 Ladies and gentlemen, it's a pleasure to be here to present some of the perspective from African cities. I have to caution ahead of my presentation that much of the work we've done has been in Nairobi and in Kenya and therefore a lot of what I'll talk about borrows heavily from the Kenyan experience as opposed to many African cities. And a good reason for that is that perhaps if a book was to be written how not to urbanize in the 21st century I think Kenya would make a good case study of how not to urbanize in the 21st century. So my topic is well-being, a perspective from African cities and the African population and hence research center has been doing quite a lot of work on trying to understand the urbanization process in sub-Saharan Africa but most importantly the consequences of this urbanization process. So I'll talk a bit about urbanization and poverty in Africa because these two processes cannot be divorced from each other. The health challenges in the urban sub-Saharan Africa with a huge focus on Nairobi, looking at the dominance of infectious diseases in the health profile but also an emerging importance of non-communicable diseases and then trying to dig a little bit deeper in the intra-urban differences in health outcomes and just one slide on what this means for policy and practice. I think you've seen this slide perhaps in many publications in different forms and shapes but I'll get to focus on the upper set of bars and what this shows is that in the last five years between 2005 and 2010 the slump the annual population growth rate in slums has been about 4.5 percent and that's compared to just 1.6 percent in sub-Saharan Africa and as opposed to 3.65 percent in other urban areas in general. So what this means is that slums have grown at a much faster rate than the rest of the population but the urban population has also grown at a faster rate than the rural population and projections between for up to 2010 show that in actual fact the population in slums in sub-Saharan Africa is probably going to double and the urban population is also going to double but then the total population sorry is going to increase by about 40 percent. So by 2010 we expect that almost more than one third of the total population in sub-Saharan Africa will actually be living in slums and about half the population will be living in cities and the consequence of that is the cities like Nairobi with a very you know almost not comparable to Hong Kong but getting there slowly of central business districts and a slum that's less than 10 kilometers from the city center or the central business district and in some of these slum settlements our estimates from the work we've done in some of the slums show that the population density is about 65,000 per kilometer squared. I was seeing the estimates from Chile which is 16,000 per kilometer squared so you can imagine maybe two and a half times of that on one kilometer squared of space and of course this brings different challenges in terms of health. Now a critical part of this I think it I cannot overemphasize the fact that it's not just a healthcare system that influences health but it has a path to play in health outcomes. I think the gentleman from Chile shared about 25 percent which is critical. So the problem is that as the urban population has grown the number of public health facilities has not kept pace with the urban growth and we've done a survey that shows that for everyone public health facility that that serves a slum settlement there about 100 private health facilities of all shapes and sizes as you'll see from these are real pictures not photoshopped so right down here we have a health clinic that also offers maternity services in one of the slums. This is a hospital. Hospitality is hospital in Kiswahili the local language and there's one up there that even has an ambulance so there's a whole range of private health providers that have sprung up to feel a gap that is left by the absence or the near absence of public health facilities and to make matters worse the few public health facilities that exist open between eight and five on weekdays and that's the time when most slum residents are out looking for employment so the result is overcrowded but I think more overwhelmed public health facilities and the dominant private profit sector in numeric terms has very limited support and integration in the public system very poor regulatory framework and some of the studies that we've done show that we did a survey in three slums Nairobi has about 80 depending on different classifications we did a survey in three slums and we're and we enumerated more than 500 health facilities but at the same time the number of registered health facilities in the whole of Nairobi was less than 450 so if three slums at 500 I don't know less than half of them or maybe a quarter of them were registered so very poor regulation in terms of the private sector very unlimited support but this is the system that more than 70% of the slum residents access that's the private sector so what are the health challenges that are dominant in urban sub-saharan Africa for the whole region in general communicable diseases infectious diseases account for the greatest disease burden I think estimates in mortality to put it around 70% of the mortality is from infectious diseases and so a similar pattern of the dominance of communicable diseases observed in urban areas and this can be explained by different factors environmental factors in urban areas specifically limited access to clean water and sanitation services a huge burden from indoor air pollution among the underfives almost 25% of children are dying from pneumonia and this can be closely linked to indoor air pollution as a result of cooking practices within these small little sharks that people live in where people cook in the same room where they sleep of course of a crowding 60,000 per square kilometer one case of measles can easily become an outbreak because of just a close proximity of people food insecurity a huge problem in terms of the results on malnutrition in children but also in women and the consequences this has for infectious diseases but also high risk behavior alcohol drug use and the association between this and sex