Urban health & development: a practical manual for use in developing countries

By Beverley Booth, Kirian Martin, & Ted Lankester Macmillan Education, London, England, 2001. ISBN 0 333 67934 2, price £12.50

This is a manual for development practitioners working with poor urban communities to improve local health conditions. It provides background information on the health problems typically encountered in such an environment, and outlines steps that can be taken to avoid or solve them.

Largely on practical grounds, the authors advocate treating communities as partners in (rather than recipients of) development. The book is written in simple and straightforward terms, with little concern for complexity, uncertainty and variability. The basic formula is one of working with community groups to: understand what the health-related problems are; decide what to do about them; and do it. Despite the emphasis on partnership, the basic institutional template is largely predetermined, and involves a 'Community Health and Development Programme', with a 'Programme Team' (made up of health specialists, development specialists and support staff), a Community Action Group (which can be based on a pre-existing community group), and jointly developed projects.

The range of health care and environmental initiatives described here goes well beyond the mandate of a typical government health authority. For the most part, it emphasizes preventing ill-health rather than treating it. Indeed, the authors suggest that it may be best to avoid using terms like 'community health committee', since the 'health' label may unnecessarily focus activities on medical care.

To some extent, this broad scope reflects one of the strengths of community health initiatives. In urban settings, health is usually worst in low-income areas, where health threats are closely linked to poverty, social exclusion, and unhealthy living and working environments. Working with poor urban communities, it is not only possible to target some of the most unhealthy groups, but also to focus on measures because of their importance to health, irrespective of whether the measures are a priority for local or national health authorities, who must define their role in relation to other government agencies. If this means working to clear drains, set up day care centres or rebuild houses, rather than setting up health clinics, so be it.

The authors focus on initiatives that relate either to health care or to environmental health improvements, and require at least some degree of health expertise to handle. One could argue for a narrower focus, so as to stay within the bounds of available skills, or for a broader one so as to include important factors such as income-generating activities, but overall they present a coherent combination of health-related issues.

Another potential strength of community health initiatives is that they can adapt to local conditions, and do not have to prejudge how best to proceed, but it is just here that the book runs into more serious difficulties. Written from a `How-to' perspective, it attempts to outline the practical steps required, not only to set up a partnership with the community, but also to tackle problems as diverse as tuberculosis and HIV/AIDS, domestic violence, and inadequate water and sanitation. The authors have clearly found it difficult to define steps that are sufficiently general to be widely applicable and sufficiently specific to be meaningful. This is hardly surprising, given the enormous diversity in low-income settlements around the world (`slums' in the book's terminology), and the complexity of the problems faced there. Unfortunately, as a result, strict adherence to the recommendations the book makes would undermine the flexibility of community-based health initiatives.

In attempting to provide a simple, straightforward presentation, the authors have also tended to rely on a representation of a typical `slum' that comes close to being a stereotype. This effect is only slightly offset by boxes containing examples, sprinkled throughout the book. Stereotyping can easily prejudice development workers, especially when it extends to descriptions of the way `slum dwellers' think and behave. Consider, for example, the problem presented first in the list of obstacles that can undermine efforts to develop partnerships with communities:

"Dependency mind set. Politicians, government agencies and NGOs frequently offer to provide slum dwellers with certain services, or to enrol them in some scheme. Over time, the people begin to feel it is the responsibility of these agencies to solve their problems. Therefore when a CHDP (Community Health and Development Programme) comes in and encourages the people to solve their own problems, they show no interest, resist, or may even be hostile."

This concern comes up a number of times in the book, and is undoubtedly based on the authors' considerable field experience. But describing a `dependency mind set' in this way involves some sweeping generalizations that could easily reinforce prejudice rather than facilitate good relations, especially among those development workers already too inclined to blame problems on the way poor people think.

Somewhat analogous difficulties arise in relation to the health problems themselves. In their very brief account of indoor air pollution, for example, the authors write that "There are two dangerous forms of indoor air pollution in crowded slums". The first "comes from the use of open fires with polluting fuels such as kerosene, coal or animal dung..."; the second "is the effect of tobacco smoke...." Even if from an international perspective these were the two most dangerous forms of indoor air pollution in 'slums', they would be quite likely not to be the most dangerous in the community in question. Indeed, there are many areas where, from a health perspective, kerosene is likely to be a considerable improvement over wood.

In short, the very premise of this book — that it is possible to generalize about how best to pursue health improvement in low-income urban areas — is questionable. At least in its current edition, it would be a mistake to see this book as a recipe for developing community-level health initiatives.

On the other hand, the topic is of immense importance and the authors clearly have a great deal of experience. Most practitioners are likely to find the simple didactic style far easier to read than a more rigorous but complex and qualified presentation. Many will appreciate its urban focus, and its wide ranging content — which even extends to topics such as soliciting support from government agencies and fund-raising. It may not have achieved its over- ambitious goals, but it takes an important step in the right direction.

Gordon McGranahan¹

¹ Principal Research Associate, International Institute for Environment and Development, 3 Endsleigh Street, London WC1H ODD, England (email: McGranahan@iied.org).