THE ENTICEMENT OF CITIES: THE HEALTH AND ECONOMIC CHALLENGES AND
OPPORTUNITIES OF RURAL MIGRATION
by
Olivia R. Cupelli
B.A. in Corporate Communication, Duquesne University, 2010
Submitted to the Graduate Faculty of
Health Policy and Management
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Health Administration
que
University of Pittsburgh
2015
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Olivia R. Cupelli
on
April 13, 2015
and approved by
Essay Advisor:
Julia Driessen, PhD, MA, BS
Assistant Professor
Health Policy and Management
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Ann M. Samler, PhD, MS, BS- LSSMBB
Part Time Faculty
Industrial Engineering
Swanson School of Engineering
University of Pittsburgh
______________________________________
_____________________________________
ii
Copyright © by Olivia R. Cupelli
2015
iii
Julia Driessen, PhD, MA, BS
THE ENTICEMENT OF CITIES: THE HEALTH AND ECONOMIC CHALLENGES AND
OPPORTUNITIES OF RURAL MIGRATION
Olivia R. Cupelli, MHA
University of Pittsburgh, 2015
ABSTRACT
Education and employment status are positively correlated with improved health. As the world
continues to undergo urbanization and rural migrants continue to travel to cities to pursue education
and employment opportunities. However, no matter how much a city has to offer, access to these
opportunities is not always available to citizens. Many migrants are forced to seek refuge in slums,
which increases the risk of public health concerns. Communicable diseases, lack of sanitation, and
an increase in social concerns, and offset the potential health inputs of education and employment
opportunities. Political and economic intervention that focus on national economic growth and
national development policies specific to urbanization can be implemented as a way to ease the
urbanization process and to decrease health inequalities of rural migrants. As evidenced by South
Korea’s rapid urbanization process, through strategic and well thought out planning and investing in
citizens through providing education and employment opportunities, healthier society can be
created. Producing a stronger workforce is the foundation for a flourishing country.
iv
TABLE OF CONTENTS
I. INTRODUCTION……………………………………………….……………………………….....1
II. HEALTH INPUTS: EDUCATION AND EMPLOYMENT…………………………..................5
II.I EDUCATION…………………………………………………………….........................5
II.II EMPLOYMENT……………………………………………………………………..….6
III. ACCESS TO EDUCATION AND EMPLOYMENT IN URBAN AREAS……………............9
III.I EDUCATION IN URBAN AREAS……………………………………………..….....10
III.II EMPLOYMENT IN URBAN AREAS…………………………………………..…...11
IV. RURAL MIGRANTS’ SETTLEMENT INTO CITIES…………………………………..…...12
V. HEALTH RISKS ONCE RURAL MIGRANTS BECOME SLUM RESIDENTS……………15
IV.I LACK OF MEDICAL CARE………………………..…………………………….......15
IV.II SANITATION AND ENVIRONMENT POLLUTION………………….…………..17
IV.III VIOLENCE AND CRIME SOCIAL ISSUES……………………………………....18
VI. POLICY PLANS TO ACCOMMODATE RURAL MIGRATION……………………..……19
IV.I ECONOMIC GORWTH AND NATIONAL DEVELOPMENT POLICIES………....21
IV.II URBANIZATION PLANS AND POLICIES TO ACCOMODATE RURAL
MIGRATION……………………………………………………………………………….24
a. CREATION OF CITIES……………………………………………………………24
b. SLUM REMOVAL…………………………………………………………..……..26
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VII.CONCLUSION………………………………………………………………………………......29
BIBLIOGRAPHY.................................................................................................................................
vi
I. INTRODUCTION
Historically, the world has been undergoing rapid urbanization spurred on by social and economic
change. In 1950, 30 percent of the global population lived in urban areas (United Nations World
urbanization prospects: The 2014 revision). In 2014, 54 percent of the world’s residents are living
in urbanized regions (United Nations World urbanization prospects: The 2014 revision). In 2009,
the world experienced something new as the urban population surpassed its rural counterpart
(Urban and Rural Areas, 2010). By 2050, 66 percent of global citizens are projected to live in urban
centers (UN, 2014).
The migration of populates from rural to urban areas has traditionally been linked to
economic and social revolutions, particularly industrial revolutions. Theoretically and practically,
cities are vital for economic development. According to a McKinsey&Company interview on
China’s infrastructure and plan for continued urbanization, “There are no rich countries that are
not urbanized, there are many urbanized countries that are not rich” (Woetzel, 2013). In theory,
urbanization drives economic activity by creating access and infrastructure (Kasarda & Crenshaw,
1991).
Rural residents experience a lack of access and infrastructure due to “low population
densities, lack of public transportation and the cost of services create significant barriers to
accessing the services that do exist” (Bull, Krout, Rathbone‐McCuan, & Shreffler, 2001). On the
other hand, urban residents have an umbrella of access. The increase in services found in an urban
1
area not only provides a full range of essential communal public health services, but also factors
that increase an individual’s health, specifically education and employment opportunities. The
relationship between health, education and employment is widely accepted and factually supported:
education and employment are both positively correlated with health (Ross & Mirowsky, 1995)
(Adler & Newman, 2002) (Grossman, 1972) (Graetz, 1993) (Stronks, van de Mheen, Van Den Bos,
& Mackenbach, 1997). This can be viewed as a cyclical relationship; individuals who are better
educated and/or employed have a more impactful contribution to society (Ross & Mirowsky, 1995).
As the number of these individuals increase, communities become richer and inadvertently more
funds are available to be invested into pre-existing and new infrastructure, including the health
system. This enhances access to education and employment opportunities to even further better the
community, and also creates a healthier workforce.
