Regional Health Forum_WHO

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ISSN 1020 4237

World Health Organization 2010

Publications of the World Health Organization enjoy copyright protection in accordance withthe provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproductionor translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World HealthHouse, Indraprastha Estate, New Delhi 110002, India.

The designations employed and the presentation of the material in this publication do notimply the expression of any opinion whatsoever on the part of the Secretariat of the World

Health Organization concerning the legal status of any country, territory, city or area or of itsauthorities, or concerning the delimitation of its frontiers or boundaries.

The views expressed in this publication are those of the author(s) and do not necessarilyreflect the decisions or stated policy of the World Health Organization; however they focus onissues that have been recognized by the Organization and Member States as being of highpriority.

Printed in India


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Editorial

Today, half the worlds people live in cities, and it has been estimated that the urbanpopulation of Asia will double by 2030. Urbanization, development and health are

inextricably linked. Jobs, education and new opportunities draw people to cities,where water systems, sanitation, housing and infrastructure struggle to keep up withrising populations; the poor and the marginalized often find themselves victims of anurban equity gap. Globally, one billion people live in urban slums.

Without urgent attention to urban planning, improving access to safe drinkingwater and sanitation, bringing health services to all and encouraging healthy lifestyles,the gap between the urban rich and poor will widen. This years World Health Dayfocuses on Urbanization and Health to draw attention to the need for action by all

sectors and peopleboth public and private, from the individual level to the nationallevelto address the issues of urban health.

This issue of the Regional Health Forum looks at urbanization in several countriesof the South-East Asia Region, as well as issues faced by the Region as a whole. Allcities struggle with transportation and water issues; all will be affected by climatechange to a greater or lesser degree; and all must address the health issues andneeds of the most vulnerable populations, such as youth.

The city is remarkable for its vitality and also for its fragility. Its very growth, ifunregulated and uncontrolled, can lead to problems of pollution, degradation of theenvironment, overwhelming of health systems, erosion of infrastructure, and thedecline in health that these factors in turn produce. Cities seem to grow by themselves,due to demographic and economic forces; but it is people who build them and live in

them. Their health is the true measure of the citys health.

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Contents

Urbanization and health

Urbanization and water, sanitation and hygiene in Bhutan 1

Tenzin Jamtsho

The urban environment and health: Delhi stands up to thechallenge 8

T K Joshi and Salma Burton

Effects of climate change on urban health in the Kathmandu Valley 15

Babu Ram Marasini

Effects of urbanization on health behaviours of young people inTimor-Leste 19

Rui Maria de Araujo

Urbanization dynamics and WHOs healthy city initiatives in theSouth-East Asia Region 25

Surinder Aggarwal and Abdul Sattar Yoosuf

Comment

Notes and news 35

Publications corner 37

Guidelines for contributors 41

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Urbanization and health

Urbanization and water, sanitation and hygiene in BhutanTenzin Jamtsho*IntroductionBhutan has followed a conservation-centreddevelopment policy that has been crucial inmaintaining a good natural resource base.The forest coverage is about 72%; it hasmountainous topography with altitude varying

from 100 metres to over 7500 metres abovesea level. The precipitation varies from 5000millimetres (mm) in the foothills to 700mm inthe high altitude region. Fed by snow and rain,the country is drained by four major riverbasins and their tributaries. The average flowdraining the whole country is estimated at2325 cubic metres (cu m) per second, whichworks out to 73 000 million cu m per yearwith per capita availability of more than

100 000cu m.

1

The Royal Government ofBhutan has made remarkable progress inhuman as well as economic developmentsince it started planned development in theearly 1960s. The government is committed tomaintaining harmony between economicdevelopment, spiritual and cultural values andenvironment conservation. The developmentphilosophy adopted by the government isbased on Gross National Happiness.

Water is crucial for development and for

the well-being of people, as well as forachieving the national goal of GrossNational Happiness. Even though Bhutan hasa fairly large quantity of fresh water it cannotafford to be complacent. The country faces anumber of challenging issues in water resource

management due to the expansion of industryand agriculture, and urbanization. Thenational population growth rate of Bhutan is1.3%, which means that its population will bedouble in fifty years. Even though the nationalgrowth rate is only 1.3%, the urban populationgrowth in Bhutan has been unprecedented. It

is estimated that by 2020, 50% populationwould reside in urban areas. Moreover, therecent trend in urban growth indicates that by2020 the urbanization level would be about73%2. Rapid urbanization and economicgrowth would mean an increase in waterdemand to satisfy domestic and agricultureneeds. At the same time, however, the watersources are either drying up or are gettingdepleted. Thus, the additional water requiredhas to be abstracted from the environment.

This would mean more water abstraction,more water treatment, more consumption andfinally more wastewater discharge into theenvironment.

Although freshwater is in abundance inBhutan, the pressure on it is bound toincrease with growing urbanization andindustrialization. The urban population in1999 accounted for 21% of the totalpopulation and is likely to increase by 50%

by the year 2020, which will raise thedemand for water in urban centres3. Localand seasonal water shortages are becomingmore frequent, and there is evidence ofincreasing sediment loads in Bhutansextensive river system4. The latter is a threat tothe rapidly-growing hydropower industry thatneeds a reliable water supply to sustain themuch-needed revenue that currently

* Department of Urban Development and EngineeringServices, Ministry of Works and Human Settlement(MoWHS), Thimphu, Bhutan

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underwrites about 45% of Bhutansdevelopment budget. Despite all thechallenges, there has been a significantincrease in access to safe drinking water from 45% of the total population in 1990, to78% in 2000. While no legislative frameworkon water supply and related rights is in place,the Bhutan Water Vision, the Water Act andWater Policy are being formulated to createan enabling environment for an integratedand efficient management of water resources.

Country profileThe following are some of the keydemographic indicators of Bhutan:

Area (square kilometres - sq. km): 38 394

Population (2005-2006) 683 982

Life expectancy (2005-2006) 66.1 years

Infant immunization coverage (2008) 90%

Literacy rate (2005-2006) 59.5%

Taking the social and economicconditions into consideration, the Human

Development Index (HDI) ranking for Bhutanin 2005 was 133 out of 177 countries5.

Institutional set-up for urban water supplyand sanitationUrban development in Bhutan was initiatedin 1983 through the Asian DevelopmentBank (ADB) and the Danish InternationalDevelopment Agency (DANIDA) thatprovided support to urban water supply andsanitation to six major towns. It was the first-ever multicredit facility obtained from ADB toimprove urban water supply and sanitation. Itwas to be executed through internationalbidding for supply of equipment and civilwork. Ever since, there have been continued

investments in urban water supply andsanitation areas supported by thegovernments of Bhutan, Denmark and Indiaand by multilateral institutions like the WorldBank and the ADB. The overall achievementof urban water supply and sanitation sectorsis largely accredited to the Government ofDenmark and other bilateral and multilateralpartners6.

Figure:Map of Bhutan

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The Ministry of Works and HumanSettlement (MoWHS) is the pivotal agency toformulate strategies and policies for humansettlement in the country. Within this ministry,the Department of Urban Development andEngineering Services (DUDES) is the Central

Government agency responsible for executingthe urban water supply and sanitationprogramme. Service-oriented municipalcorporations have been established in thetwo biggest urban centres, namely Thimphuand Phuentsholing6.

The Thimphu Municipal Corporationenjoys the highest degree of autonomy withthe Municipal Charter granted to it in 2003 asper the Bhutan Municipal Act of 1999.Phuentsholing, the second largest town wasgranted financial autonomy for water andsanitation in 1996 and is now gearing up toreceive the Municipal Charter similar to theone granted to Thimphu MunicipalCorporation. In other districts, municipalcorporations that provide municipal services tourban residents have been established. Thesesmaller municipal authorities are placed underthe district administration for their routinefunctioning and management of services.

Urban water supply and sanitation projects areplanned and designed by the central agencybut are often implemented by the districtadministration with technical backstoppingfrom the central department.

The Royal Government of Bhutan hasenacted various acts, policies, rules andregulations, and codes to enable effectiveand efficient urban water and wastemanagement.

Water supply and sanitation coverage inurban areasBhutan consists of twenty districts and about69% of the population lives in rural areas.Urban areas consist of 54 towns. Almost alltowns are supplied with piped drinking water.

The recently-published World HealthOrganization (WHO)/United NationsChildrens Fund (UNICEF) Joint MonitoringProgramme (JMP) report indicates that in2008 urban water supply coverage in Bhutanwas 99%. Water supply facilities have reachedalmost all households in urban Bhutan.However, water supply is still irregular in mosttowns mainly due to the rapid growth of urbanpopulation. The expansion of water supplyand sanitation systems is not commensuratewith the rapid population growth. Thereforethe limited water supply has to be stretchedfor a larger population, which leads torationing of the supply. Another problemassociated with insufficient water supply is thehigh water loss in the system due to breakageof old pipes and sometimes illegal tapping by

some residents (Table 1).

Table 1: Water loss in Thimphu citywater supply system (2006-2010)

Year Percentage loss2006-2007 28%

2007-2008 27%

2008-2009 25%

2009-2010 23%

The major water quality problem is withmicrobiological contamination. Most urbanwater supply systems in Bhutan have a basicwater treatment facility. However, due to lackof monitoring of water quality, inadequatetreatment facilities, and poor maintenance ofthe system, water that flows from taps is notalways safe to drink. The majority of residents

in urban areas either boil or filter the tapwaterbefore drinking.

