The influence of cities, urban environments, and informal settlements on population health and microbial communities URBANIZATION AND SLUMS: NEW TRANSMISSION PATHWAYS OF INFECTIOUS DISEASES IN THE BUILT ENVIRONMENT A WORKSHOP DECEMBER 12-13, 2017 THE NATIONAL ACADEMIES Lee W. Riley, MD School of Public Health, University of California, Berkeley
138 years later--chennai, India, 2010
2007 Sustainable Development Goal: Target 11.1 of Goal 11: Access for all to adequate, safe and affordable housing and basic services and upgrade slums by 2030.
UN Human Settlements Program: The Challenge of Slums: Global Report on Human Settlements, 2003 Demographic, spatial, economic, legal, and social indicators of 1 billion people who live in slums Life expectancy, under-5 mortality, access to improved water sources and sanitation Slum upgrading programs Poverty reduction programs Missing: HEALTH BURDEN!!
Slum --Operational definition Human settlements with inadequate access to safe water inadequate access to sanitation and other infrastructure poor structural quality of housing overcrowding insecure residential status United Nations Expert Group, Nairobi, 2002
Number of slum dwellers (in millions) in developing countries (UN Habitat Report 2016) 1000 900 800 700 600 500 400 300 200 100 0 1990 2000 2014
This side: Diarrhea ARI TB AIDS STIs Influenza Sepsis UTI Hospital infections Pharyngitis Leptospirosis Meningitis Hepatitis A, B,C Vaccine-preventable diseases MDRTB This side: Diarrhea ARI TB AIDS STIs Influenza Sepsis UTI Hospital infections Pharyngitis RHD Advanced stage cervical cancer Microcephaly Paraisopolis, Sao Paulo, Brazil
The root cause of urban slums is not in urban poverty but in urban wealth. (Gita Verma, Slumming India, 2002)
Slum-specific factors that contribute to adverse health outcomes Using UN definition Inadequate access to sanitation and other infrastructure Increased rat density Leptospirosis, typhus, Open sewers Hookworm, leptospirosis, diarrhea, cholera, dengue, malaria, hepatitis, growth retardation Suboptimal schools Poor nutrition (under-nutrition, obesity), poor health education Inappropriate/inadequate health services Poor vaccine coverage, maternal health complications, under utilization of health services, rheumatic heart disease, suicide, chronic diseases (hypertension, diabetes), drug-resistant TB Lack of residential infrastructure (street lighting, public bathrooms) Violence to women; intentional injuries
Slum-specific factors that contribute to adverse health outcomes Using UN definition Insecure residential status Informal tenure and lack of title deed Lack of representation Exclusion from health care services; decisions important for the community that affect health Eviction poor access to health care services, schooling, work; traffic accidents Toxic chemical exposure poisoning, respiratory diseases, cancer Low service utilization chronic diseases, unwanted pregnancy, STIs, HIV infection, substance abuse-related illnesses
Slum-specific factors that contribute to adverse health outcomes Using UN definition Overcrowding Opportunities for disease transmission Tuberculosis Other respiratory diseases Pharyngitis Meningitis Scabies Superinfections of the skin Acute glomerulonephritis Rheumatic heart disease Zika virus infection and its congenital consequences
Rheumatic heart disease (RHD) RHD: immunologically-mediated chronic complication of Group A (GAS) streptococcal (Streptococcus pyogenes) pharyngitis WHO: prevalence peaks at 24-35 yrs Brazil: RHD with congestive heart failure and mitral valve regurgitation: mean age= 12 yrs (Camara et al, 2002) mean age= 9 yrs (Camara et al, 2004) http://www.heart-valve-surgery.com/heart-surgery-blog/2010/05/02/rheumatic-heart-valve-disease-common/
Salvador, Brazil X San Marcos Quinto Centro Jorge Valente
GAS emm type diversity, Salvador, Brazil, April-Oct, 2008 Simpson s Diversity index (Steer et al, 2009) High income countries: 92.1% Africa: 98/1% Pacific regions: 97.9% Tartof et al. BMC Infectious Diseases 2010
Private clinic Proportion of Isolates (%) 25 20 15 10 5 0 36% 12.0 1.0 66.0 87.0 Jorge Valente st2904.1 27G.0 105.0 118.0 82.0 22.0 76.0 77.0 81.1 83.1 89.0 st3850.0. 53.0 High income countries Slum clinics Proportion of Isolates (%) Proportion of Isolates (%) 25 20 15 10 5 0 25 20 15 10 5 0 21% Emergencia Sao Marcos 12.0 st2904.1 1.0 11.0 105.0 27G.0 33.1 75.0 66.0 69.1 87.0 92.0 st3757.0 14% Quinto Centro 49.3 12.0 66.0 1.0 89.0 22.0 st6735.0 100.0 77.0 87.0 Tartof et al. BMC Infectious Diseases 2010 st3850.0 st2904.1 stg480.0 stns1033.0 stns1033.0 African region countries Included in 26-valent vaccine Not included in vaccine (Steer et al, Lancet ID, 2009)
Zika virus epidemic, Brazil
Congenital Zika Syndrome Photographs: Felipe Dana/AP Photos: Claudete Cardoso, MD
Congenital Zika Syndrome February, 2016: A public health emergency of international concern, World Health Organization November, 2016: WHO declared end to public health emergency status of Zika epidemic. May, 2017: Brazil declared end to public health emergency of Zika epidemic L. Riley C. Cardoso
C. Cardoso This is only the beginning
Slum health research vs advocacy Where do we go from here??? Cannot wait for alleviation of poverty, disparity, inequality, etc Cannot wait for social capital development, technology transfer, UN Sustainable Development goals, etc Need to act now to: Formally recognize the existence of this population. Work with residents of slums to assess burden of disease in this population. Develop new metrics Precision public health research to measure biological, sociological and environmental determinants of disease Provide data for national governments. Identify and implement novel interventions, specifically designed for slums. Get those in position of influence to set the priority straight.
The main stock exchanges go up or down 3 percentage points and this is a world event This cannot be! It s time to flip the tortilla. Pope Francis, 2013
Global Health Equity Scholars Program: UC Berkeley, Yale, Stanford, Florida Internat Univ GHES.berkeley.edu Lebanon, Beirut Bangladesh, Dhaka Colombia, Cali Peru, Lima Dominican Rep Nicaragua, Managua Ethiopia, Addis Ababa Ghana, Legon Tanzania, Shinyanga Mozambique, Maputo India, Delhi, Chennai, Mysore Uganda, Kampala Nepal, Pokhara Kenya, Nairobi and Kisumu Malawi, Zomba Samoa, Apia Malaysia, Kuala Lumpur Zambia, Lusaka South Africa, Tugela Ferry Zimbabwe, Harare
Acknowledgements: UC Berkeley: Jason Corburn Robbie Snyder Sara Tartof Kate Lovero Eva Raphael Mariel Marlow Michele Barocchi Guillermo Jaime-Douglass Claire Boone Kristina Emodi Emily Pearman Brendan Flannery April Pena Brazil: Claudete Cardoso Felipe Piedad Beatriz Moreira Mitermayer G. Reis Edson Moreira Edgar Carvalho Adriano Queiroz Others: Albert Ko (Yale) Warren Johnson (Cornell)