However, even with an increase in access to factors that are known to improve health, urban
development generally brings forth unique public health concerns. Cities, primarily in the
developing world, are plagued with the consequences of rapid rural migration that is both a cause
and effect of urbanization. In these low-resource settings, a significant proportion of lower socioeconomic classes that migrate to cities generally find themselves inhabiting slums (Bloom &
Khanna, 2007). Slums create public health concerns, as “People living in these settlements
experience the most deplorable living and environmental conditions, which are characterized by
inadequate water supply, squalid conditions of environmental sanitation, breakdown or nonexistence of waste disposal arrangements, overcrowded and dilapidated habitation, hazardous
location, insecurity of tenure, and vulnerability to serious health risks” (Arimah & Branch, 2001).
As a result of these conditions, the spread of communicable diseases, environment health risks and
social health concerns are exacerbated (Sclar, Garau, & Carolini, & 2005) (Unger & Riley, 2007).
2
Often, cities in developing countries do not have the financial support, governmental support or the
infrastructure to prevent or eliminate slums (Ooi, & Phua, 2007). These cities that once represented
the opportunity for a better life for migrants present overwhelming obstacles and become a dismal
reality of hopelessness.
Although rural migration in the developing world can be a unique challenge due to the lack
of support for migrants, there are particular steps and government interventions that can alleviate
the most common challenges that are associated with rural migration. First, national governments
should implement specific economic growth and national development policies that focus on
providing education and employment opportunities to rural migrants and slum dwellers, and these
policies should be developed to compliment economic development initiatives (Pillay, 2010)
(Psacharopoulos, 1994) (Streeten, Burki, Haq, Hicks & Stewart, 1981). Second, national
governments should implement detailed urbanization plans and policies that specifically target rural
migration. These plans should focus on the development of cities in undeveloped areas that have
economic potential, as a way to create and implement the services that cities offer that generate
more economic growth that and increased wellbeing of citizens and the country as a whole (Li,
2011). In addition, in existing cities and cities that are being developed, housing infrastructure
needs to be created that will accommodate large numbers of people: in existing cities plans to create
better housing facilities for slum dwellers should be implemented and in cities that are undergoing
development, plan and policies need to be implemented that will prevent the formation of slums.
The urbanization of The Republic of Korea provides a unique and successful case study on a
country’s shift from developing to developed, while undergoing rapid urbanization and
experiencing a substantial increase in rural migration. Following the Korean War, the Korean
national government focused on assertively modernizing South Korea through a series of policy
3
initiatives that included emphasis on providing education and employment opportunities to citizens.
In addition, throughout the decades following the war, the national government focused on creating
new cities and slum removal.
The aim of this essay is to focus on the health inputs of education and employment and the
benefits and costs of migration in relation to these opportunities and overall health. In developing
countries rural migrants often find themselves as slum inhabitants, where they are limited in
opportunities and are exposed to different health risks than in their rural homeland (Harpham,
2009). The modernization of South Korea provides an excellent example of how countries can
urbanize rapidly and overcome common obstacles. Insight can be gleaned in regards to the effects
of human capital--focused national development policies on economic growth and specific
urbanization plan and policies to accommodate rural migration. This paper is set up as follows:
Section II will examine the evidence for education and employment as determinants of health
status; Section III will explore the difference in access to services in rural and urban areas; Section
IV will look into health problems in urban areas, specifically focusing on the health risks of slum
inhabitants; and Section V will lay out strategic policy plans that should be considered to
accommodate rural migration and promote the health and wellbeing of city inhabitants.
4
II. HEALTH INPUTS: EDUCATION AND EMPLOYMENT
II.I Education
The causal relationship between education and health has been widely accepted and factually
supported. Veritably, education leads to better health. Michael Grossman has done pioneering work
on the relationship between education and health. Grossman’s research is based on human capital
theory (Culyer & Newhouse, 2000), which posits that individuals collect knowledge and as the
stock of knowledge, or human capital, increases, economic productivity rises. According to
Grossman, health is an element of human capital and education is a vital component in raising
human capital (Becker, 2007). In order to positively increase human capital through enhancing
health, an individual must invest in their health stock through a variety of “health inputs”.
The Grossman model explores the notion that one’s health is determined by multiple
elements, not just medical care: “The distinction between health and health inputs, which is
embedded in the multivariate production function, is a useful point of departure for research on the
effects of education and health because it emphasizes a variety of mechanisms that govern health
outcomes” (Behrman &
Stacey, 1997). These “health inputs” include environmental factors,
income, housing conditions, heating, diet and lifestyle and education. Education provides people
with knowledge and skills that enable them to make more informed and sensible decisions. As
education enhances rational decision-making, it also sways our desire for better health and
contributes positively and profoundly to an individual’s health stock (Behrman & Stacey, 1997)
Education is foundational to increasing one’s health. In the article The Links Between
Education and Health (Ross & Wu, 1995), sociologists researched the reasons for the relationship
between education and health. Like Grossman, Ross and Wu support that there are many factors
5
that collectively increase an individual’s “health stock”. Their analysis reveals three explanations as
to why education has a positive correlation with health.
Education provides an environment where skills and habits are developed. Beyond practical
skills such as reading, writing, communicating, and socializing, knowledge is acquired through
critical thinking, analyzing, problem solving, and reasoning. These skills are the foundation of the
explanation provided by Ross and Wu. The first theoretical explanation supports that better
educated individuals have an increased chance to have better stable employment and higher income
opportunities, which may protect their health through financial freedom and health care benefits
(Ross & Wu, 1995). The second supports that that an increase in education leads to an increase in
control over one’s life: “Belief in person control is a learned expectation that outcomes are
contingent on one’s choices and actions… The sense of control improves health partially through
health enhancing behaviours” (Ross & Mirowsky, 1999). The third supports that better lifestyle
decisions, such as incorporating fitness and a balanced diet, are more likely to be made by those
with more education (Ross & Wu, 1995).
However, the link between not only education and positive health stock but also education’s
impacts on employment, social-psychological resources, and health lifestyle create support for a
new argument: All health inputs contribute to an individual’s “health stock”, however education is
foundational for other heath inputs. Better education leads to better employment opportunities,
which contribute to better health. The following section will explore the next aspect of the equation;
better employment and higher incomes lead to healthier individuals.