The urban sanitation coverage stands at88%. Only five towns have seweragetreatment plants. However, only about 30%households in these towns are connected tosewerage treatment plants. The rest are allconnected to septic tanks or traditional pits.The toilets in towns without sewerage treatment



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plants are connected to septic tanks. There isevery possibility of sewage from the septictanks and pits seeping into the groundwaterand rivers, thereby polluting the fresh watersources.

With rapid economic and population

growth in urban areas, and changinglifestyles, Bhutan is facing increasingchallenges in managing solid waste.Concerns of unsatisfactory disposal of solidwaste in some of the bigger urban townshave been noted in the recent years. Aperson in urban Bhutan produces about0.25 kg solid waste per day.

A study conducted in 10 towns in2007revealed that organic waste formed the

largest proportion of municipal solid wastewith 58.05%.

Not all towns in Bhutan have a solidwaste management system. Some of thebigger towns have municipal waste collectionservices. But in places where such services arenot available, waste is disposed of in smallgarbage pits and burnt. While some waste isburnt in open spaces, a good section ofpeople dispose the waste in the streets, drains,rivers and streams, and bushes. Some towns

use landfill sites to dispose of municipal wastebut none qualify as a sanitary landfill as thestandard norms are not followed. All suchactions lead to pollution of the environment,especially the air, water bodies and openspaces.

Developing human resources inmunicipalities and setting up proper wastemanagement systems would go a long way inpreserving the pristine environment that

ultimately improves the quality of life. Thehigh organic content of urban solid wastegives opportunity to explore composting asan option for managing waste in a more eco-friendly manner. Municipal authorities arealso looking at the means of segregatingwaste at the point of generation andimplementing recycling or reusing whereeverit is relevant.

Impact of water and sanitation on healthWater, sanitation and hygiene are thefoundations of good health. It is estimatedthat 88% of diarrhoeal deaths worldwide areattributable to unsafe water, inadequatesanitation and poor hygiene. Some of thewaterborne and water-related diseasesprevalent in urban Bhutan are diarrhoea,typhoid, skin infections, conjunctivitis, dengueand malaria. With improvement in the healthcare system combined with increasing accessto water and sanitary facilities, diarrhoealmortality especially in under-five children hasreduced drastically in the past decade.However, decrease in diarrhoeal morbidityhas not been significant. The reasons for thiscould be water safety issues and unhygienicpractices. For instance, typhoid cases arereported every year from various townsduring monsoons a typhoid outbreak wasreported in Damphu town in 200. TheDepartment of Public Health that investigatedthe outbreak gave clear evidence of the maincause being water contamination at thesource and during distribution of water in thesystem due to broken pipes and lack oftreatment facility.

Dengue was reported for the first time inBhutan in July 2004; 2579 suspecteddengue cases were reported in the outbreakin 2004. Since then, several cases havebeen reported every year especially fromPhunstholing town. The dengue-causingmosquito breeds in clean and stagnantwater easily found in homes such as flowerpots, water tanks, old tyres, rainwatergutters, or water collected in any smallcontainers. Therefore, proper storage and

management of water at home and insurrounding areas is very important inpreventing dengue. Table 2 presents theincidence of the top ten diseases in Bhutanin 20087.



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Table 2: Top ten diseases in Bhutan, 2008Sl.No Name of the disease Numbers in2008

1 Common cold 266 164

2 Skin infections 97 514

3 Peptic ulcer syndrome 63 039

4 Musculo-skeletal 61 001

5 Acute pharyngitis/tonsilitis 60 510

6 Other disorders of the skin andsubcutaneous tissues

59 335

7 Diarrhoea 58 537

8 Other diseases of the digestive system 54 859

9 Other respiratory and nose diseases 51 145

10 Conjunctivitis 37 240

Table 3 indicates the number ofwaterborne disease cases in the past five years7.

Table 3: Waterborne diseases in the past f ive years(2004-2008)7

Year and number of cases reportedName ofdisease/infection 2004 2005 2006 2007 2008

1 Cholera 27 29 38 5 18

2 Typhoid 2 148 2 948 2 871 2 055 1 927

3 Diarrhoea 69 539 67 301 70 939 64 100 58 537

4 Dysentery 31 110 31 404 31 631 26 601 24 411

ChallengesThe following are the challenges:

(1) Water quality data assessment andmanagement is lacking for urban centres.It is very important to have a water qualityinformation management system for allurban centres as it would help in properwater resource planning and allocation inurban areas.

(2) Human resources: Human resources andcapacity building have always been bigchallenges in the context of urbanization.With increasing population, the pressureon the existing urban infrastructure is alsoincreasing. The municipal offices are

usually not manned with adequate andqualified staff. The municipal in-charge/engineers or lower-level staff whoshoulder responsibilities have in fact littleor no formal training.

(3) Funding: In most developed countriesimportant projects are not restricted to thefunds available whereas in Bhutan, thescarcity of financial resources acts as alimitation to infrastructure development.With urbanization, the government will

have to prioritize water and sanitationactivities.

(4) Proper solid waste managementstrategies: Landfill is currently the mostpreferred alternative for waste disposalby local municipal authorities as it is stillthe cheapest and easiest method ofgetting rid of wastes away from towns(out of sight, out of mind), in theabsence of strict environmentalregulations on landfill disposal. Recycling

infrastructures are an essentialcomponent of integrated solid wastemanagement for resource recovery andfor reducing wastes going to landfills.

(5) Operation and maintenance of urbaninfrastructure: Even though thecoverage of water and sanitationinfrastructure in Bhutan is good, itsfunctionality still remains poor. Urbancentres should implement approachesand tools that help to improve waterquality and quantity, and eventually thesustainibility of water supply andsanitation systems.

(6) Availability of better alternatives: In orderto provide an urban infrastructure, it isimportant to have many alternatives interms of cost-effectiveness, sustainabilityand efficiency.



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ConclusionWhile health is an important component forthe growth and development of any country,the lack of safe drinking water and poorsanitation in Bhutan contribute to widespread

and recurring health problems. In order totackle this problem, the government allocated8% of its 2008-2009 budget to improve thehealth services, both in terms of their qualityand accessibility, as improving health is seento be central to the achievement of thenational vision of Gross NationalHappiness.8

As a result of the high priority accorded bythe Royal Government of Bhutan to providingaccess to safe drinking water and basicsanitation, the country has made sustainableprogress in providing these services in bothrural and urban areas.

Safe, adequate and accessible suppliesof water with proper sanitation are the

foundation and an essential component ofprimary health care. Insufficient provision ofsafe drinking water and sanitation resultsdirectly and indirectly in communicablediseases, health risks, poor health andenvironmental pollution. Bhutan has always

considered water and sanitation as one of thebasic primary health care components thatcontributes directly to Gross NationalHappiness and is also a very importantindicator of progress made towards achievingthe Millennium Development Goals (MDGs).Therefore, the goal of achieving universalaccess to adequate safe drinking water in theTenth Five Year Plan has been accorded thestatus of one of the top three priorities of thenew government. Ever since the water supply

and sanitation programme started in 1974,sanitation has always been part of the watersupply component. Therefore developmentsin the area of sanitation have to be viewed inthe overall context of developments in thearea of water supply.

References and bibliography(1) Royal Government of Bhutan. Bhutan water policy.

Thimphu: Bhutan Water Partnership, 2003.

http://www.moa.gov.bt/moa/downloads/downloadFiles/MoADownload8uv5955mb.pdf- accessed 24February 2010.

(2) Royal Government of Bhutan, Ministry of Works andHuman Settlements. National Urbanization Strategy.Thimphu: MWHS, 2006.

(3) United Nations Environment Programmes. UNEPAnnual Report 2001. Nairobi, 2002.http://www.unep.org/pdf/annualreport/AR_2001_FINAL_MINUS_PIS.pdf- accessed 24 February 2010.

(4) Royal Government of Bhutan, Ministry of Agricultureand Forests. Bhutan water policy Thimphu, MoA,

2002, p. 3.(5) United Nations Development Programme. Human

development report 2007/2008: fighting climatechange: human solidarity in a divided world. NewYork: UNDP, 2007.http://hdr.undp.org/en/reports/global/hdr2007-2008/chapters/ - accessed 23 February 2010.

(6) SACOSAN. Bhutan country paper for South Asianconference on sanitation. Paper presented at the third

South Asian conference on sanitation. 8-21November 2008. New Delhi, 2008, p. 3-4.http://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.doc accessed 25 February 2010.

(7) Royal Government of Bhutan, Ministry of Health.Annual health bulletin. Thimphu: MoH, 2009.

(8) SACOSAN. Bhutan country paper for South Asianconference on sanitation. Paper presented at the thirdSouth Asian conference on sanitation. 8-21November 2008. New Delhi, 2008, p. 1.http://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.

doc accessed 25 February 2010.

(9) Office of the Census Commissioner. Population andhousing census of Bhutan, 2005. Thimphu: Office ofthe Census Commissioner, 2005.http://www.nsb.gov.bt/pub/phcb/PHCBfactsheet2005.pdf- accessed 25 February 2010.

