Urbanization and mental health

a developing world perspective

Urbanization is a phenomenon that has existed as far back as recorded history. Humans live alone or in groups, depending on preference and need, but as social creatures we are generally inclined to seek out mates, to form social connections, developing communities, and ultimately creating societies that exist, be they urban or rural. However, in recent times it appears that the worldwide trend is towards increasing urbanization with the creation of cities and now megacities, that is, those with populations of over 10 million. By 2030, it is projected that there will be 41 such mega-cities across the world (http://www.un.org/en/development/desa/news/population/world-urbanization-prospects-2014.html accessed on 18th February 2018). Hence notwithstanding cultural or ideological differences that exist between and within continents – there is a universal phenomenon that provides a commonality. Whether urbanization constitutes actual progress or simply progression is worthy of debate. In so doing, one needs to consider what is gained, but also what is lost. There are push and pull factors each requiring elucidation in addressing the merits of this phenomenon.

The current issue of the publication has brought together a series of articles that highlights mental health issues related to urbanization in Brazil, Russia and India together with a general perspective that serves as context. This editorial will add further information from China and South Africa, that is, ‘BRICS.’ In 2003, Goldman Sachs coined the acronym BRIC having understood that by 2050, the economies of these four countries combined would be a dominant force. South Africa was included in 2011, leading to ‘BRICS’. (https://www.investopedia.com/terms/b/brics.asp?partner=asksa accessed on 18th February 2018). In essence, the association of the countries was not seen as political but understood to have potential as an economic bloc. And yet there is a political dimension that underpins the association noting not only the anti-apartheid stance of the BRIC countries but also the active involvement with support during the anti-apartheid struggle from the then Union of Soviet Socialist Republics (USSR) and the related Eastern Bloc countries of that time. In common, post-apartheid, is that each of the countries is viewed as developing with all, according to World Bank data, falling into the so-called Low and Middle Income Country (LAMIC) group (https://data.worldbank.org/income-level/low-and-middle-income accessed on 18th February 2018). Collectively the LAMICs have a combined population of almost 6.5 billion of a total world population of approximately 7.6 billion (http://www.worldometers.info/world-population/ accessed on 18th February 2018), that is, constituting 85%. Within this group are the BRICS countries with a total population of approximately 3.05 billion based on projections published by the United Nations in the 2017 revision of World Population Prospects (https://www.un.org/development/desa/publications/world-population-prospects-the-2017-revision.html accessed on 18th February 2018). It has been estimated that by 2050, 66% of the world's population will live in urban areas with almost all of the increase in such populations emanating from Asia and Africa – with India and China together with Nigeria contributing to the largest urban growth. It has been noted that managing urban areas constitutes one of the major challenges of the 21st century with respect to attaining the developmental agenda set by the United Nations. (http://www.un.org/en/development/desa/news/population/world-urbanization-prospects-2014.html accessed on 18th February 2018). Noting the trend towards urbanization is the concurrent trend towards decreasing rural populations. Whilst Africa and Asia are urbanizing rapidly, these continents are still home to 90% of the total rural population of the world (http://www.un.org/en/development/desa/news/population/world-urbanization-prospects-2014.html accessed on 18th February 2018).

There is an increasing emphasis on mental health as integral to the health of a person, and with good reason ^[1]. Moreover, worldwide trends that demonstrate the extent to which mental illness contributes to loss of quality of life, as well as life itself, underscores the need to consider phenomena that impact – be that impact positive or negative ^[2]. In this regard, urbanization needs to receive appropriate recognition as such a factor noting the worldwide trend. Whilst the phenomenon of urbanization would generally relate to individuals moving within a country, the current crisis of migrants and refugees will further contribute to such movement across countries, and continents, with an estimated 4.2 million such refugees originating from the Syrian Arab Republic alone (https://www.un.org/development/desa/publications/world-population-prospects-the-2017-revision.html accessed on 18th February 2018).

Common to the articles by Okkels et al. (pp. 258–264), Morozov (pp. 272–275) and Chandra et al. (pp. 276–281) are the noted problems associated with urbanization including homelessness, environmental pollution, substance abuse and violence. Moreover, the need for governmental policy to provide a strategy for managing the emergent problems is also emphasized. The article by Asevedo et al. (pp. 265–271), however, focuses on a specific issue, that is, the link between suicide and economic indicators in an urban setting – with interesting findings suggesting local more than general economic factors being implicated. Within China, a range of issues have been raised with regard to urbanization and health generally – noting rapid change within the country and growth of urban centres ^[3]. In a cross-sectional survey linking the 2010 population census with Center of Epidemiological Studies depression Scale (CES-D), it was found that high-population density cities demonstrated higher CES-D scores ^[4], with ethnic minorities also having higher scores. The role of changing family structure and income was studied by Filho et al.^[5] who noted that the number of married couples in a neighbourhood lowered the risk of externalising mental disorders. Noting that China's urbanization rate rose steeply from 1978 to 2016 Xiao et al.^[6] sought to assess the impact of housing on mental health, specifically that of migrants moving into urban from rural areas. Of interest was that housing conditions impacted indirectly on migrant mental health being mediated by neighbourhood satisfaction whereas local residents were directly impacted by housing conditions. In this respect, the issue of sense of community was observed to be an important element of migrant mental health in an urban setting. Such a finding echoes that of the phenomenon of urban social exclusion experienced by migrants which impacts on their mental health ^[7]. Collectively, the data provide a range of issues that speak to the earlier noted need for policy and planning at a Governmental level to mitigate the impact of urbanization on mental health, accepting that a range of issues not mentioned but operational in other settings likely apply. Within a South African – and African – context, a major consequence of urbanization has been the lack of resources to provide adequate psychiatric care. Specifically, that the services audited in a specific region proximal to the city of Johannesburg in South Africa did not meet any of the norms required by the country's National Mental Health Policy Framework and Strategic Plan 2013–2020. In this instance, policy existed but resources did not – specifically human resources ^[8]. This issue is pervasive throughout Africa wherever principles of community-based care are adopted in local polices but with poor implementation against a background of competing priorities ^[9] and with the pace of urbanization associated with fragmentation of families, economic stress, interpersonal violence and substance abuse – this is a pressing need.

Notwithstanding the apparent benefits of urbanization in terms of proximity and access to resources, the BRICS experience suggest that there are a multitude of issues – common to these countries – that require careful consideration if the risks are not to outweigh the benefits.

Acknowledgements

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Conflicts of interest

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