II.II Employment
In addition to education, the employment status of an individual also has been proven to affect an
individual’s health status. Overwhelmingly, “people who work for pay report better physical well6
being than others, most of whom are unemployed, retired, or keeping house” (Ross & Mirowsky,
1995).
However, education’s effect on employment cannot be overlooked, as it has been
established that “education improves health and improves the odds of full-time employment”
(Mirowsky & Ross, 2003). While both are considered health inputs, education leads to better
employment, which ultimately leads to better health.
As previously stated, Grossman’s research on health inputs has supported education as a
leading health input. Grossman also considers the effects of employment and has determined that
wage has a significant effect as well: “The complexity of a particular job and the amount of
responsibility it entails certainly are positively related to the wage. Thus, when an individual with a
high wage becomes ill, tasks that only he can perform accumulate. These increase the intensity of
his work load and give him an incentive to avoid illness by demanding more health capital" (Culyer
& Newhouse, 2000). As wage increases, a higher optimum level of health is acquired, which
increases the number of healthy days (Culyer & Newhouse, 2000). Although there is a clear
connection between education and employment, Grossman notes the importance of not just
asserting there is a link between education and employment, but understanding why education
affects employment status and ultimately health status.
Understanding the relationship between employment and health is necessary in order for
society to purposefully use employment to increase health. Initially, the relationship indicates that
the finances associated with employment status are responsible for healthier lifestyles (Mirowsky
& Ross, 2003). However, research has revealed that both causation and selection factors exist in
the relationship between employment and health. In selection, it is not employment that affects
health, but health that affects the type or amount of employment an individual participates in: “In
general, good health may improve the chances of finding and holding fulltime jobs, which is called
7
the healthy-worker hypothesis” (Mirowsky & Ross 2003). Individuals who are considered health
risks are not desirable employees because employers fear that their health may cause them to be
inefficient workers and financial liabilities to the company (Mirowsky & Ross 2003). Regardless
of the cause, there is a relationship between health and employment; understanding this cause
provides insight on increasing employment opportunities through education and infrastructure.
Research has confirmed that both causation and selection of employment affect health. A
sociological study published in Social determinants of health revealed that employment improves
the health of both men and women (Marmot & Wilkinson, 2005).
Similarly other studies
conducted in different countries have found the same link supporting the causation theory through
linking financial stress to ill health:
“These British findings are echoed in other countries. Kessler et al found that
financial strain was the strongest mediating factor between unemployment and
reported ill health in their American study, and was far more important than
reduced social integration or an increased number of life events. A Dutch study
found similarly that present or anticipated financial problems were the mediating
factors between unemployed status and reported health problems in both men and
women; the other important factor was loneliness. In a study in Malmo, Sweden,
the relationship between threatened redundancy and psychological and
physiological health as far more important than reduced social integration or an
increased number of life event, which supports the causal relationship” (Marmot
& Wilkinson, 2005).
In addition, Marmot and Wilkinson’s study also reinforced the selection hypothesis theory that
healthier people are more likely to not only acquire but also retain employment than unhealthier
8
individuals (2005). The causal social hypothesis indicates that employment enhances psychological
health through the alleviation of financial anxiety, which enables an individual to make independent
and often better decisions about their health. The connections between health, education,
employment and health have been solidly supported over time and in different countries. This
relates to migration because there is a difference in access to education and employment
opportunities in rural and urban locations (Chambers, 2014).
III. ACCESS TO EDUCATION AND EMPLOYMENT IN URBAN AREAS
Historically, cities are a fundamental element of economic productivity and provide an umbrella of
access to education and employment opportunities, which theoretically should enhance the health
status of citizens (Duijsens, 2010) (Chambers, 2014). Thus enter rural migration.
Rural migration is the movement of people from rural to urban areas. The shift from a rural
to an urban setting is often prompted by changes in society, such as industrialization and
modernization, and often occurs while a country is undergoing urbanization (Watson, 1993).
Urbanization can be explained as the shift that occurs when an urban population increases and
society must react to the increase in proportion (Luo, 2014). Traditionally, urban areas are the
center for the development and the application of new ideas and “may be looked on as the crucial
places in developing countries in which adaptation to new ways, new technologies, new
consumption and production patterns, and new social institutions could be achieved” (United
Nations Centre for Human Settlements & International Conference on Population and
Development, 1994). As a country experiences industrialization and modernization, often people
are drawn to cities: “Millions of people are drawn be the prospect of a better life, in which they can
9
share in the opportunities that the city offers. Economic prospects are the most important factor
underlying urban influx” (Duijsens, 2010). The increased access in particular to education and
employment opportunities are a driver of rural migration (Harris & Ullman, 1945) (Rural/Urban Job
Creation) (Jayasuriya & Wodon 2002).
III.I Education in Urban Areas
Rural migration is encouraged by access to more and better educational facilities. Traditionally,
cities have the platforms for better education and learning opportunities (Nelson, 1970). While an
increase in population calls for more facilities, more teachers, and more resources, research has
supported that nearby proximity of urban institutions is the driving factor that makes education in
urban areas more appealing than rural areas (Jayasuriya & Wodon 2002).
Substantial cost savings may result from large numbers of individuals in close proximity.
Urbanization creates avenues to provide access but at a lesser cost than in rural counterparts. This
enables more citizens to be reached and offers greater opportunity:
“We conjecture that the importance of urbanization may stem from the fact that it
is typically cheaper to provide access to education and health services in urban
than in rural areas. As noted in the latest World Development Report published by
the World Bank (forthcoming), the cost advantage in urban areas should be
especially important for public
services with substantial fixed costs. This
includes not only network infrastructure, but also education and health facilities.
Even when services are provided in rural areas, they may not reach those in the
smallest communities” (Jayasuriya & Wodon 2002).