(10)Carl E. Taylor. Reconnaissance trip report. Thimphu:1962.
http://www.moa.gov.bt/moa/downloads/downloadFiles/MoADownload8uv5955mb.pdfhttp://www.moa.gov.bt/moa/downloads/downloadFiles/MoADownload8uv5955mb.pdfhttp://www.unep.org/pdf/annualreport/AR_2001_FINAL_MINUS_PIS.pdfhttp://www.unep.org/pdf/annualreport/AR_2001_FINAL_MINUS_PIS.pdfhttp://hdr.undp.org/en/reports/global/hdr2007-2008/chapters/http://hdr.undp.org/en/reports/global/hdr2007-2008/chapters/http://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://www.nsb.gov.bt/pub/phcb/PHCBfactsheet2005.pdfhttp://www.nsb.gov.bt/pub/phcb/PHCBfactsheet2005.pdfhttp://www.nsb.gov.bt/pub/phcb/PHCBfactsheet2005.pdfhttp://www.nsb.gov.bt/pub/phcb/PHCBfactsheet2005.pdfhttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://ddws.nic.in/infosacosan/PPT/SACOSAN%20Bhutan%20Country%20Paper%202008%20November.dochttp://hdr.undp.org/en/reports/global/hdr2007-2008/chapters/http://hdr.undp.org/en/reports/global/hdr2007-2008/chapters/http://www.unep.org/pdf/annualreport/AR_2001_FINAL_MINUS_PIS.pdfhttp://www.unep.org/pdf/annualreport/AR_2001_FINAL_MINUS_PIS.pdfhttp://www.moa.gov.bt/moa/downloads/downloadFiles/MoADownload8uv5955mb.pdfhttp://www.moa.gov.bt/moa/downloads/downloadFiles/MoADownload8uv5955mb.pdf


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(11)World Bank. Bhutan Urban development project.Washington, 2007.http://go.worldbank.org/X5Q5IZ2D31 - accessed 25February 2010.

(12)United Nations Population Division. World populationprospects.The 2006 revision database. New York:United Nation, 2007.

(13)Royal Government of Bhutan, Ministry of Works andHuman Settlement. Divisions under department ofurban development and housing. Thimphu.http://www.dudh.gov.bt/DIVISION/Division.htm -accessed 23 February 2010.

(14)WHO Country Office for Bhutan. Health informationwater & sanitation. Thimphu.http://www.whobhutan.org/EN/Section4_26.htm -

accessed 23 February 2010.

http://go.worldbank.org/X5Q5IZ2D31http://www.dudh.gov.bt/DIVISION/Division.htmhttp://www.whobhutan.org/EN/Section4_26.htmhttp://www.whobhutan.org/EN/Section4_26.htmhttp://www.dudh.gov.bt/DIVISION/Division.htmhttp://go.worldbank.org/X5Q5IZ2D31


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The urban environment and health: Delhi stands up to the challenge

T K Joshi*, Salma Burton**

Global scenarioThe World Health Organization (WHO) haschosen the theme of Urbanization andHealth for World Health Day for the currentyear 2010. According to WHO, as of now,over three billion people live in cities. A recent

report by the United Nations PopulationDivision observed that half of the worldspopulation now lives in urban areas, and ithas been projected that within the next30 years, nearly two thirds people will live incities.1 The urban areas of the less wealthyregion of the world are likely to experiencemuch of the growth in population (growth from1.9 billion in 2000 to 3.9 billion in 2030),with the most rapid increase in numbers likelyto occur in Asia and Africa. As an example,

the number of urban dwellers in the leasturbanized region, Asia (1.4 billion), is alreadygreater than the urban population in NorthAmerica and Europe combined (1.2 billion) in2000.2

The growing mega cities attract migrantsfrom impoverished areas and the resultinginflux of poor migrants ends up in slums wherethe environmental conditions and the facilitiesare inadequate to maintain human health. Aslum is defined by The United NationsHuman Settlements Programme (UN-HABITAT)as one that includes a wide range of low-income settlements and/or poor human living

conditions.3 If governments neglect theenvironmental and urban causes of thegrowing health burden on the urban poor, thenations and the global society will simplyaccumulate massive health debt, which willbe far more expensive to pay off.4

Indian scenarioBetween 1951 and 1991, the Indian urbanpopulation rose from 62.4 million in 1951 to217.6 million in 1991. About two thirds of theurban population are concentrated in 317Class I cities (population of over 100 000),half of which lives in 23 metropolitan areaswith populations exceeding 1 million.

The rapid growth of population in Indiaand the corresponding need for transportation

and energy resulted in an unplanned urbangrowth adding to the problem of air pollutioncaused predominantly by vehicles, withsignificant contribution by industry and thermalpower plants in some pockets. The impact ofvehicular emissions on the general populationis heightened by the emissions occurring at theground level. According to the CentralPollution Control Board (CPCB), vehiclescontribute significantly to the total air pollutionload in many urban areas. The number of

motor vehicles increased from 0.3 million in1951 to 37.2 million in 1997, with 32%concentrated in 23 metropolitan cities. Delhiwith about 8% of the total registered vehicles,had more registered vehicles than those in theother three metros (Calcutta, Chennai andMumbai).5 the aforementioned trends forcedpolicy-makers to clean up the air and takeaction to improve the public transportationsystem.

* Director, Occupational and Environmental HealthProgramme, Centre for Occupational and EnvironmentalHealth, Maulana Azad Medical College, New Delhi

** Regional Adviser, Occupation and EnvironmentalHealth, Regional Office for South-East Asia,World Health Organization, World Health House,I P Estate, New Delhi - 110002



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Investigators studied the relationshipbetween levels of particulate matter and dailydeaths in Delhi between 1991 and 1994. Theaverage total suspended particulate (TSP) levelin Delhi was 375 micrograms per cubic metre(g/m3) approximately, five times the annual

average standard of WHO. The levels duringthe time period mentioned above exceededWHO'S twenty-four-hour standard on 97%days on which readings were taken. Theauthors noted that if one cares about life-years lost, the impacts of a 100-microgramincrease in TSP in Delhi are more startling.6

Case study of Delhi with regard to itsresponse to the urban transport challengeDelhi was named as National Capital Territory(NCT) of Delhi on 1 February 1992 followingthe Sixty-ninth Amendment to the Constitution. According to the 2001 census, Indiaspopulation stood at 1028.7 million. Theeconomic survey conducted in 2005-2006noted a rise in Delhis population from 9.4million in 1991 to 1.38 million in 2001. Table1 gives the details of Delhis population.

Table 1: Population of Delhi Economic Survey,2005-2006S. N. Total population 13 850 5071. Males 7 607 234

2. Females 6 243 273

3. Total rural population 944 727

4. Rural males 522 087

5. Rural females 422 640

6. Urban population 12 905 780

7. Urban males 7 085 147

8. Urban females 5 820 633

Delhi also has the distinction of being themost urbanized union territory with a

population density of 9340/sq km against thedensity of 43/sq km in the Andaman andNicobar Islands, another Union Territory.7According to the Ministry of Health and FamilyWelfare, Government of India, there has beena steady growth in urban population due to

people migrating from rural areas since 1961.It is clear that urban population has increasedsteadily with more than 500 million now livingin urban India.

The NCT of Delhi not only has the highestdensity of population in India but also has thelargest number of people living in an urbanenvironment, as approximately 93.7% of thepopulation live in the city. Such urbanconcentration with shortage of space createsovercrowding and forces many of the

immigrants to live in cramped conditions in theslums. According to the Registrar General ofCensus, India, it was estimated that nearly 2025 890 people live in slums, of which themales number 1 138 063, and femalescomprise 887 827.7 However, the white paperprepared on Delhi estimated that nearly 30%of Delhis population lived in squatter slums.8

The present urban scenario of Delhi hasresulted from an allround increase in industrial

units and vehicular traffic. There were nearly8000 industrial units in Delhi in 1951 but by1991 this figure went up to 125 000. Thenumber of vehicles in the city increased rapidlyfrom 235 000 in 1975 to 2 629 000 in1996, and is expected to reach six million in2011. Of the total air pollution load in theregion, vehicular pollution is responsible for67% approximately 3000 metric tonnes(mt) per day. The next contributor is industrythat causes 25% air pollution. The main

culprits identified are the coal-based thermalpower plants. The three power plants in theNCT of Delhi together generate 6000 mt offlyash per day. There are 16 big drainstraversing the landscape of Delhi, whichdischarge 1900 million litres per day ofmunicipal sewage and wastewater into theriver Yamuna. The industrial effluentcontributes 320 million litres per day. The



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amount of solid waste generated in the city isabout 5000 mt per day. In certain localities,the noise levels are attaining alarming levels.An action plan was prepared towards the endof last millennium by the Union Ministry ofEnvironment and Forests, Government of

India, after undertaking monitoring for variouspollutants.8

Monitoring: The Central Pollution ControlBoard, the regulatory and the chief monitoringagency regularly measures air quality atvarious locations in Delhi. The measurementsare made for sulfur dioxide, oxides of nitrogenand particulates. The ambient air quality datahave revealed elevated values for suspendedparticulate matter (SPM) at all monitoringstations, namely 367-452 g/m3 on an

annual average basis as against theprescribed standard of 140-360 g/m3.Though the annual mean value of sulfurdioxide (15-26 g/m3) and oxides of nitrogen(28-46 g/m3) remain within the prescribedlimit of 60-80 g/m3, there is a rising trend. Ascompared with 1989, the sulfur dioxideatmospheric concentrations in 1996 registereda 109% elevation, and oxides of nitrogen an82% elevation. The suspended particulatematter atmospheric concentration has shown

only a nominal rise because of the installationof electrostatic precipitators by thermal powerplants in Delhi.

