Frauke Kraas

Megacities as Global Risk Areas

In the last few decades a striking world-wide trend towards rising fatalities and economic losses due to natural and man-made hazards can be observed. One major influencing factor is growing urbanization, megacities being particularly prone to supply crises, social disorganisation, political conflicts and natural disasters. They can be both victims and producers of risks. This article concentrates on major risks and gives examples of a) environmental hazards (such as earthquakes and volcanic eruptions, storms, floods, droughts and heat waves, snowfall, frost and avalanches as well as global sea-level rise). Furthermore b) man-made hazards such as air, water and soil pollution, accidents, fires, industrial explosions, sinking land levels, diseases and epidemics, socio-economic crises, civil riots and terror attacks, nuclear accidents as well as war, germ and nuclear warfare are addressed. Finally, the most remarkable deficits in research are summarized, as well as future tasks.

Socio-Economic Development in the Mekong Delta: Between the Prospects for Progress and the Realms of Reality

Socio-economic development in the Vietnamese Mekong Delta is shaped by a complex web of interacting and dynamic trends. Based on the analysis of statistical data, special reports, planning documents and scientific literature, the chapter examines the key dimensions of such trends, paying particular attention to agricultural transformation, industrialization, migration and urbanization. It is argued that changes in these fields have been producing ambiguous economic net-effects and socially stratified development outcomes over the last decades. On the one hand, the agricultural sector in the Mekong Delta has been experiencing profound production gains due to de-collectivization, expansion, intensification and diversification. This has contributed to overall poverty reduction in the Delta and to the economic progress of the entire country. On the other hand, the Mekong Delta lags behind the national average in terms of many development indicators in the socio-economic sphere (e.g. education levels or housing conditions). Under stress from multiple economic and environmental pressures and risks, small-scale farmers increasingly have difficulties securing a minimum level of profitability and a stable livelihood base. Rising inequalities, high incidences of landlessness, and labour migration, notably into urban areas, are among the most significant consequences. At the same time, industrial development falls short of earlier expectations. The Delta’s secondary and tertiary sectors are presently unable to sufficiently absorb the former agricultural labour force. As a result, strong outmigration occurs, most importantly to Ho Chi Minh City and its neighbouring provinces. Guided by development theory we argue that next to the neoclassical expansion of conventional capital stocks for fostering endogenous growth potentials, development in the Mekong Delta heavily depends on institutional factors, enabling social and economic development. Aspects such as the need for improved access to land or for extended education and professional training, more integrated planning, and intensified promotion of economic innovations are discussed in detail.

Urban Climate Change Adaptation in the Context of Transformation: Lessons from Vietnam

The imperative of adapting cities to risks associated with climate change will reveal the strong potential of political and administrative action at the level of local urban governments. Action at this level facilitates adaptation solutions that are closely linked to the specific needs, wants and capacities of local communities and economies. At the same time, the need to adapt to climate related impacts creates new, and in many cases, unprecedented challenges for local governments, often exceeding their current capacities in terms of risk awareness, expert knowledge, access to information, finance, or legal responsibility. This paradox is most apparent in emerging economies that have recently undergone, or are currently experiencing, political and economic transformations, including (re-)orientation towards market-oriented economies, administrative liberalisation, decentralisation, dynamic urbanisation and changing socio-political paradigms. Drawing on empirical research based on coastal and delta cities in Vietnam, focusing particularly on the example of Can Tho City in the Mekong Delta, this paper analyses the challenges local urban governments face with respect to formulating and implementing climate change adaptation strategies for their city in the context of transformation. The paper argues that challenges are particularly evident in the fields of urban growth and expansion, administrative reform and decentralisation, the fragmentation of sector responsibilities, the broadening of the actor spectrum and planning and management paradigms. Lessons learned can be utilised for other local urban governments experiencing similar conditions. Knowledge gaps and future research needs are also explored.