10
While cost is a contributing factor to a higher quality of education in urban areas, the characteristic
of close proximity could also encourage competition, not only between institutions but also for
quality employees (Jayasuriya & Wodon 2002).
III.II Employment in Urban Areas
Most people migrate to cities to pursue better employment opportunities: “One of the key factors of
rural-urban migration is the lack of employment in rural areas, increasing exponentially the evergrowing challenges related to providing adequate basic infrastructure to a growing number of
unplanned low-income urban settlements. The lack of reliable infrastructure assets in rural areas
leading to the lack of access to basic social services, markets and job opportunities, often force the
local rural population to migrate” (Rural/Urban Job Creation).
As previously noted, the increase in economic activity cultivates a greater economic power
in cities than in their rural counterparts. Measures of contribution to GDP and total population tend
to be much higher in urban areas. For example, in Thailand “the city of Bangkok contributes more
than one-third (36.3%) to the country’s GDP while containing only 10% of the country’s
population” (Duijsens, 2010).
As a result of the larger concentrated populations in cities, opportunities of scale are
considerably higher as a result of a larger consumer market (Krugman, 1980). This means that the
prospect of opportunity in comparison to risk is higher in terms of the consumer market. When the
opportunity of scale is higher, a variety of different business opportunities are also supported. This
encourages financial prosperity not just for individuals, but for the urban center as a whole:
“…cities provide financial power, holding banks, insurance companies, and stock exchanges.
Supported by communication networks, these cities are indispensable nodes in international
11
financial flows” (Duijsens, 2010). In developing countries, it is in general the larger cities rather
than smaller cities that offer the greatest opportunities: “in developing countries at lower income
levels, the largest cities in a country may be heavily manufacturing oriented and are also the places
where the country’s limited public infrastructure and high skill labor are concentrated…In
developing countries bigger cities are also typically the point of technology importation and
adaptation….” (Henderson, 2010). Cities in themselves create an economic center because of dense
population, increase in infrastructure, and increase in employment, which increases overall
opportunity simply from the natural make-up of what makes a city a city.
IV. Rural Migrants’ Settlement into Cities
Rural migration is a vital component of the urbanization process (Ledent, 1982). Urbanization is a
fundamental aspect of a competitive economy and has enhanced the opportunities available to
citizens, which ultimately affects their health status: “They see the move from the countryside to
cities as a natural result of the modernization and industrialization of societies and point out many
upsides of urban life, which range from increased average income to improved health” (Bloom &
Khanna 2007). However, once migration occurs, the access that ideally is attributed to a city is not
always available to migrants or accessible at all. In many developing countries, a lack of finances,
infrastructure, and economic development prohibit cities from keeping up with the influx of people.
This not only creates an environment with fewer economic opportunities, it also increases urban
poverty. With little financial ability and little choice, the urban poor often take up residence in slum
developments.
At the turn of century, 924 million global citizens were estimated to inhabit slums or other
informal housing units (Un-Habitat, 2004). It is predicted there will be a rise in the
12
number
of citizens living in cities and likewise, the number of those inhabiting slums is also projected to
increase to 2 billion by 2030 (Urban Slum Dwellers Could Double, 2003). The term slum is a
general label that refers to impoverished characteristics of the housing settlements (Duijsens, 2010).
With a lack of education and financial resources, residents “usually have no other option than to
live in informal settlements, characterized by a lack of basic infrastructure and absence of services”
(Duijsens, 2010). In Brazil they are referred to as “favelas”, in America the “ghetto”, in India, the
“Indianshawls”, and in Turkey, the “gacekond”. Despite the different terms for these environments
“What all these areas have in common is that they are the locus for concentrated poverty and
corresponding vulnerability, and that their inhabitants are exposed to multiple hazards and violence
(Duijsens, 2010). The extreme poverty seen in these areas is further proliferated by the lack of both
intangible and tangible resources for slum residents: “A large proportion of the residents are rural
migrants, displaced persons, illegal and legal immigrants, unemployed, and refugees (Bloom, &
Khanna, 2007).
Research has been conducted in attempt to further understand slum residents who were rural
migrants. In Bright City Lights and the Slums of Dhaka: Determinants of rural-urban migration in
Bangladesh, the rural migration process was explored (Ullah, 2004). After interviewing “197
randomly selected migrants and their families” and conducting statistical analysis, the study
revealed that migrants were populating slums more so than other categories of residents: “Data
analysis reveals that the flow of migration to the major cities in Bangladesh is the result of rural urban dichotomies in income, employment opportunity and absorptive capacity. A significantly
higher percentage of migrants live in slums as compared to other places (Ullah, 2004). This study
supports the argument that while not all slum residents are rural migrants, migrants are at more at
risk for becoming slum dwellers as they search for a better life in urban areas (Ullah, 2004).
13
In another study, Circular migration patterns and determinants in Nairobi slum settlements,
research was conducted on elements of rural migration flows in two slum settlements in Nairobi
City between 2003 and 2007 (Beguy, Bocquier & Zulu, 2010). The results revealed:
“The high intensity of migration with a quarter of the total slum population and a
third of those aged 15-30 being renewed annually. A circular migration system is
at play whereby the majority of slum dwellers are short-term migrants spending
on average less than 3 years in the area. Migration is more intense during early
adulthood (20-24), and despite very similar determinants across gender, mobility
is more intense among women compared to men. The high population turnover is
due to the insecurity of livelihoods, tenure, and poor basic amenities and social
services in slum settlements” (Beguy, Bocquier & Zulu, 2010).
This study provided more support that rural migrants make up a significant portion of a slum’s
population, as in this study 25 percent of resident in the two slum communities were migrants.
However, due to a variety of reasons, there is a high turnover of these residents (Beguy, Bocquier &
Zulu, 2010). This indicates that while migrations are more vulnerable to becoming slum residents,
they may not always remain in the slum.