According to a study of air pollution in Asian countries, the respirable particulatematter (RSPM) or PM10 is the main pollutant.However, in cities where the number ofvehicles is increasing, there is greater concernover levels of nitrogen dioxide (NO2) andozone (O3). Delhi recorded the highest levels

of SPM and PM10, much higher than the levelsfound in Bangkok, Beijing or Manila. Evenother Indian cities like Chennai, Kolkata andMumbai had lower values of PM10.

9

Initiatives to improve urban air quality inDelhiAn important development took place in 1998in Delhi. In order to address the issues of

environment and health, an authority, notifiedas the Environment Pollution (Prevention andControl) Authority for the National CapitalRegion, was constituted. It comprised eminentenvironmentalists and executives.10

The Authority was conferred with the

necessary powers to protect and improve thequality of the environment, and to prevent,control and lessen environmental pollution. Itwas empowered to issue directions in respectof complaints relating to the violation of anorder passed by any authority pertaining to:

standards for maintaining the qualityof the environment in its variousaspects;

standards for omission or discharge

of environmental pollutants fromvarious sources;

restriction of areas in which anyindustries, operations or processes orclass of industries or processes shallnot be carried out or shall be carriedout subject to certain safeguards;

procedures and safeguards for theprevention of accidents that maycause environmental pollution and

remedial measures for suchaccidents; and

procedures and safeguards for thehandling of hazardous substances.

The compressed natural gas experimentOn 5 April 2002, a three-judge Bench of theSupreme Court directed the Delhi governmentto comply with its orders on the conversion ofdiesel-run buses in the capital to thecompressed natural gas (CNG) mode. Theapex court on three earlier occasions hadcalled upon the government to replace dieselwith an alternative fuel through its orderspassed on 21 October 1994, 28 March 1995and 9 February 1996. The Bench ruled that itsorders could not be nullified or altered byadministrative decisions of the central andstate governments. The court also directed the



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Government of NCT Delhi to phase out dieselbuses at the rate of 800 a month, starting 1May 2002. The Central Government was alsodirected to give priority to the transport sector,including private vehicles, in Delhi and otherhighly air-polluted cities, and eventually in the

entire country, for allocation of CNG.

11

The Central Pollution Control Board

(CPCB) is the regulatory and technical arm ofthe Union Ministry of Environment and Forests,Government of India, which through the StatePollution Control Boards (SPCBs), and StatePollution Control Committees keeps a watch onthe state of pollution throughout the country. TheBoard conducted a comparative study to assessthe environmental impact of CNG introduction,the results of which are presented in Table 2.

Except for carbon monoxide and sulfur dioxidewhich showed a decline, other parameters suchas SPM and PM10 have registered an increase.Table 3 shows how immediately after theintroduction of CNG in 2001, the parametersdeclined but started rising again.

Table 2: Ambient air quality of Delhi Comparison of pre-CNG introduction (2000) levels with those in 2008*

ParameterPrescribed

annual standard(residential) 2000 2008*Percentageincrease/decrease

No. of Vehicles(Approx. inhundredthousands)

35 55 57

Sulphur dioxide 60 18 5 (-72)

Nitrogen dioxide 60 36 48 33

SPM 140 405 413 2

RSPM 60 159 192 21

Carbon monoxide 2000 4686 2348 (-50)

Source: Central Pollution Control Board (CPCB), DelhiAll values are in g/m3* Data of November and December have been taken from the year 2007 foraveraging the values for 2008Observations:Increase in number of vehicles (57%); nitrogen dioxide (33%); SPM (2%) andRSPM (21%)Decrease in sulphur dioxide (72%) and carbon monoxide (50%)

Table 3: Levels of pollutants in Delhi (2000-2003) Parameter 2000 2001 2002 2003Sulfurdioxide

18 14 12 19

Nitrogendioxide

36 34 39 45

SPM 405 348 424 352

RSPM 159 137 166 148

Carbonmonoxide*

4686 4183 3258 3831

Source: CPCBAll values are in g/m3

Figure 1 shows the rise in the number ofvehicles from 3 500 000 in 2000 to5 500 000 in 2008; this led to a rise in levelsof some of the pollutants in urban air.

Figure 1:Increase in the population of vehicles inDelhi since 2000Number of vehicles in Delhi

35

55

0

10

20

30

40

50

60

2000 2008

Year

In

100

thousands

Figure 2 shows the growth of CNG-driven vehicles in NCT of Delhi. The number

of CNG-based vehicles in all categories hasbeen rising over the years, starting from2001.

An elaborate study undertaken in Delhifound that the concentration of carbonmonoxide, sulphur dioxide and PAHs recordeda significant decrease after the introduction ofCNG as an alternative to diesel or petrol-fuelled vehicles, but an increase in NOx



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concentration was noticed. However,concentrations of BTX (benzene, toluene, andxylene), SPM, and PM10 showed no significantchanges. Nonetheless, a fall in BTXconcentration was noticed due to reduction inthe benzene content in petrol. Furthermore,the SPM and PM10 concentrations in Delhiseem to be related not only with vehicularemissions, but also with other anthropogenicand natural emission sources.12

Major initiatives taken to reduce airpollution in Delhi Unleaded petrol introduced in the

National Capital Region in September1998.

Sulfur content in diesel reduced from0.5% (April 1996) to 0.05% (April 2000).

Catalytic converters introduced inpassenger cars in April 1995.

Gasoline in benzene reduced from 5%(April 1996) to 1% (November 2000).

Restrictions imposed on operation ofgoods vehicles during daytime fromAugust 1999.

Diversion of interstate buses.

Time clocks installed at red lights.

Figure 2:Total number of vehicles in Delhi (by category) (2001-2003)

2001(31 March)

2002(31 March)

2003(31 March)

2003(31 October)

Total number of CNG vehicles in Delhi (by Category)

Buses

Mini Buses

Taxis

Three-wheelers

Private cars

Construction of fly over and sub ways forsmooth flow of traffic.

Metro rail for mass rapid transportintroduced.

Introduction of pre mixed 2T oil for twostroke engine from April, 1999.

Introduction of CNG for commercialtransport vehicles (buses, taxis, autorickshaws etc.)

Ethanol blended (5% petrol) introduced.

More than 15 year old commercialvehicles phased out from 1998.

'Pollution Under Control' certificate withthree month validity introduced

Fuel quality standard (Bharat Stage I, II,III and IV) introduced.

Overhaul of Delhis urban transportsystem, and the Delhi Metro RailCorporation (DMRC) ProjectThe Department of Transport under theGovernment of National Capital Territory ofDelhi in 2002 prepared a plan to tackle theproblems of urban transport brought about by



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rising concentrations of pollutants, shrinkingroad space, and rising number of fatal roadaccidents, all of which created a public healthcrisis. The projection that by 2021 thepopulation of Delhi will zoom to 27.9 millionfrom the existing 13.8 million, added to the

urgency.

13

It was proposed that a mass transport

system including a metro, commuter rail andbuses be developed. Considering this, the 245km of a metro system network to meet thedemand of a rapidly-urbanizing city, 2021was chosen as the target year. Though Phase Iof this network got completed in 2005, majorconstruction work on different routesconnecting Delhi to neighbouring towns is stillon to create, at the end of the day, an

Integrated Rail and Bus Transit (IRBT) system.The downside of the ambitious metro railproject has been a spate of accidents atvarious construction sites. According to theGovernment of India, the two major projectsunder way in Delhi at present are those ofDMRC, and construction of the forthcomingCommonwealth Games (CWG) sites.Construction workers employed at the DMRCand CWG sites total 120 364 and 11 089respectively.14

ConclusionThe introduction of CNG was the result of ajudicial directive to address air pollution inDelhi. The early results of the switch to CNGwere encouraging and people could feel theimprovement in air quality. However, the levels

of RSPM went up and stood at 150 g/m3(averaged) in 2008 a 40% increase over theprevious decade. A major contributor to thisrise has been the new vehicles on the road. In2005-2006, the number of vehicles that wereregistered daily was about 1000, up from 580

daily in 2000-2001. The total number ofvehicles increased from 3.6 million in 2001 to4.8 million in 2006. The growing traffic alsoled to an increase in the suspension ofroaddust in the atmosphere; this has becomea critical source.15 Another case study showsthat Delhis population is likely to double by2020. The number of vehicles is also likely togo up by 3.7 times over the same period. Thecase study also projects that travel demand inDelhi would increase from 73 billion

passenger kilometres in 1997 to 253 billionpassenger kilometres in 2020.16

The NCT of Delhi is an example wherejudicial activism, combined with political willand inputs provided by nongovernmentalorganizations and international agenciessaved the city from near disaster on account ofits explosive urban growth, compounded byinadequate and poorly implementedregulations. The use of CNG to reduce airpollution appears to have been a transient

success, as the increase in number of vehiclesare neutralizing the gains achieved throughCNG. Therefore, a new and innovativestrategy focused on promoting masstransportation with less dependence on fossilfuels can offer a better solution. However, theissue of air quality will continue to present achallenge to city planners.