Knowledge, attitude, and practices with respect to disease surveillance among urban private practitioners in Pune, India

Background Participation of private practitioners in routine disease surveillance in India is minimal despite the fact that they account for over 70% of the primary healthcare provision. We aimed to investigate the knowledge, attitudes, and practices of private practitioners in the city of Pune toward disease surveillance. Our goal was to identify what barriers and facilitators determine their participation in current and future surveillance efforts. Design A questionnaire-based survey was conducted among 258 practitioners (response rate 86%). Data were processed using SPSS™ Inc., Chicago, IL, USA, version 17.0.1. Results Knowledge regarding surveillance, although limited, was better among allopathy practitioners. Surveillance practices did not differ significantly between allopathy and alternate medicine practitioners. Multivariable logistic regression suggested practicing allopathy [odds ratio (OR) 3.125, 95% confidence interval (CI) 1.234–7.915, p=0.016] and availability of a computer (OR 3.670, 95% CI 1.237–10.889, p=0.019) as significant determinants and the presence of a laboratory (OR 3.792, 95% CI 0.998–14.557, p=0.052) as a marginal determinant of the practitioners willingness to participate in routine disease surveillance systems. Lack of time (137, 55%) was identified as the main barrier at the individual level alongside inadequately trained subordinate staff (14, 6%). Main extrinsic barriers included lack of cooperation between government and the private sector (27, 11%) and legal issues involved in reporting data (15, 6%). There was a general agreement among respondents (239, 94%) that current surveillance efforts need strengthening. Over a third suggested that availability of detailed information and training about surveillance processes (70, 33%) would facilitate reporting. Conclusions The high response rate and the practitioners’ willingness to participate in a proposed pilot non-communicable disease surveillance system indicate that there is a general interest from the private sector in cooperating. Keeping reporting systems simple, preferably in electronic formats that minimize infrastructure and time requirements on behalf of the private practitioners, will go a long way in consolidating disease surveillance efforts in the state. Organizing training sessions, providing timely feedback, and awarding continuing medical education points for routine data reporting seem feasible options and should be piloted.Background Participation of private practitioners in routine disease surveillance in India is minimal despite the fact that they account for over 70% of the primary healthcare provision. We aimed to investigate the knowledge, attitudes, and practices of private practitioners in the city of Pune toward disease surveillance. Our goal was to identify what barriers and facilitators determine their participation in current and future surveillance efforts. Design A questionnaire-based survey was conducted among 258 practitioners (response rate 86%). Data were processed using SPSS™ Inc., Chicago, IL, USA, version 17.0.1. Results Knowledge regarding surveillance, although limited, was better among allopathy practitioners. Surveillance practices did not differ significantly between allopathy and alternate medicine practitioners. Multivariable logistic regression suggested practicing allopathy [odds ratio (OR) 3.125, 95% confidence interval (CI) 1.234–7.915, p=0.016] and availability of a computer (OR 3.670, 95% CI 1.237–10.889, p=0.019) as significant determinants and the presence of a laboratory (OR 3.792, 95% CI 0.998–14.557, p=0.052) as a marginal determinant of the practitioners willingness to participate in routine disease surveillance systems. Lack of time (137, 55%) was identified as the main barrier at the individual level alongside inadequately trained subordinate staff (14, 6%). Main extrinsic barriers included lack of cooperation between government and the private sector (27, 11%) and legal issues involved in reporting data (15, 6%). There was a general agreement among respondents (239, 94%) that current surveillance efforts need strengthening. Over a third suggested that availability of detailed information and training about surveillance processes (70, 33%) would facilitate reporting. Conclusions The high response rate and the practitioners’ willingness to participate in a proposed pilot non-communicable disease surveillance system indicate that there is a general interest from the private sector in cooperating. Keeping reporting systems simple, preferably in electronic formats that minimize infrastructure and time requirements on behalf of the private practitioners, will go a long way in consolidating disease surveillance efforts in the state. Organizing training sessions, providing timely feedback, and awarding continuing medical education points for routine data reporting seem feasible options and should be piloted.