A third study, Migration and Vulnerability among Adolescents in Slum Areas of Addis
Ababa, Ethiopia, looked into adolescent rural migration in Ethiopia and the transition into
adulthood: This study uses data from a population-based survey of over 1000 adolescents aged 10–
19 in slum areas of Addis Ababa. Twenty-three per cent of boys and 45 per cent of girls have
migrated into the city, mostly from rural areas, mainly for educational
or
work
opportunities.
Nearly one quarter of female migrants moved to escape early marriage in their rural homes
(Erulkar, Mekbib, Simie, & Gulema, 2006).
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This study further supports the argument that educational and employment opportunities are
a driving force for rural migration. With these theories being supported by a variety of studies
conducted in different countries, it is clear that while not slum residents are migrants, migrants’
makeup a significant, although varied, proportion of slum communities.
V. Health Risks Once Rural Migrants Become Slum Residents
Regardless of the origins of a slum dweller, the health risks that are inherent to a slum affect all
slum dwellers, including rural migrants. Often characterized as heavily populated poor housing
units, which lack access to clean water and sanitation, electricity, and law enforcement (Ballesteros,
2010), slums are a significant problem worldwide. Their creation or longevity is generally a sign of
economic difficulties, such as economic stagnation recession, and depression, high unemployment,
poverty, poor planning, natural disasters and importantly, rapid rural-to-urban migration (Stokes,
1962). The urban slum, often within sight of the institutions and opportunities that prompted
migrants to move, creates cyclical barriers that often prevent residents from pursuing education and
employment opportunities, and expose residents to heightened health risks. Exposure to
communicable diseases, environmental pollution and a lack of sanitary measures, and increased
social health concerns all offset the opportunities for education, employment, and better health.
IV.I Lack of Medical Care
In general, access to medical care is extremely underdeveloped in slums (Kapadia-Kundu &
Kanitkar, 2002). While it is common for treatable diseases to be present in slums, more often than
not residents do not have access to medication (Unger & Riley 2007). While a lack of funds is a
logical contributing factor to the lack of health care, an additional major factor is that health
providers often avoid providing service to slum residents (Kapadia-Kundu & Kanitkar, 2002).
15
Many reasons exist as to why avoidance is common: prejudices, lack of health care providers, lack
of funds etc.; however, a significant and practical explanation can be attributed to infrastructure, or
the lack of it (Marsh, Husein, Kadir, Luby, Siddiqui, Khalid, 2000). Some slums do not have roads
passing through them and even in the ones that do possess roads, more often than not, the roads are
so narrow that vehicles cannot pass through (Marsh, Husein, Kadir, Luby, Siddiqui, & Khalid,
2000). This restricts emergency vehicles and ambulances to the outer perimeter of slum and inhibits
access to most of the slum community.
In the rarity that medical services are available to slum residents, generally the care is not
adequate or near the traditional standards of care accepted in the developed world (Zaidi, 2006).
Health services available to slum dwellers are typically “comprised of an inconsistent patchwork of
public, private, and charity-based providers. In a study published in Nourishing our Future:
Tackling Child Malnutrition in Urban Slums", it was revealed that over half of slum inhabitants
either self-medicate, when medication is available or seek the service of private practitioners, many
of whom are often poorly trained or unlicensed (Zaidi, 2006).
The inadequate care that takes place in slum allows for the progression of preventable
diseases, and residents are often victims at high rates (Sclar, Garau, & Carolini, & 2005). Diseases
that are airborne, such as cholera and typhoid, spread rampantly, while non-airborne diseases such
as HIV and AIDS also have a notable presence in slums (World Health Organization, 2004). Drug
resistant diseases are a common concern, along with the spread of diseases both nationally and
internationally due to immigration (Weiss & McMichael, 2004).
The lack of medical care is especially problematic in slums because of the overcrowding
living conditions that exacerbate the spread of communicable diseases: “Slum dwellings have high
occupancy rates in all-purpose rooms. Cooking, sleeping, and living with 13.4 people per 45 m2
16
room, as in the slums of Kolkata, India, places residents at risk of respiratory infections, meningitis,
and asthma. In Manila, the Philippines, children living in squatter settlements are nine times more
likely than other children to have tuberculosis” (Unger & Riley, 2007). The spread of diseases in
slums is a major public health concern locally, nationally, and even internationally, as the world
found out with the spread of Ebola in 2014. While the slums in West Africa contributed to the
spread of the disease, Ebola became a major concern for developed countries as visitors and
residents traveled infected with the disease (Vogt, 2014). The lack of access to medical care is a
prime concern for not only slum dwellers but for the world as a whole, as the epidemics that start in
the slums do not stay contained in slums.
IV.II Sanitation and Environmental Pollution
Environmental health risks are prevalent public health concerns in slums and facilitate the spread of
disease. Traditional urban environmental health problems are exacerbated by the poor
living
conditions and lack of governmental regulation that characterize the slums: “Residents therefore are
often at risk from diseases and injuries associated with poor sanitation, unsafe
drinking-water,
dangerous roads, polluted air, indoor air pollution and toxic wastes” (McMichael, 2000) (Cutler &
Miller, 2005). A critical aspect of the urbanization process is creating infrastructure for access to
clean water. Access to clean water is a vital public health measure due to the illnesses, such as
malaria or diarrhea, that spread as a result of contaminated water (Clearing the waters: a focus on
water quality solutions, 2010). A study conducted on the urban poor’s access to water and
sanitation publicized highly disproportionate figures. According to data from Indian cities,
sanitation and the state: the politics of the failure to provide, “under half of the urban poor could
access adequate sanitation compared to about 95% of the urban non-poor” (Chaplin, 2011).
17
Many cities in developing countries lack access to not only clean water, but also sewage
infrastructure. Inadequate sewage collection is a significant cause of disease spread and slums are
notoriously known for their poor latrine systems. Latrine location, type, usage, and design all play a
vital role in health outcomes for slum residents (Katukiza, 2010). A common latrine seen in slums
in the pit latrine, which is essentially a hole in the ground that collects human waste, and it is more
usual than not for pit latrines to be unlined (Tilley, Lüthi, Morel, Zurbrügg & Schertenleib, 2008).