References(1) United Nations. World urbanization prospects: the

2003 revision. New York, 2004.

(2) Vlahov D, Freudenberg N, Proietti F, Ompad D,Quinn A, Nandi V, Galea S. Urban as a determinantof health.Journal of Urban Health. 2007 May;84(Suppl 1): 1626.

(3) United Nations Human Settlements Programme (UN-Habitat). The challenge of slums: global report on

human settlements 2003. Nairobi: UN-Habitat, 2003.http://www.unhabitat.org/downloads/docs/GRHS.2003.0.pdf- accessed 23 February 2010.

(4) Sclar ED, Garau P, Carolini G. The 21st centuryhealth challenge of slums and cities. Lancet. 2005Mar 5; 365(9462): 901-3.

(5) India, Ministry of Surface Transport. Report of theworking group on road transport for the 9th five-yearplan (1997-2002). New Delhi: MoST, 1996. p. 136
http://www.unhabitat.org/downloads/docs/GRHS.2003.0.pdfhttp://www.unhabitat.org/downloads/docs/GRHS.2003.0.pdfhttp://www.unhabitat.org/downloads/docs/GRHS.2003.0.pdfhttp://www.unhabitat.org/downloads/docs/GRHS.2003.0.pdf


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(6) Maureen L. Cropper, Nathalie B. Simon, AnnaAlberini, Seema Arora, P. K. Sharma. The healthbenefits of air pollution control in Delhi.American

Journal of Agricultural Economics. 1997 Dec.; 79(5):1625-1629.

(7) Registrar General and Census Commissioner of India.Census of India. New Delhi: Office of the RegistrarGeneral, 2001.

(8) India, Ministry of Environment and Forests. Whitepaper on pollution in Delhi with an action plan. NewDelhi: MoE&F, 1997.http://envfor.nic.in/divisions/cpoll/delpolln.html -access 16 February 2010.

(9) Huizenga C, Haq G, Schwela D, Fabian H, Ajero M.Air quality management capability in Asian cities.August 2004.http://www.cleanairnet.org/caiasia/1412/articles-59072_paper.pdf- accessed 16 February 2010.

(10)India, Ministry of Environment and Forests. In exerciseof the powers conferred by sub-sections (1) and (3) of

section 3 of the Environment (Protection) Act, 1986 (29of 1986). Order. S.O. 93 (E). New Delhi: MoE&F,1998.

(11)Frontline. The Hindu: India's national magazine. 2002Apr. 27 - May 10; 19(9).

(12)Ravindra K, Wauters E, Tyagi SK, Mor S, Van GriekenR. Assessment of air quality after the implementation ofcompressed natural gas (CNG) as fuel in publictransport in Delhi, India. Environmental Monitoringand Assessment 2006; 115 (1-3): 405-417.https://uhra.herts.ac.uk/dspace/bitstream/2299/2029/1/901262.pdf- accessed 23 February 2010.

(13)Tackling urban transport: operating plan for Delhi.

Delhi: Transport Department: 2002.http://web.iitd.ac.in/~tripp/delhibrts/brts/hcbs/hcbs/gnctpress1.htm - accessed 16 February 2010.

(14)India, Press Information Bureau. Construction workerscovered by Employee State Insurance, and EmployeeProvident Fund act. Rajya Sabha. Wednesday, July 29,2009.

(15)Air pollution in Delhi. URBANEMISSIONS.info. NewDelhi. 2009.http://www.urbanemissions.info/simair/SIM-22-2009-AQ-Management-Delhi.html - 16 February 2010.

(16)Anjana D, Parikh J. Transport scenarios in two

metropolitan cities in India: Delhi and Mumbai.Energy Conversion and Management. 2004; 45(15-16): 2603-25.

http://envfor.nic.in/divisions/cpoll/delpolln.htmlhttp://www.cleanairnet.org/caiasia/1412/articles-59072_paper.pdfhttp://www.cleanairnet.org/caiasia/1412/articles-59072_paper.pdfhttps://uhra.herts.ac.uk/dspace/bitstream/2299/2029/1/901262.pdfhttps://uhra.herts.ac.uk/dspace/bitstream/2299/2029/1/901262.pdfhttp://web.iitd.ac.in/~tripp/delhibrts/brts/hcbs/hcbs/gnctpress1.htmhttp://web.iitd.ac.in/~tripp/delhibrts/brts/hcbs/hcbs/gnctpress1.htmhttp://www.urbanemissions.info/simair/SIM-22-2009-AQ-Management-Delhi.htmlhttp://www.urbanemissions.info/simair/SIM-22-2009-AQ-Management-Delhi.htmlhttp://www.urbanemissions.info/simair/SIM-22-2009-AQ-Management-Delhi.htmlhttp://www.urbanemissions.info/simair/SIM-22-2009-AQ-Management-Delhi.htmlhttp://web.iitd.ac.in/~tripp/delhibrts/brts/hcbs/hcbs/gnctpress1.htmhttp://web.iitd.ac.in/~tripp/delhibrts/brts/hcbs/hcbs/gnctpress1.htmhttps://uhra.herts.ac.uk/dspace/bitstream/2299/2029/1/901262.pdfhttps://uhra.herts.ac.uk/dspace/bitstream/2299/2029/1/901262.pdfhttp://www.cleanairnet.org/caiasia/1412/articles-59072_paper.pdfhttp://www.cleanairnet.org/caiasia/1412/articles-59072_paper.pdfhttp://envfor.nic.in/divisions/cpoll/delpolln.html


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Effects of climate change on urban health in the Kathmandu Valley

Babu Ram Marasini*

BackgroundThe effects of climate change on inland highaltitude cities such as Kathmandu, Nepal aremultifarious. Specifically, a health-relatedimpact has been shown in changing patternsin disease outbreaks.

Kathmandu is a mountainous valley with899 square kilometres in total surface area, atan altitude of 1372 metres from mean sealevel. The total population of the KathmanduValley was estimated to be 2 million in 20091.There are three districts and five municipalitiesand some suburban areas within theKathmandu Valley. Kathmandu, being thecapital city of Nepal, has very high populationpressure due to its better security, health,

education and ongoing economic activities,especially in the construction sector. TheKathmandu Valleys bowl-shaped topography,which restricts air movement and traps airpollutants,2 make it vulnerable to extremeclimate conditions and air pollution. However,the valley is not directly connected with theHimalayas through glacial rivers, so it is notvulnerable to glacial lake outburst floods(GLOF), which is one of the most importantexpected factors for severe flooding in rivers

and low-lying areas.

Nepal is divided into three ecologicalbelts: the Himalayan belt in the north on theChinese border, the plain or terai belt in thesouth adjoining northern India, and the hilly

belt lying in between the high and lowecological regions. The Kathmandu Valley fallsin the hilly region. Rainfall in Nepal is verymuch linked to the South Asian monsoonpatterns.

Objective, methodology and processThe objective of this paper is to review theeffects of climate change on environmentaland urban health of population living in theKathmandu Valley.

A review of secondary literature focusingon studies and articles related to climatechange and environmental and urban healthin the Kathmandu Valley has been undertaken.Policy-level recommendations have been

provided based on the reviewed studies andarticles.

Evidence establishing linkages betweenclimate change and urban health is notsubstantial. Therefore, this paper is restricted interms of its conclusions, and neither is itexhaustive.

The findings have been presented in termsof the following parameters: water supply andsanitation, air pollution, and the effects of

climate change on urban health.

Water supply and sanitationThe daily requirement of water in theKathmandu Valley is 280 million litres ofdrinking water per day; however, KathmanduUpatyaka Khanepani Limited (KathmanduValley Water Supply Limited) is supplying only

* Senior Health Administrator, Ministry of Health andPopulation, Kathmandu, Nepal



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160 million litres per day.3 Drying up oftraditional sources of drinking water anddecreases in water flow in rivers flowing in thevalley due to erratic rainfall patterns has led toshrinking of drinking water production and anincrease in river pollution. To compensate for

the decreased water production, water supplyagencies are using underground water fordrinking purposes, and this is also causing adecrease in the underground water level everyyear. Use of underground water is drying uptraditional water spouts, which is one of thesources of drinking water for the poor andunderprivileged because piped drinking wateravailability is very low in many areas of theKathmandu Valley. This is affecting the healthof the poor as they are compelled to consume

unsafe water.There is a complex relationship between

unplanned growth in urban populations andenvironmental health. As urban populationgrows, the demand for essential services suchas water, sanitation and sewerage fails to meetthe supply. Contaminated surface andgroundwater sources, poor faeces disposaland inadequate sanitation and seweragenegatively affect human health.

Lack of adequate water supply is makingsanitary conditions unsatisfactory in many partsof the valley. Rapid urban growth has alsoincreased the daily production of solid wasteand consequently, proper and timely disposalis becoming a major problem. Improper solidwaste disposal causes the germination ofharmful vectors, viruses and bacteria,especially during summers. Climate change isresulting in extreme weather events, whichfurther contribute to changing patterns of

morbidity and mortality associated with vector-borne and water-borne diseases.

