low-quality fast food attributes to diabetes, hypertension, heart disease and obesity(7, 10). The lack of exercise and in combination with an unhealthy diet becomes detrimental to one’s health(10).
Combating Negative Health Outcomes of Urbanisation: The Interdisciplinary Approach
How can we develop a liveable and healthy city without the negative aspects of urbanisation? There is no one method or solution, however, the approach should address urban design and planning, supporting urban development with a public health perspective(7). Developing an urban environment that is low-stress, safe, low in traffic, injuries, and crimes, green, and encourages physical activity and social integration(7). Hence, an interdisciplinary approach is ideal. Although challenging as each discipline presents its own particular concept and ideologies, it is also essential for positive urban planning with health needs in mind, shifting development practices and involving dialogue with stakeholders and policy-makers(2). For instance, Hanoi is developing with various professionals who often work separately(7), however addressing its urbanisation challenges requires effective collaboration between researchers, architects, engineers, health professionals, urban managers, economists and policy-makers(2).
In an interdisciplinary team, specialists can work together, as it is vital to have voices from different sectors participating in the dialogue collectively(7). Also, engaging with the communities and ensuring the active inclusion of citizens during the urban planning process is important(7). This restores citizens pride and involvement in the development of their city and is a step in developing cities that supports its population’s well-being, health, happiness and quality of life(7). As a linear urban planning approach is no longer ideal under the complexity that is ‘urbanisation’(2).
It is proven that urban inhabitants can have good health and a sense of happiness and well-being when supported by an environment that encourages pro-activity, reducing the risk factors for diseases(7). From a public health perspective, action needs to be taken to reduce environmental stressors (i.e. air and noise pollution, traffic), creating more green spaces, built environment that inspire physical activity and healthier food diets, developing healthcare systems combat communicable diseases and the rise of NCDs and addressing poverty and inequality exacerbated by urbanisation. Above all, healthy urbanisation can be achieved by empowering populations to control their health and determinants through a positive urban environment and governance that fosters equal social opportunities for health for all(14).
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