This is creates a significant problem due to unlined pit latrines contamination of groundwater
(Katukiza, 2010).
Another common method is the flying toilet method, in which slum residents defecate and
urinate into bags that are eventually disposed into the surrounding areas (Mulama, 2006). This
method also puts the health of slum dwellers at risk, as illnesses can spread through human waste.
Flush toilets and ventilated latrines systems are a rare luxury in slum: “Five million slum residents
live without toilets in Mumbai; if each person defecates half a kilogram per day; 2.5 million
kilograms of human waste contaminate their environment each day” (Unger, Riley, 2007).
Water and sanitation precautions directly affect health outcomes. Those who lack access to
clean water and sanitary living condition are susceptible to many diseases. In fact, diseases spread
through contaminated water are the “leading cause of morbidity and mortality worldwide and a
defining danger of living in slums” (World Health Organization, 2003).
IV.III Violence and crime Social Issues
In addition to communicable disease and environmental health risks, slum inhabitants are also at
substantial risk for social health issues. Studies have revealed that violence and crimes create unsafe
environments for slum dwellers (Un-Habitat, 2004). While traditionally, poverty is associated with
higher crime rates, the lack of law enforcement, policing and government regulations are factors
18
that significantly affect the crime rate (Un-Habitat, 2004). The structural configurations of slums
also create physical barriers that inhibit and deter law enforcement. The narrow streets that prevent
emergency vehicles access within the slum also create potential hazardous conditions for police.
The overabundance of people inhabiting slums also creates another barrier for patrolling.
While many assume that slum dwellers are the ones who are committing illegal acts, according to
the 2003 UN-Habitat report, residents are more often than not victims rather than criminals.
Common crimes that are typically seen in slums are drug trafficking, prostitution, gambling, and
gangs (Unger & Riley, 2007). While illicit criminal actives are common in slums, homicide and
rape are also a concern. Sexual violence is a leading cause of violence to women who reside in
slums (Magar, 2003). For example according to a United Nations News Service report, “one of four
teenage girls is raped each year in Nairobi slums” and in Brazil, “young men in the favelas are up to
five times more likely to die from homicide than their urban counterpart” (Unger & Riley, 2007).
The lack of law enforcement exacerbates the violence and crimes that occur in slums and increase
risk to social health detriments.
VI. POLICY PLANS TO ACCOMMODATE RURAL MIGRATION
Research has shown that the positive health inputs of education and employment are motivators of
rural migration. Rural migration is a fundamental component of a flourishing society and a
counterpart of urbanization; however, the increase in urban inhabitants creates challenges.
Statistics support that once migrants leave their rural establishments, many find themselves as slum
dwellers and at risk for unique health risks. National governments must not only take part in the
urban planning process but most importantly, they must create and implement strategic policies.
19
While at first, one may think the solution is create policies that limit urbanization or deny
migrants the ability to relocate to cities, in actuality such policies would only exacerbate the
negative effects or urbanization. Policies that focus on stopping the relocation of people only
prohibit economic development and growth and limit the opportunities available to citizens.
Policies that accommodate economic and national growth and urbanization need to be implemented
in order to accommodate rural migrants and ensure they have access to opportunities that will in
return promote the overall wellbeing of society.
For insight, researchers often look to other countries for guidance on policy and
development (Dolowitz & Marsh, 2000). The Republic of Korea is one such example of a country
that pursued policies to manage urbanization and support urban planning. While experiencing rapid
rural migration, South Korea strategically implemented policies that resulted in positive economic
growth and social development (Pillay, 2010). As migrants made their way into cities, it was
important for urban policies to complement economic growth. Specific economic and national
development plans were created to align education reform with economic productivity objectives
(Hanson, 2007). In addition, urbanization plans and policies that focused on the creation of cities
and removal of slums were implemented to accommodate rural migration (Pillay, 2010). South
Korea’s urbanization process was not perfect, but it does illustrate the importance of focusing on
the education and employment opportunities. In addition, while South Korean citizens do continue
to have health concerns, such as environmental pollution and chronic diseases, since the country
began to rapidly develop in the 1950s, the Korean population has become healthier and the life
expectancy of citizens has rapidly increased since the Korean War (Yang, Khang, Harper, Smith,
Leon, & Lynch, 2010).
20
VI.I Economic Growth and National Development Policies
As established, education is a key factor in generating healthier citizens and education access is
greater in urban rather than rural areas. However, location hardly matters if access is not provided.
The education and employment opportunities that drive rural migration are often inaccessible. This
creates a space for improvement through policy. Countries looking to prompt rural migration or
experiencing rural migration should implement education policy that not only reaches rural
migrants and slum dwellers but also is developed to compliment economic development initiatives.
The correlation between education and economic activity has prompted debate as to whether
the effect of economic productivity catalyzes or complements economic growth. A study that
analyzed the role of investment and physical capital accumulation in economic growth and
development found that these factors should not guide policymaking (King & Levine, 1994).
Rather “capital accumulation seems to be part of the process of economic development and growth,
not the igniting source” (King & Levine, 1994). This indicates that the capital accumulation of
tangible capital, investments, social capital and human capital will be cultivated with proper
development.
An opposing study argues that education alone does not solely prompt economic growth;
rather it is that human capital compliments physical capital. One suggestion is that “physical capital
does not flow to poor countries [because] these countries are poorly endowed with factors
complementary to physical capital, so that the marginal product of physical capital in developing
countries may not actually be that high, despite its apparent scarcity relative to the developed
countries” (Lucas, 1990). In this argument, economic growth is driven by a combination of
educated and skilled citizens who have access to factors of production, such as machines and
buildings. Nonetheless, regardless of the debate on whether policies that enhance human capital are
21
meant to be made to guide economic development or complement it, human capital is necessary for
the growth of countries.