There exits a climate change and waternexus. Climate change results in extremeweather events, which in turn has an impacton the way water is used. Water variability isseen to be more of a threat on growth thanwater scarcity. This variability is expected toincrease with climate change. The Kathmandu

Valley is highly vulnerable given the highpopulation density, poverty and dependenceon rainfall. As a result, the effects of climatechange on water resources could either leadto cooperation or conflict as competition forresources and stress from extreme weather

events increase. The possibility of conflict isgreater, and this would have a detrimentalimpact on growth, security and sustainability.The problem of sanitation, associated withwater variability and water scarcity, would alsoworsen.

Air pollutionAir pollution is emerging as a major problemin Nepals urban centres, particularly in the

Kathmandu Valley and large cities. Thisproblem is further compounded by rapid andhaphazard growth, leading to densesettlements, the mushrooming of pollutingindustries, a poor road network, and a largelyunmanaged transportation system. Airpollution in the valley, particularly theconcentration of particulate matter (PM), isalready several times higher than national andinternational standards. Data for 2005indicate an average PM10 level of 135

microgrammes per cubic metre for residentialurban areas in the valley.4 This air qualitycontinues to deteriorate, mainly due to risingnumbers of vehicles and industries, andcontributes to the presence of a thick haze.

Climate change and urban health in theKathmandu ValleyExtreme weather events are being witnessed in

the Kathmandu Valley as a result of climatechange. Global warming is resulting in anincreased length of summers with warmerdays, more days with higher intensity of rainfallper day, and fewer days of rainfall.

As mentioned earlier, climate change andrapid urbanization is resulting in theemergence of new vectors and viruses. A studyhas shown the existence of at least 12 types of



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mosquitoes ofculexand anopheles species inthe Gokarna area, a suburban area ofKathmandu.5 Aedes aegypti a vectorresponsible for dengue fever, was also foundin Kathmandu in June 2009.6 Japaneseencephalitis (JE) cases have been reported

from hilly districts of Nepal since 2004. Thecause of acute encephalitis in hill andmountain districts is noted to be consistent withthe report of JE endemicity in the KathmanduValley7. Circulating filarial antigen (CFA) ofWuchereria bancrofti was particularly high inthe village development committees (VDCs)tested in that area (e.g. 20% in Kathmanduand Bhaktapur, 26% in Kavre)8. Leptospirosishas been found in half of the 36 patients in astudy carried out by Patan Hospital, Lalitpur in

patients with acute febrile illnesses

9

andseroprevalence of 32.5% was found inresidents of Kathmandu Valley in another studyon leptospira infection carried out byTribhuvan University Teaching Hospital,Kathmandu.10

Lalitpur district is located in the west andsouth of the Kathmandu Valley, and 13 casesof malaria were detected in this district in2006; out of these, two were confirmed casesof indigenous malaria11.

Bacterial diseases such as cholera,typhoid fever and food poisoning are alsogradually increasing in the valley because ofpoor quality of drinking water, deterioratingsanitary conditions and problems linked to thesolid waste disposal system; increases intemperature due to climate change can leadto the widening of the geographic range ofvectors.

Discussions and conclusionsClimate change is having an impact on urbanhealth in the Kathmandu Valley. The effect ofclimate change on health can be minimized byimproving the quality of drinking water,sanitation, solid waste disposal and managingurban population growth. There is an urgentrequirement to complete a major water supplyproject to meet the requirement for safedrinking water in the Kathmandu Valley; theMelamchi Water supply project is beingimplemented. Upgrading of roads is requiredas flooding of roads and low-lying areas is aregular phenomenon due to intense rain, andthis requires upgrading of the seweragesystem.

Since there is little evidence to establishthe cause-effect relationship between climatechange and effects on urban health, moreapplied research needs to be undertaken. It isimperative to have a stronger diseasesurveillance system in place. Vulnerabilityassessment needs to be conducted to identifyhot spots of disease outbreaks linked tochanging climate. Advocacy among allstakeholders has to be promoted, and astronger focus put on multisectoral

convergence. Community resilience needs tobe built up through capacity building andempowerment. This will hopefully result inmitigation and adaptive mechanisms beingput in place by the community, thereforeincreasing sustainability.

References and bibliography(1) Government of Nepal, Ministry of Health and

Population. Nepal District Health Profiles 2007. EHAPublications No. 22. Kathmandu, December 2007.

(2) World Bank. Nepal: country environmental analysis,strengthening institutions and management systems forenhanced environmental governance. Washington,2008. http://www-

wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdf- accessed 26 February 2010.

(3) Kathmandu Upatyaka Khanepani Limited (KUKL).Katmandu. Web site:http://www.kathmanduwater.org/home/index.php
http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www.kathmanduwater.org/home/index.phphttp://www.kathmanduwater.org/home/index.phphttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdfhttp://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/04/09/000020439_20080409135430/Rendered/PDF/389840white0cover0Nepal0CEA1webversion.pdf


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(4) Strategic Foresight Group. International Workshop onChallenges of Water Stress and Climate Change in theHimalayan River Basins: Collaborative DialogueProcess, Kathmandu 6-7 August 2009. Mumbai,2009.http://www.strategicforesight.com/Kathmandu%20Report.pdf- accessed 26 February 2010.

(5) MoEST website. www.moest.gov.np - accessed on 22February 2010.

(6) Pradhan SP et al. Epidemiological study of lymphaticfilariasis in Gokarna village development committeeduring August and September 1997.Journal of NepalHealth Research Council. 1998; 2:13-17.

(7) Gautam I, Dhimal MN, Shrestha SR, Tamrakar AS.First record of Aedis aegypti (L) vector of dengue virusfrom Kathmandu, Nepal.Journal of Natural HistoryMuseum. 2009; 24: 156.

(8) Bhattachan A, Amatya S, Sedai TR, Upreti SR,Partridge J. Japanese Encephalitis in hill and mountaindistricts, Nepal. Emerging Infectious Diseases. 2009

Oct; 15 (10): 1691-2.http://www.cdc.gov/eid/content/15/10/pdfs/1691.pdf- accessed 27 February 2010.

(9) Sherchand JB, Obosomer V, Thakur GD, Hommel M.Mapping of lymphatic Filariasis in Nepal. Filaria

Journal. 2003 Mar 19; 2(1):7.http://www.filariajournal.com/content/pdf/1475-2883-2-7.pdf- accessed 27 February 2010.

(10)David Murdoch et al, The etiology of febrile illness inadults presenting to Patan Hospital In Kathmandu,Nepal.American Journal of Tropical Medicine and

Hygiene. 2004; 70(6): 670-675.http://www.ajtmh.org/cgi/content/abstract/70/6/670 - accessed 27 February 2010.

(11)Rai SK, Shibata H, Sumi K, Uga S, Ono K, ShresthaHG, Matsuoka A, Matsumura T. Serological study ofleptospira infection in Nepal by one-point MCAmethod.Journal of Infectious Diseases Antimicrobial

Agents. 2000 Jan-Apr: 17: 29-32.http://www.idthai.org/Publication/pdf/Vol17-1/Ch5-V17-1P29-32.pdf- accessed 27 February 2010.

(12) Government of Nepal, Ministry of Health andPopulation. The internal assessment of malaria andkala-azar control activities, 2004, 2005, 2006.Department of Health Services, Epidemiology andDisease Control Division, Teku, Kathmandu, 2007.

http://www.strategicforesight.com/Kathmandu%20Report.pdfhttp://www.strategicforesight.com/Kathmandu%20Report.pdfhttp://www.moest.gov.np/http://www.cdc.gov/eid/content/15/10/pdfs/1691.pdfhttp://www.cdc.gov/eid/content/15/10/pdfs/1691.pdfhttp://www.filariajournal.com/content/pdf/1475-2883-2-7.pdfhttp://www.filariajournal.com/content/pdf/1475-2883-2-7.pdfhttp://www.ajtmh.org/cgi/content/abstract/70/6/670http://www.idthai.org/Publication/pdf/Vol17-1/Ch5-V17-1P29-32.pdfhttp://www.idthai.org/Publication/pdf/Vol17-1/Ch5-V17-1P29-32.pdfhttp://www.idthai.org/Publication/pdf/Vol17-1/Ch5-V17-1P29-32.pdfhttp://www.idthai.org/Publication/pdf/Vol17-1/Ch5-V17-1P29-32.pdfhttp://www.ajtmh.org/cgi/content/abstract/70/6/670http://www.filariajournal.com/content/pdf/1475-2883-2-7.pdfhttp://www.filariajournal.com/content/pdf/1475-2883-2-7.pdfhttp://www.cdc.gov/eid/content/15/10/pdfs/1691.pdfhttp://www.cdc.gov/eid/content/15/10/pdfs/1691.pdfhttp://www.moest.gov.np/http://www.strategicforesight.com/Kathmandu%20Report.pdfhttp://www.strategicforesight.com/Kathmandu%20Report.pdf


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Effects of urbanization on health behaviours ofyoung people in Timor-Leste

Rui Maria de Araujo*

IntroductionUrbanization is defined by the United Nationsas the movement of people from rural tourban areas, whose population is projected to

amount to half of the worlds population in2008, rising to about 60% in 20301. As anincreasingly higher number of people leavefarms and villages to live in cities particularly inthe developing countries, urban centres willgrow at a rate previously unseen in mankindshistory. According to the UN State of theWorld Population 2007 report, 93% of urbangrowth will occur in developing nations, with80% of it occurring in Asia and Africa2.

