The healthcare issues of those who live in the more densely populated areas of the world are important not only because of there are so many of them; but also because urbanization is fast gathering momentum all over the world and dense urban population simultaneously throws up challenges and offers special solutions. The potential for problems includes increased chances of infections, larger volumes of waste products at risk of poor handling, the presence of pollutants, an apparent increase in stress, and a concentration of more serious mental health problems. Solutions are influenced by economies of scale in providing services, a more varied array of resources, a concentration of expertise and the potential for closer proximity to others with similar interests and needs.
The world population is rapidly becoming more and more urban. In the Indian context, an urban area is the one in which 75% of the population lives by non-agricultural occupations. By this criterion, 1 out of every 9 Indians lived in an urban setting in 1901. Today, every fourth Indian is a city-dweller. From 26 million in 1901, the urban population of India has grown to 218 million in 1991. 10 top cities account for more than 5% of the Indian population.
The twentieth century has seen India in a demographic transition. At the beginning of the century endemic disease, periodic epidemics, and famines kept the death rate high enough to balance out the high birth rate. Between 1911 and 1920, the birth and death rates were virtually equal, about 48 births and 48 deaths per 1,000 population. The increasing impact of curative and preventive medicine (especially mass inoculations) brought a steady decline in the death rate. By the mid-1990s, the estimated birth rate had fallen to 28 per 1000 and the estimated death rate had fallen to 10 per 1000. In 1901 there were some 77 persons per square kilometer; in 1981 there were 216 and by 1991 there were 267 persons per square kilometer.
According to a study done this year, there are 19 cities in the world with a population density in excess of 10,000 people per square kilometer, out of which 5 are from India. Mumbai tops the global list with a density of 29650, followed by Kolkata (23900). The India average is 324 and the figure for the entire populated area of the world is less than 100.
Urban populations exhibit extremes of income inequality. Income inequality has a significant negative impact on health. This impact is greater for infants and those between 15 and 64 years of age. A study reveals that when poverty is concentrated within a geographic area, mortality is significantly elevated. Conversely, a concentration of affluence is associated with lower mortality, at least in the elderly. Closer proximity increases the rates of transmissible diseases such as tuberculosis and other respiratory infections.
In a rural setup it is possible to be the master of one's health habits. On the other hand, one is forced to use the public transport system and be subjected to close proximity with a great number of others. Then there is also an increased level of stress, which is known to increase the risk of illness. (The density of urban populations and the related stresses have also been associated with increased rates of violence.)
Cities are a centre of immigration from rural areas and they experience a constant influx of people from other cultures and climates. This may add to the health challenge in a number of ways. Beyond specific diseases, immigrants bring different expectations of the healthcare system, and a different understanding of the range of interventions appropriate to various disease conditions. The cost of housing may force people to live in slums and on the streets. This has important implications for healthcare, as homelessness may result in healthcare going to a lower rung on the priority list of a family or of an individual. The excessive crowding adds another dimension of stress to the risks of mental and physical ill health.
People in urban areas do not grow food but buy it from the market. The food has to travel long distances to reach the urban market. This makes 'fresh' a relative term. On the other hand, large concentrations of people make it economically reasonable to regularly import food from all over the globe, making formerly seasonal fruits and vegetables available year-round.

The food availability in urban areas differs by income level, as does every other aspect of urban life and health. The quality and quantity of food available and affordable to lower income families is such that they suffer nutritionally. Water supply through taps is another health hazard since urban governing bodies in India are yet to wake up to the need to supply clean water to the residents all the year round. Water supply systems need regular maintenance and main pipes installed decades ago remain a regular rupture hazard in older urban areas, as is evident from the frequent pipe bursts in Mumbai in the recent past.
The concentration of populations in urban areas also means an increased accumulation of waste products. Removal of human waste and garbage is a major concern in any city. Trash and garbage that accumulate in urban areas must be disposed of safely. The garbage incinerator is not feasible due to both volume of material and the air pollution caused by burning. Landfill disposal requires moving the material outside the urban boundary, and safety requirements for landfills are being increasingly flouted. While many areas do not want any waste disposal nearby, the acceptance and processing of urban waste has been welcomed by some economically suffering 'backward' areas. Efforts to recycle waste have met with varying degrees of success. Little attention is being paid to the steller service ragpickers are rendering. The collect various items from the garbage and the trash cans and sort them according to their utility. There is an elaborate system of picking up the sorted material and delivering it to reuse industry. The Municipal staff as also the general public is not appreciative of this service; on the other hand the poor ragpickers, majority of whom are women, have to face contempt from the public.