Many studies suggest significant investment in human capital is necessary for a country to
consistently develop: “Previous studies have shown handsome returns to various forms of human
capital accumulation: basic education, research, training, learning-by-doing and aptitude building.
The distribution of education matters” (Ozturk, 2001). The theory is that education increases
productivity and innovation, which in return encourages technological advances, and also secures
“economic and social progress and improving income distribution” (Ozturk, 2001). It is a prudent
choice for countries that are experiencing rapid rural migration to implement strategic education
policies and use education as a way to invest in human capital.
The development of South Korea’s policies towards education and economic productivity
provide insight on successful and strategic policy planning that compliment economic goals through
education reform. Education has been without a doubt a central feature and focus of South Korea’s
successful urbanization and economic development (Hanson, 2007).
Prior to the Korean War, the economy was driven by a “manual workforce”. Following the
War, the economic focus shifted to a skills-based workforce (Hanson, 2007). To respond to the
changing economic needs, education policies were implemented that focused on producing a skilled
workforce by establishing educational infrastructure, expanding primary and secondary education,
and increasing vocational education (Pillay, 2010) (Hanson, 2007). It was a strategic decision to
implement development policies that “focused on achieving sustained productivity growth by
consistently increasing the value-added of output. To achieve this, a highly educated labour force
was necessary. As a result, the education system has developed in tandem with the various stages of
economic development” (Pillay, 2010).
22
Beginning after the Korean War, South Korea implemented education policies that
correlated with the “industrial needs for human resources” (Pillay, 2010). The 1960s saw the
cultivation of policies and practices that favored both export and import-substitution industries of
agriculture and manufacturing (Pillay, 2010). Concurrently, “considerable capital accumulation and
investment in primary education during this period allowed a gradual shift up the value-added chain
toward more sophisticated commodities” (Pillay, 2010). The following decades would bring heavy
industry development and improve technological capabilities through improving the access and
value of technical and vocational training in the 1970s (Hanson, 2007). In the following decade,
deregulation occurred and trade was made open, occurring at the same time the government began
to invest in higher education due to the increased “economic competiveness based on high-level
technology and information industries” (Hanson, 2007). By the 1990s high value-added
manufacturing native high-technology innovation was pursed (Pillay, 2010).
While it may seem that it the strategic education planning and growth implemented by the
government was mainly to complement the over-all growing economy and the creation of new
industries, education reform also inadvertently served as served as a safety net. Financial reforms
were promoted as a result of wage increases and An increase in their currency’s value The
education system reform that took place over the decades was the foundation for the reforms:
“Together with the setting up of a modern and accessible information infrastructure, there was
continued expansion of research and development capabilities in South Korean industries, which
drew on the skilled labour force that had resulted from the government’s expansion of the higher
education system” (Pillay, 2010). South Korea’s investment in human capital paid off as their
skilled labor force proved that it was not only boosting Korea’s economic opportunity, but the labor
force was driving South Korea’s growth and presence in the competitive global market.
23
Following the reforms, policies were implemented with the intent of creating a knowledgebased economy. During this time innovation was highly encouraged due to the belief that
innovation would increase productivity and inadvertently create economic growth (Pillay, 2010).
As history would unfold, South Korea did experience rapid and overall successful economic
growth. Heavy contributors to this growth were the building of an information infrastructure and
attaching the potential of science and technology (Pillay, 2010).
While all countries looking to develop may not necessarily pursue a technology and
information based economy, South Korea provides a prime example of why human capital
investment is necessary for economic growth: “Most observers agree that South Korea's spectacular
progress in modernization and economic growth since the Korean War is largely attributable to the
willingness of individuals to invest a large amount of resources in education: the improvement of
"human capital." (International, B. P. U, 2005). Putting a monetary value on their investment made
by the Korean government, the percentage of GNP allocated for education had grown from 2.2% in
1975 to 4.5% by the mid-1980s (International, B. P. U, 2005). South Korea strategically sought to
create a strong country by creating skilled citizens. Through creating education infrastructure and
making it a central aspect of society, the government not only created greater employment
opportunities, but also based on research has made their country healthier as a whole due to the
positive correlation of health and education.
VI.II Urbanization Plans and Policies to Accommodate Rural Migration.
a. Creation of Cities
Cities play vital roles in society, as the positive correlation between urbanization and socioeconomic development has been proven: “There are no rich countries that are not urbanized, there
24
are many urbanized countries that are not rich” (Woetzel, 2013). Cities are forces against poverty
and drivers of prosperity: “Countries that are highly urbanized have higher incomes, more stable
economies, stronger institutions and are better able to withstand the volatility of the global economy
than those with less urbanized populations” (Un-Habitat, 2004). As evidence proves, countries
should actively aim to continuously develop already established cities and create new cities as a
way to ensure the economic growth and overall wellbeing of citizens and the country as a whole.
Prudent policies that focus on sustainability and creating cities with access to safe and secure living
conditions are necessary when planning for urbanization.
In order for urbanization to be successful, cities need to be sustainable. Along with the
usefulness of governmental management of education reform, coordination between the
government and the market is a way that sustainability can be achieved. The World Bank created
the “Urbanization hypothesis” which is a new approach at addressing urbanization problems in
developing countries through analyzing three main traits of economic growth:
“The first trait is that economic growth should not let any areas suffer from
difficulties such as poverty or deterioration even though this “does not always
bring about the prosperity of the entire areas.” Based on this aspects, “good
policies help achieve both concentration of economic activities on urban areas
and improvement of quality of life.” Second, economic growth should lead to
comprehensive growth throughout the country even if a government allows
imbalanced economic growth for specific areas.” Also, comprehensive growth
can be achieved by economic integration of both underdeveloped and
developed areas at the regional level. Finally, “economic integration can be
made by agglomeration, migration, and specialization is, “market force”.