Rates of urbanization vary between

countries, and urbanization is normallydetermined by individual initiatives in searchfor better economic opportunities. Forexample, in developed countries, people find itdifficult to improve their standard of livingbeyond basic sustenance in the rural areas,because farm life is dependent onunpredictable environmental conditions, andin times of drought, flood or pestilence,survival becomes extremely problematic.Cities, in contrast, are places where money,services and wealth are centralized on onehand, and on the other, better basic servicessuch as education, health care, water andsanitation, as well as better opportunities andvariation of jobs are provided3. In developing

countries, however, despite similarities in themotivation for rural dwellers to migrate tourban centres, unlike their peers in thedeveloped world, they normally findthemselves living in suburbs, without much

access to better basic services, and often timesending up as unemployed and the mostmarginalized ones of their society. In additionto that, available data indicate a range ofurban health hazards and associated healthrisks such as substandard housing; crowding;air pollution; insufficient or contaminateddrinking water; inadequate sanitaztion andsolid waste disposal services; vector-bornediseases; industrial waste; increased motorvehicle traffic injuries; stress associated with

poverty; and unemployment4

.In Timor-Leste, recorded information

about the dynamics of urbanization dates backto the mid-1800s when, the capital city of Dili,founded on 10 October 1769, by 1860 hadup to 2% of the total population of Timor-Leste5. The percentage of urban Dilispopulation during the Portuguese colonialperiod, however, remained almost unchangedthroughout the early and mid-Tenth century,(1.8% of the total population by 1927 and1.5% by 1970), but increased to about 18%by 1996, during the Indonesian militaryoccupation, and by 2004, when the firstpopulation census of an Independent Timor-Leste was conducted, it was 19%5, 6, 7.

The initial agglomeration of population inthe capital city of Dili since the mid-19thcentury was mainly driven by colonial policy,

* The author is currently working as a generalpractitioner in Dili, Timor-Leste, and was Minister forHealth of the Democratic Republic of Timor-Leste,between 2001 and 2007.



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and there were no indications of ruralindigenous people migrating to seek bettereconomic advancement5. The rapid increasein population movement from outlying districtsto the capital city of Dili, during the late 1900sand the first decade of this century, however,

appear to have been caused by political,social and economic instability experienced bythe rural population in Timor-Leste, firstly dueto 24 years of military occupation, andsecondly because of post-independencedevelopment initiatives8. This increasing trendof urbanization in Timor-Leste, apart fromcarrying obvious political, social, economicand environmental effects for the country ingeneral, is also producing effects on the healthof population and individuals, particularly in

the aspects of risk-taking and health-seekingbehaviours. This paper seeks to explore anddiscuss some of these effects of urbanizationby examining practices related to alcohol andtobacco use, and to unsafe sex among youngpeople in Timor-Leste.

Urbanization in Timor-LesteTimor-Leste is a post-conflict country thatgained its independence in 2002, after

Portuguese colonial rule between the 1500sand 1975, and the liberation struggle wagedby its people against Indonesian militaryoccupation between 1975 and 1999. Morethan 40% of its estimated population of1 149 000 (2010) live below the nationalpoverty line of less than US$ 0.88 per day,with 85% of them living in rural, and mainlysubsistence agricultural areas8.

In this sense, the definition of an urban

place applicable to Timor-Leste involvesspatial concentration of people whose lives areorganized around non-agricultural activities.By this classification, the population of Dili isby far the most urban in Timor-Leste at almost90%. The population census of 2004identified that the five most densely populatedsubdistricts of the country were located in thecapital, representing 21% of the countryspopulation, but occupying only 1.5% of its

land area. By contrast, the 25 most sparselypopulated sub-districts are home to 21% ofthe population but these cover almost 50% ofthe countrys land area7. Some additionalcharacteristics of urban Dilis populationdescribed by the census 2004 are summarized

in the following paragraph

7

.Firstly, in 2004, only 54% of the total

population of Dili was born in Dili, and 46%were migrants from outlying districts.Secondly, there is a concentration of males inand around Dili, reflecting a movement ofmales and particularly young men, to thecapital in search of work. Thirdly, Timor-Lestes average household size is 4.7, butDilis average household size is 5.2 in four ofits five subdistricts, partially explaining the

large number of people who have migratedfrom rural areas, and lastly, urbanization inDili reflects a population that is less than 65years old. Dili has the highest proportion ofpopulation older than 18 years whograduated from high school, with theproportion of males being higher than that offemales by 7.3%. Moreover, taking the agegroup between 15 and 34 years as thedefining age range for young people inTimor-Leste, the data from the same census

show that 30% of the population belong tothis age group, and 35% of them live in urbanareas9.

The social benefits of living in urban areasin Timor-Leste can be attested frominformation provided by the Timor-Leste Surveyof Living Standards (TLSLS) conducted in2007, which for example, showed that thepercentage of population living in urban areaswith good housing conditions was twice as

much compared to those living in rural areas,and the average travel time to hospitals andclinics, secondary schools or busterminals/stops, was half for those living inrural areas8. Additionally, the rate of highestsecondary school attainment among youngpeople in 2007, was 26.7% in urban and9.7% in rural areas respectively, while the rateof ability to both read and write withoutdifficulty was 66.7 in urban areas and 40.4 in



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rural areas. Nevertheless, as in many otherdeveloping countries, the misconceivedassumption that urban areas provide betteropportunities for economic life can also beobserved in Timor-Leste. The evidence fromthe TLSLS showed that the total unemploymentrate in urban areas (11.5%) was significantlyhigher compared to rural areas (2%). Amongyoung people, 7.1% in rural areas wereunemployed whereas in urban areas thepercentage was 41.5%9.

Health behaviour among urban and ruraldwellers in Timor-LesteBroadly speaking, a better educationattainment is associated with having abeneficial health behaviour. This means that abetter educated person is more likely to avoidrisk-taking behaviours leading to vulnerabilityto contract a disease. In urban areas, betteraccess to health facilities, and better economicstatus of the population are associated withbetter use of health-care services. In factexamples in many countries corroborate thisassumption, and in Timor-Leste, despite thelack of disaggregated information specificallyfocused on young people, a health care-seeking behaviour study conducted in 2008concluded that long distances to healthfacilities in rural areas discouragedattendance, in particular for non-urgentconditions and preventive care. And during thewet season, even short distances could be abig problem10. Moreover, economic factorsfurther complicate access to and use of healthfacilities in rural areas particularly due to theunaffordable costs associated with referral toanother health facility, including hiringtransport and accompanying the patient to thefacility10. Similarly, urban dwellers are likely tobe more responsive to healthy behaviourattitudes advocated by health authorities. TheTLSLS, for example, found that 68% urbandwellers slept under a mosquito net comparedto only 47.3% rural dwellers, and 25.6%children less than 5 years old were fullyimmunized, compared to 18% in rural areas9.

Contrasting this positive associationbetween living in urban settings and thelikelihood of practising healthy attitudes is,however, the fact that rural dwellers in Timor-Leste perform better in respect of their purposeof visit to a health-care provider. The TLSLS

showed, for example, that 39.8% rural peoplevisited a health-care provider for treatment,and 7.8% for preventive care, compared to27.9% for treatment, and 5.6% for preventivecare in the case of the urban population9. Thiscan mean a low awareness of the need tohave treatment and preventive care on the partof urban citizens, which can potentiallycontribute to their poor health status.

Practices of risk-taking behaviour withregard to alcohol and tobacco use, andof unsafe sex among young people inTimor-LesteLiterature on alcohol and tobacco use, and onunsafe sex among young people in Timor-Leste is not widely available. Nonetheless, arange of publications provide evidence on themagnitude of the problem in the generalpopulation. Firstly, the WHO GlobalInformation System on Alcohol and Healthstates that the adult per capita consumption ofalcohol in Timor-Leste is around 0.4 litres ofpure alcohol, and that overall, the recordedconsumption has decreased in recent years.Beer accounts for 97% of alcoholconsumption, wine 3% and spirits less than1%, and there is no information about the useof surrogate alcohol11. There is also noinformation about the prevalence and patternsof alcohol consumption and its associatedhealth risk behaviours, particularly amongyoung people.

Secondly, Timor-Leste has one the highestprevalence rates of cigarette smoking amongadolescents. The Global Youth TobaccoSurvey conducted in 2006 reported that theprevalence rate of cigarette smoking amongin-school adolescents in Timor-Leste was



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32.4%, the highest compared to othercountries in the South-East Asia Region, andperhaps one of the highest in the world. Thisprevalence rate was more than twice as highcompared to Indonesia (12.6%) and Brazil(15.4%) and eight times higher than Cuba

(4.2%)

12

. The highest prevalence rate everreported was for Greece with 16.2%13. Twothirds students live in homes where otherssmoke, while 7 in 10 students are exposed tosmoke in public places and two thirds of themhave parents who smoke12. While there areinadequate data to draw upon, the rate oftobacco use among adults in Timor-Leste in1995 was 53.9% in men, and 6% in women14,while recent estimations put it to be as high as70-80%15. Such high prevalence of smoking

among men and in-school adolescents inTimor-Leste can be a sign of unhealthybehaviour having its origins in the post-conflictenvironment that is getting increasinglyurbanized.