and of course the attendant risks of HIV for instance but then as I said limited access to preventive health services for non communicable diseases we estimate that this as time goes on will outstrip communicable diseases in the next few decades and this is a result of increased behavior risk factors specifically diet alcohol use and tobacco use surprisingly or not surprisingly especially in this lamp settlements physical inactivity is not a huge problem because people work for miles and miles and miles looking for work and then in terms of diet very limited dietary diversity but also very surprising a high use of street foods and fast foods in these slump settlements this is very recent data that shows that the households with the severest food insecurity are the households which are most likely to consume street foods and our assumption has been that in this poor environment if you're to for instance control some of the salt consumption perhaps it's most it's important to focus on the household consumption patterns but then we find that most are consuming food outside the household and then of course other environmental factors air water and soil pollution I think you've had the problem of e-west especially in countries like Nigeria and then limited access to screening and other preventive services and just put it to perspective in terms of risk factors over the last 15 years the prevalence of overweight and obesity among women of reproductive age has almost doubled from around 13% to 25% but this this is at the national level the increase is more marked in urban areas where the rates now are almost 40% among women of reproductive age compared to 20% in rural areas and similar results are found in Ghana. A third cause of death from injuries this both intentional and intentional and mostly driven by road safety or lack thereof with increasing traffic volumes this is a typical Nairobi Street on a typical day limited access to emergency services imagine you're stuck somewhere in an ambulance in this I mean there's unless you're going to fly over the the traffic but even if you had an an emergency as a result of a road traffic accident somewhere else it's unlikely you reach anywhere in time to save your life of very high levels of interpersonal violence as a result of limited social cohesion especially in these slam settlements crime and insecurity and limited access to law and enforcement law enforcement and judicial services so as a result of the limited access to preventive services I mentioned earlier we find very low levels of children who are fully vaccinated only 51% very high levels of malnutrition and stunting HIV prevalence almost double the national the rural average contraceptive rates that are very high and a lot of other indicators when look at the top causes of death we find that the the the combined mortality from injuries and non-communicable diseases in a relatively young age group is almost the same as the combined death from HIV and age-rated death but among males in this age group injuries and accidents contribute almost one-third of the mortality while in females it's HIV that is mostly the communist cause of death other indicators if you compare the infant mortality rate path 1000 live birth almost 96 per 1000 compared to 60 for Nairobi as a whole and 58 for the whole of Kenya and down here under five I mean maternal mortality rate almost 700 in the Nairobi slums as compared to 488 for the whole of Kenya I'll skip I'll just go briefly about this the one of the indicators where the urban the urban is doing worse than the rural areas is teenage pregnancy in the previous slide there the urban average is about 18% and the rural is slightly above above 17 but if you dig that if you dig deeper within the urban within the urban population the richest urban in 1993 had a four times less probability for a teenager of being pregnant or having a child by age 19 and it has gone slightly up to about nine but still compared with the urban poor it's around 26% almost three times three times the risk of being a teenager and pregnant this is my last slide about the increasing risk for cardiovascular diseases which is one of the five major communicable diseases and what this shows that this is exclusively among the slum population a diabetes prevalence of about 4% which is not bad but for an age group of 18 and above if you take it at a high age group it's around 11% but the most disturbing statistic is that out of these people who are diabetic only 20% of them are previously diagnosed or they are aware that they are diabetic and of those who are aware about two-thirds are on treatment and of those who are on treatment that's in the last one year only 51% are on treatment in the last two weeks but at the population level if you start with 100 diabetics less than one of them are actually well controlled and the majority is because they're not aware those who are aware not treated those are treated and not even properly treated and the findings on high blood pressure not very different so what this shows is that undetected and treated and uncontrolled risk factors who somebody who is a diabetic today will be a kidney failure in about five years time at this rate or will be heart attack or a stroke in about five years time at the rate the rate of lack of awareness lack of treatment and lack of control so the implications for police and practice I think for urban sub-saharan Africa it's difficult to address urban health in sub-saharan Africa without addressing the plight of the urban poor and our research has shown that if you ask them what are your most important needs employment is high on the list so it's not enough to say we shall provide health services employment is about the for 40% of the respondents is the most important need a triple burden of disease is evident as we showed infectious disease communicable and injuries and we think that health and other social indicators for the urban poor increasingly drive national indicators and slump settlements positively a highly resource to their entrepreneurs their civil societies their humanitarians and policies and programs that aim to improve health and well-being in urban sub-saharan Africa need to harness all these resources I thank you