25
Therefore, “any policies should not act against the market, and economic
growth and sustainability can be determined according to coordination”
(European Commission, 2010).
In the case of South Korea, strategic urban planning was at the core of their urbanization and
economic development process. As migration occurred and cities become increasingly densely
populated, opportunities become more competitive. In order to compensate for an increase in need
for employment and in order to create new economic ventures, cities were created: “The national
government played an important role in decisively modernizing South Korea through urban growth
over the decades; for example, the city of Ulsan was constructed in 1963 through a series of
ambitious government initiatives and grew into an important industrial town” (Kwon, 2001). This
not only gave a boost to the Korean economy but also prevented urban sprawl from occurring.
b. Slum Removal
Population density and economic opportunity are not the only reasons why governments
should be involved in the planning and sustaining process of cities. Urban planners must implement
infrastructure to accommodate increasingly large numbers of people, but at a higher standard than
slums provide. As white collar workers have progressively taken over cities, the visual ascetics and
deliverability of cities have increased: “…the trend of globalization demands a more modern and
urban infrastructure, and high-class and educated professionals are sensitive to the living and
working environment” (Kwon, 2001). Not surprisingly, this expectation is problematic when the
subject of the slum arises, as non-slum dwellers have a stronger influence in society and are in
support of slums removal (Kwon, 2001). Additionally, slums create perpetual cycles of poverty and
ill health. Regardless of the reason for removing slums, slum removal has to occur strategically. If
slums are not eliminated properly then the situation only becomes worst.
26
Common countermeasures when dealing with slums are to remove the slum, to relocate the
inhabitants, or to upgrade to the slum, none of which have proven viable long term. Slum removal
simply visually makes the slum disappear but does not address what caused the formation of the
slum originally. Slum relocation only exacerbates the problem by displacing the poor and relocating
inhabitants further away from the employment opportunities they are seeking. Slum upgrading puts
a band-aid on the problem because while basic infrastructure, such as water or houses, is provided
in the slum, upgrading does not address the socio-economic statues that characterize slums, which
casts doubt if upgrading can contribute to sustainable improvements (Huchzermeyer & Karam,
2006). Some may argue that slums cannot be eliminated. However, the United Nations believes that
a combination of city planning, slum upgrading, and the creation of infrastructure and poverty
reduction is key to the elimination of slums.
As previously noted, Seoul, South Korea is home to fifty percent of the country’s
population. However, Seoul was not always the major city in South Korea. Rapid rural migration
contributed largely to an increase in the city’s population, from 2.5 million in 1962 to 10 million in
1988 (Greene, 2003). In addition to the new rural migrants, “a lack of developable land led to a
persistent housing shortage in Seoul, despite efforts to expand and modernize the city’s housing
supply” (Greene, 2003). As the city became more densely populated, slum inhabitation became
increasingly popular.
Unable to accommodate the mass number of people inhabiting Seoul and the Seoul slums,
in 1966 the Korean government “ undertook its first major slum clearance project” by ordering
Large-scale evictions… aimed at replacing 136,000 squatter units with 90,000 public housing units”
(Greene, 2003).
Following the order, by 1970, more than 50 percent slum residences were
destroyed; however, fewer than 17 percent of the 90,000 public housing units had been built. Those
27
who were forced from their homes were required to take care of themselves in “outlying areas, far
away from jobs and social networks” (Greene, 2003). The clearing project continued into the 1970s,
although a new program was implemented, the Residential Redevelopment Program: “Under this
program, the City was supposed to designate certain squatter areas as Substandard Housing
Redevelopment Districts (SHR districts), rezone the designated land for residential use, expedite
code approvals, and then sell the land to occupants at far below market price. However, the SHR
program lacked adequate funding, improvements proceeded slowly, and squatter settlements
continued to proliferate” (Greene, 2003). Once the 1980s had arrived, more than 2 million prior
slum dwellers took up residence in illegal housing.
There were multiple factors that complicated this process, such as the slum residents not
having rights, the government’s inability to provide low-cost housing, and the pressures from the
economic market. This is not surprising as, “Seoul’s forced eviction program during the 1980s is
estimated to be one of the largest government-sponsored eviction programs of any city in the world
in recent decades” (Greene, 2003). These examples of forced eviction programs and lack of housing
planning provides excellent support that an ill formed strategy will only proliferate the situation, not
make it better. Since the 1990s, Korea has focused on increasing the number of residential units to
solve housing shortages so far because the Korean government has thought that maintaining the
optimal housing supply ratio means providing people with opportunities to purchase or rent their
houses without any barriers (Ha, 2004). While South Korea has struggled in the past, adequate
housing policies have become a governmental initiative and have shown signs of success. While
exact data has not been collected and variation between slums exists, their has been a significant
decrease in slum settlements since 1960s and 1970s, when it was common to have 20–30% of the
cities population inhabiting slum and illegal squatter settlements (Ha, 2001)
28
VII. CONCLUSION
Education and employment status are positively correlated with improved health, just as poverty is
positively correlated with poor health. As the world continues to undergo urbanization and rural
migrants continue to travel to cities, city centers can host top universities, academic opportunities,
and vast employment opportunities. However, no matter how much a city has to offer, access to
these opportunities is not always available to citizens.
As many migrants are forced to seek refuge in slums, the health risks they are exposed to
offset the potential health inputs of education and employment opportunities. Heightened
communicable diseases, lack of sanitation, and an increase in social concerns, particularly violence
and crime, are all accepted attributes of slum communities. Without political and economic
intervention, health inequalities will continue to plague poor migrants.
Governmental policies that focus on national economic growth and national development
policies specific to urbanization can be implemented as a way to ease the urbanization process and
accommodate rural migrants. As evidenced by South Korea’s experience, the transformation of a
country is possible in a short period of time, but only with strategic and well thought out planning.
When a country invests in their citizens through providing education and employment
opportunities, they inadvertently create a healthier society, creating a stronger workforce that is the
foundation for a flourishing country.
29
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