Both air and noise pollution are of great concern in urban areas. The need to move large volumes of materials into urban areas, and to move large numbers of people around within urban areas, means that there is a need to devise more environmentally sound means of locomotion and transportation will continue. People must be concerned not only with visible particulate matter (smoke and ash from fireplaces) but with a wide range of chemicals associated with the increase of chronic disease.
Urban hospital systems have provided a critical link in access to health care. Many hospitals, especially in the metro cities, have a long history of service. Public health system in India suffers from many problems which include insufficient funding, dearth of facilities leading to overcrowding and a severe shortage of trained health personnel. There is also a lack of accountability in the public health delivery mechanisms.
These are some of the reasons which have placed India at the lowest rank in the Human Development Index. According to the Planning Commission, the country has a shortfall of six lakh doctors, 10 lakh nurses and two lakh dental surgeons. This has led to a dismal patient-doctor ratio of 1 doctor for every 10,000 Indians. However, India holds the top position in migration of physicians to developed countries like UK and the US. We are subsidizing the healthcare of the more affluent countries! The much publicised National Urban Health Mission is yet to see the light of day. The scheme plans to monitor and improve the health of 22 crore people living in urban slums in 429 cities and towns. It was to be launched mid 2008 but the mission is yet to become functional. NURM is aimed at providing accessible, affordable, effective and reliable primary healthcare facilities to the urban poor.
The concentration of people also means that specialized services are economically viable. A person with a relatively unusual condition who lives in an urban area is more likely to find the needed care than a similar individual in a rural location. A number of schemes such as the Urban Malaria Scheme, National Filarial Control Program have been introduced for the urban population but the ills of urban healthcare in India are many. Overcrowding, poor housing, choked drains, high density of insects and rodents, lack of garbage disposal facilities, poor personal hygiene and hygienic conditions mar the Indian urban slums. Children are the worst sufferers under such conditions and to quote an example, a study has revealed that children under 2 years in the city of Ludhiana had 3.8 episodes of diarrhea per year.
The healthcare planning in India has so far focused on the rural areas. The urban slum (all clusters of 20-25 or more households having no roofs or having non-concrete roofs, and not having any facility of drinking water, toilets or drainage would be considered as slums. Earlier, the cluster size for identification of slums was 60 households) population in India is expected to be more than 930 lakhs by 2011 but they have to depend upon private medical practitioners for their health requirements. Most of these practitioners are either expensive or unqualified. Out of more than 3000 urban local government bodies, very few have some healthcare system in place.
There is a cultural angle to the issue of healthcare of the urban poor. The urban slums are full of migrant people, mostly men who have left their ancestral abodes and have opted to live in inhuman conditions in an alien environment to earn a livelihood to support them and their families. If the poverty is hopeless or, if there are no ties worth retaining, the whole family migrates. They leave their village behind but take their beliefs and traditions and customs with them. It is natural for them to seek the first shelter with their own kin. And so, within the boundaries of a modern, vibrant metropolitan city like Mumbai or Delhi, there exist clusters of people following antiquated customs and hazardous practices. No wonder fresh polio cases keep surfacing in Mumbai in spite of an alert and active healthcare delivery by the Mumbai Municipal Corporation and a long, persistent immunisation campaign.
The contradiction here is obvious. Good, affordable healthcare is available and yet the needy poor do not access it. They are conditioned to believe that such services are not meant for them. It is a classic case of Mohammed and the Mountain. Here too, the service providers have to develop a means to take Health to those who lack it. The strategy has to be two-pronged. On the one hand, the newly arrived migrant has to be made aware of his rights as a citizen. And, the healthcare staff also has to be indoctrinated to adopt a responsive mind-set.

Urban health issues are as complex as the city itself. The city cuts off the poor migrant from his emotional and conventional support systems. The city also offers him / her hope in the form of livelihood and access to better healthcare, better education opportunities for his offspring. But the City is the manifest future for the hopeful and the aspiring, and consequently urban healthcare is of paramount importance for a developing country like India.