Thirdly, despite the scarcity of evidence onsexual behaviour of the Timorese people,including young people, a qualitative surveyconducted in 2004 in the capital city of Dilishowed that risky sexual behaviour was not thenorm in Timor-Leste even among groups

commonly believed to engage in such riskybehaviour, such as truck drivers andstudents16. Nevertheless, the same survey alsofound that a high proportion of the selectedpopulation reported non-marital sex, andcondom use was universally low even incommercial and anal sex. Most extramaritalsex was commercial, but in addition tocommercial sex partners, 22% of heterosexualhigh-risk men reported having sex with a girlfriend. Just 1% male clients reported to

always using condom during sex with sexworkers, and two thirds reported that they hadnever used a condom at all. Bisexualbehaviour was not uncommon, becausenearly half the men included in the study hadhad sex with men, and also reported to havinghad sex with women, while 12% soldiers anddrivers reported to having had sex with bothmen and women15.

Contrasting this seemingly urban sexualbehaviour in Dili is the higher percentage ofrural populations knowledge regarding waysto avoid HIV/AIDS. The TLSLS found, forexample, that 50.2% rural population felt thatuse of condoms could prevent HIV/AIDS,

compared to only 31.4% urban population,and that 56.7% rural population were of theopinion that avoiding sex with people havingmany partners could prevent HIV/AIDS, whileonly 27.2% urban dwellers felt the same way9.

Relationship between urbanization andhealth behaviour, and risk-taking practicesamong young people inTimor-LesteThe available evidence summarized in theprevious sections does not provide a cleardistinction between heath behaviour and risk-taking behaviour among young people livingin urban and rural areas nor any sign ofassociation between urbanization and heathbehaviour or risk-taking behaviour amongyoung people. Nevertheless, the followinghighlights can be proposed. Firstly, it appearsthat contemporary urban agglomeration inTimor-Leste has a significant component ofyoung people who established themselves inthe capital city prior to, and duringindependence of the country in 2002, insearch of a better life. Although there are nostudies related to the effects of urbanization ontheir health behaviour or risk-taking practices,the rate of unemployment which they aresubject to can represent a significant precursorto risk-taking practices related to alcohol andtobacco use, as well as to unsafe sexualpractices.

Secondly, despite better access to health-care services and better health practices suchas bednet use, the urban dwellers performworse in respect to the purpose of visits to ahealth-care provider, as compared with theirrural peers. Again, lack of disaggregatedhealth-seeking behaviour data on urban and



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rural young people makes it difficult to drawany association between urbanization andhealth-seeking behaviour of young people.Nevertheless, since 35% young people agedbetween 15 and 34 years in Timor-Leste live inurban areas, they may as well be reasonably

included in the category of those with lowerperformance with regard to their purpose ofvisits to a health-care provider.

Thirdly, alcohol consumption, althoughnot alarmingly high, is quite significant amongTimor-Lestes population. As with otherbehaviours mentioned above, no studies havebeen conducted in Timor-Leste to ascertain themagnitude of the problem, particularly amongthe young people living in urban and ruralareas, and yet anecdotal accounts widely

circulating in the community point to asignificant involvement of young urbandwellers of Dili in alcoholic-related behaviourduring the periods of political unrest andviolence in 2006.

Fourthly, prevalence of cigarette smokingamong Timorese males, includingadolescents, is the highest in the South-EastAsia Region, and perhaps one of the highest inthe world. No disaggregated data among

urban and rural areas can be found in theresults of studies that are available.Nonetheless, as 85% poor people live in ruralareas, and one important enabling factor foradolescent smoking in Timor-Leste is having apocket money of more than US$ 5 a month, itis most unlikely that rural adolescent studentswould be the most heavy cigarette smokers.

Finally, risky sexual behaviour is highamong urban men, but knowledge of effective

ways to prevent HIV/AIDS and sexuallytransmitted infections (STIs), including use ofcondom and avoiding sex with people havingmany partners, is higher among the ruralpopulation, as compared with people living inurban areas. Despite not providing an

accurate association between urbanizationand risky sexual behaviour of young men, orpositive knowledge on prevention of HIV/AIDSand STIs in rural young men, these findingssuggest higher risk-taking sexual behaviouramong men living in urban areas.

ConclusionThe extent to which urbanization is likely topromote or discourage health-seeking

behaviour and risk-taking practices amongyoung people in Timor-Leste is difficult to beestablished on the basis of the availableinformation. Nevertheless, the existingevidence suggests that the current trends ofurbanization, coupled with the ubiquitouspoverty in rural Timor-Leste, as well as highunemployment rates in the urban capital city ofDili, are likely to continue to exert theirinfluence, both beneficially and harmfully, onthe health-seeking behaviour patterns, and

risk-taking practices of Timor-Lestes citizens. Ifthe right policies aimed at averting theclassical consequences of urbanization,including its health hazards, are to be in place,then substantial attention should be given to amore detailed evidence-gathering in this area,which could help policy-makers to deviselocally-sensitive interventions for the benefit ofeveryones health in a not-so-distant urbanizedTimor-Leste.

References(1) United Nations. World urbanization prospects: 2005

revision. New York: UN Department of Economic andSocial Affairs, 2006.

(2) United Nations Population Fund. State of worldpopulation 2007: unleashing the potential of urbangrowth. New York: UNFPA, 2007.http://www.unfpa.org/swp/2007/presskit/pdf/sowp2007_eng.pdf- accessed 25 February 2010.

(3) Wikipedia. Urbanization.http://en.wikipedia.org/wiki/Urbanization - accessedon 25 February 2010.

(4) Moore M, Gould F, Keary BS. Global urbanizationand impact on health. International Journal onHygiene and Environmental Health. 2003; 206(4-5):269-78.
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(5) Gunn GC. Timor Loro Sae 500 years. Hongkong:Livros do Oriente, 1999.

(6) Kanwil Kesehatan Timor-Timur. Profil KesehatanPropinsi Timor-Timur Tahun 1996. Jakarta: Republic ofIndonesia, Ministry of Health 1996.

(7) Timor-Leste National Statistics Directorate. Timor-Leste: census of population and housing 2004: atlas.

Dili: National Statistics Directorate, 2006.(8) Timor-Leste National Statistics Directorate. Population

projections 2004-2050: analysis of census results,report 1. Dili: National Statistics Directorate, 2006.

(9) Timor-Leste National Statistics Directorate. Timor-Leste survey of living standards: report. Dili: NationalStatistics Directorate, 2007.

(10)Zwi AB, Blignault I, Glazebrook D, CorreiaV, BatemanSteel C.R, Ferreira E, Pinto, BM. Timor-Leste healthcare seeking behavior study. Sydney: University ofNew South Wales, 2009.

(11)World Health Organization. WHO Global InformationSystem on Alcohol and Health (GISAH). Geneva:WHO, 2009.http://apps.who.int/globalatlas/default.asp - accessed25 February 2010.

(12)Kusumawardani N, Rahman K, Warren CW, JonesNR, Asma S, Lee J, Serekai M. Report on global youthtobacco survey Timor-Leste. 2006.http://www.searo.who.int/LinkFiles/GYTS_TimorLeste.pdf- accessed 25 February 2010.

(13)Siziya S, Muula AS, Rudatsikira E. Prevalence andcorrelates of current cigarette smoking amongadolescents in Timor-Leste. Indian Paediatrics. 2008

Dec; 45 (12): 963-8.

(14)Indonesia national socio-economic survey 1995 and2001. Chapter 1: Cigarette consumption andsmoking prevalence. Jakarta, March 2004. p. 1-11.http://www.litbang.depkes.go.id/tobaccofree/media/TheTobaccoSourceBook/TobaccoBook/7_ch.1-March18.03.pdf - accessed 26 February 2010.

(15)Indigo Foundation. East Timor, Tobacco ControlProgram. Dickson ACT, 2008.http://www.indigofoundation.org/easttimor.php -accessed on 26 February 2010.

(16)Pisani E. and Dili Survey Team, HIV, STIs and RiskBehavior in East Timor: An historic opportunity foreffective action (FHI-IMPACT/East Timor Project, Dili,East Timor, 2004). Dili: Family Health International,2004.

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Urbanization dynamics and WHOs healthy city initiativesin the South-East Asia RegionSurinder Aggarwal* and Abdul Sattar Yoosuf**

AbstractIt is an accepted fact that the fast and skewed urbanization process that is presently taking place in theWHO South-East Asia (SEA) Region is becoming a powerful agent of change and is accompanied witheconomic opportunities, environmental threats and health challenges. The present paper examinesprimarily the process of urban dynamics and its health challenges in the SEA Region and how the healthycity initiatives have responded to this urban challenge to sustain and promote health in various urbansettings and vulnerable communities. We present in brief a review of the healthy cities programme incountries of the SEA Region and the constraints in engaging the healthy settings process. Finally, wepresent a critical analysis of the healthy city programme in countries of the SEA Region including(i)strengths and limitations of healthy cities projects in South-East Asia; (ii) lessons learnt, (iii) the wayforward; and (iv) the future of the healthy settings movement in a fast urbanizing Region.

ContextFor the first time, half the world populationnow lives in urban areas. By 2030, this isexpected to swell to almost five billion.1Furthermore, a large share of new urbangrowth shall be borne by developing countrieslike China and India and by emerging megacities like Bangk

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Regional Health Forum_WHO