Challenges to the surveillance of non-communicable diseases – a review of selected approaches

BackgroundThe rising global burden of non-communicable diseases (NCDs) necessitates the institutionalization of surveillance systems to track trends and evaluate interventions. However, NCD surveillance capacities vary across high- and low- and middle-income countries. The objective of the review was to analyse existing literature with respect to structures of health facility-based NCD surveillance systems and the lessons low- and middle-income countries can learn in setting up and running these systems.MethodsA literature review was conducted using Pub Med, Web of Knowledge and WHOLIS databases to identify citations published in English language between 1993 and 2013. In total, 20 manuscripts met inclusion criteria: 12 studies were analysed in respect to the surveillance approach, eight supporting documents in respect to general and regional challenges in NCD surveillance.ResultsEleven of the 12 studies identified were conducted in high-income countries. Five studies had a single disease focus, three a multiple NCD focus and three covered communicable as well as non-communicable diseases. Nine studies were passive assisted sentinel surveillance systems, of which six focused on the primary care level and three had additional active surveillance components, i.e., population-based surveys. The supporting documents reveal that NCD surveillance is rather limited in most low- and middle-income countries despite the increasing disease burden and its socioeconomic impact. Major barriers include institutional surveillance capacities and hence data availability.ConclusionsThe review suggests that given the complex system requirements, multiple surveillance approaches are necessary to collect comprehensive information for effective NCD surveillance. Sentinel augmented facility-based surveillance, preferably supported by population-based surveys, can provide improved evidence and help budget scarce resources.

Global Change, National Development Goals, Urbanisation and International Migration in China: African Migrants in Guangzhou and Foshan

The migration of African traders to Guangzhou, located in southeastern China, started in the 1990s and has ever since been increasing. During the last years, the neighbouring city of Foshan has become a second centre of African migration. While a growing number of migrants have been moving from Guangzhou to Foshan, an increased direct migration to Foshan can also be witnessed. The aim of this contribution is to demonstrate how the dynamics and complexity of processes in and between the two cities as well as regional, national and global conditions and developments are influencing this new migration flow. Urban development aims, their interpretation and implementation at various levels are considered, together with the reactions, flexibility and adaption strategies of the migrants. Furthermore, this example highlights how global developments (e.g. global economic crisis 2008/2009, China’s entry to the WTO), national conditions (e.g. national immigration regulations, development strategies, hosting of major international events) and interurban competition and co-operation are interrelated and have diverse impacts on the migration flows. The analysis is based on a quantitative survey of 253 African migrants, four expert interviews and 14 qualitative interviews with African migrants.

Marketization and Informalization of Health Care Services in Mega-Urban China

Introduction of the market, privatization and decentralization have been the dominant corner stones throughout the first two decades of China’s reform line after the introduction of the open door policy in 1978. Many China researchers (e.g. Wang 2008; Wu 2008) thereby judge, that China’s development path was not merely a transition from planned economy to market-oriented economy, but that a “market society” emerged, in which market principles permeate also noneconomic arenas and “threatened to become the dominant mechanism integrating all of society (and even political life)” (Wang 2008: 18). The marketization of the health sector thereby entailed that social security schemes and therewith financing of public health care collapsed almost completely and out-of-pocket payment became the dominant factor defining people’s access to health care.

Does rapid urbanization aggravate health disparities? Reflections on the epidemiological transition in Pune, India.

Background Rapid urbanization in low- and middle-income countries reinforces risk and epidemiological transition in urban societies, which are characterized by high socioeconomic gradients. Limited availability of disaggregated morbidity data in these settings impedes research on epidemiological profiles of different population subgroups. Objective The study aimed to analyze the epidemiological transition in the emerging megacity of Pune with respect to changing morbidity and mortality patterns, also taking into consideration health disparities among different socioeconomic groups. Design A mixed-methods approach was used, comprising secondary analysis of mortality data, a survey among 900 households in six neighborhoods with different socioeconomic profiles, 46 in-depth interviews with laypeople, and expert interviews with 37 health care providers and 22 other health care workers. Results The mortality data account for an epidemiological transition with an increasing number of deaths due to non-communicable diseases (NCDs) in Pune. The share of deaths due to infectious and parasitic diseases remained nearly constant, though the cause of deaths changed considerably within this group. The survey data and expert interviews indicated a slightly higher prevalence of diabetes and hypertension among higher socioeconomic groups, but a higher incidence and more frequent complications and comorbidities in lower socioeconomic groups. Although the self-reported morbidity for malaria, gastroenteritis, and tuberculosis did not show a socioeconomic pattern, experts estimated the prevalence in lower socioeconomic groups to be higher, though all groups in Pune would be affected. Conclusions The rising burden of NCDs among all socioeconomic groups and the concurrent persistence of communicable diseases pose a major challenge for public health. Improvement of urban health requires a stronger focus on health promotion and disease prevention for all socioeconomic groups with a holistic understanding of urban health. In order to derive evidence-based solutions and interventions, routine surveillance data become indispensable.Background Rapid urbanization in low- and middle-income countries reinforces risk and epidemiological transition in urban societies, which are characterized by high socioeconomic gradients. Limited availability of disaggregated morbidity data in these settings impedes research on epidemiological profiles of different population subgroups. Objective The study aimed to analyze the epidemiological transition in the emerging megacity of Pune with respect to changing morbidity and mortality patterns, also taking into consideration health disparities among different socioeconomic groups. Design A mixed-methods approach was used, comprising secondary analysis of mortality data, a survey among 900 households in six neighborhoods with different socioeconomic profiles, 46 in-depth interviews with laypeople, and expert interviews with 37 health care providers and 22 other health care workers. Results The mortality data account for an epidemiological transition with an increasing number of deaths due to non-communicable diseases (NCDs) in Pune. The share of deaths due to infectious and parasitic diseases remained nearly constant, though the cause of deaths changed considerably within this group. The survey data and expert interviews indicated a slightly higher prevalence of diabetes and hypertension among higher socioeconomic groups, but a higher incidence and more frequent complications and comorbidities in lower socioeconomic groups. Although the self-reported morbidity for malaria, gastroenteritis, and tuberculosis did not show a socioeconomic pattern, experts estimated the prevalence in lower socioeconomic groups to be higher, though all groups in Pune would be affected. Conclusions The rising burden of NCDs among all socioeconomic groups and the concurrent persistence of communicable diseases pose a major challenge for public health. Improvement of urban health requires a stronger focus on health promotion and disease prevention for all socioeconomic groups with a holistic understanding of urban health. In order to derive evidence-based solutions and interventions, routine surveillance data become indispensable.

From habits of attrition to modes of inclusion: enhancing the role of private practitioners in routine disease surveillance.

BackgroundPrivate practitioners are the preferred first point of care in a majority of low and middle-income countries and in this position, best placed for the surveillance of diseases. However their contribution to routine surveillance data is marginal. This systematic review aims to explore evidence with regards to the role, contribution, and involvement of private practitioners in routine disease data notification. We examined the factors that determine the inclusion of, and the participation thereof of private practitioners in disease surveillance activities.MethodsLiterature search was conducted using the PubMed, Web of Knowledge, WHOLIS, and WHO-IRIS databases to identify peer-reviewed and gray full-text documents in English with no limits for year of publication or study design. Forty manuscripts were reviewed.ResultsThe current participation of private practitioners in disease surveillance efforts is appalling. The main barriers to their participation are inadequate knowledge leading to unsatisfactory attitudes and misperceptions that influence their practices. Complicated reporting mechanisms with unclear guidelines, along with unsatisfactory attitudes on behalf of the government and surveillance program managers also contribute to the underreporting of cases. Infrastructural barriers especially the availability of computers and skilled human resources are critical to improving private sector participation in routine disease surveillance.ConclusionThe issues identified are similar to those for underreporting within the Integrated infectious Disease Surveillance and Response systems (IDSR) which collects data mainly from public healthcare facilities. We recommend that surveillance program officers should provide periodic training, supportive supervision and offer regular feedback to the practitioners from both public as well as private sectors in order to improve case notification. Governments need to take leadership and foster collaborative partnerships between the public and private sectors and most importantly exercise regulatory authority where needed.

Health Inequities in the City of Pune, India

Since the so-called urban turn in the year 2008, more than half of the population worldwide is living in cities. This is leading to a growing number of people whose health is being influenced by urban living conditions. Whereas a third of the urban population worldwide is currently living in small urban centres with a population of below 100,000, 16% lives in so-called emerging megacities (five to ten million inhabitants) and megacities (above ten million inhabitants); two thirds of these megacities are located in poor or newly industrializing countries (UN 2010). Megacities – especially in Asia and Africa – have grown at a very high pace over the last decades with many implications for the urban population.