Addressing Public Health Challenges in Urban Slums: An Interview with Rob Breiman

Rob Breiman

More than half of the world’s population now lives in cities and towns. By 2030 this number will increase to almost five billion, with most of the growth taking place in Africa and Asia. The rise in population, however, will happen in smaller towns and cities, which have fewer resources to handle the magnitude of change. Rapid urbanization leads to increased poverty in these areas. Currently, more than one billion people live in urban slums, which are overcrowded, polluted, dangerous, and lack clean water and proper sanitation.

Robert Breiman, director of the Emory Global Health Institute (EGHI), knows the impact of urban slums on public health. His past work in Bangladesh and Kenya has made addressing the challenges of urban slums and public health one of his top concerns. IDN program coordinator Stephanie Stawicki recently sat down with Breiman to discuss his work in this area and EGHI’s commitment to advancing public health and development in urban slums.

You most recently worked with CDC-Kenya as the country director and head of the Global Disease Detection Division. Can you describe your work in Kenya? What types of projects was the division working on?

CDC-Kenya is the CDC’s largest and one of its oldest overseas field operations. By the time I left, there were 32 American staff working and living in Kenya and more than 1,800 Kenyans working under the CDC’s technical guidance (either as US government locally employed staff or as employees of the CDC’s principal partner in Kenya, the Kenya Medical Research Institute). The CDC works all around the country and in the East African region. The Kenya work is principally in Kisumu (at one of the world’s premier field stations) and in Nairobi. The CDC has been working in Kenya for nearly 35 years with a long history of focus on malaria, other parasitic diseases, and enteric and diarrheal diseases. Since the onset of the President’s Emergency Plan for AIDS Relief, improving diagnostic capacity, care and treatment, and prevention of HIV infection have been major components of CDC-Kenya’s presence there. The Global Disease Detection work has taken off during the past 10 years.

Global Disease Detection started in 2004 in Kenya with my arrival there with several American colleagues and grew to include: an emerging infections program; the Field Epidemiology and Laboratory Training Program; an influenza program that assists in preparedness for influenza epidemics and pandemics; a Refugee Health Program that monitors the health of people living in the two refugee camps and assists with resettlement programs to the US; a Diagnostics and Laboratory Science program; and the Integrated Human and Animal Health Program, which builds capacity to characterize risk of pathogens moving from animals to humans.

As I understand it, you have a strong interest in the development of urban slums, especially in Africa and Asia. How did this interest develop? Was it a particular project or experience that piqued your interest? 

While I was working in Bangladesh, I had the opportunity to be involved in multiple disease surveillance, epidemiologic, and vaccine studies in two urban slums in Dhaka. Dhaka is probably the most densely populated city in the world and it is the poorest. The vast majority of its residents live in outrageously crowded slums, which are totally informal—that is, there are few, if any, government services with regard to sanitation, water, security, and emergency response. At that time [2000-2004], these were the most desperate living conditions I ever had seen. The public health problems that arise in these settings are vastly different than those that must be addressed in rural environments (where most public health efforts in the developing world have traditionally been focused), and the solutions and tools one can use to address the problems are often also different.

When I moved to Kenya to start the emerging infections program, the CDC was already deeply involved in work in rural western Kenya, where infant mortality, malaria parasitemia, and HIV seroprevalence were quite high, but there was essentially no urban work going on and minimal understanding of disease risk in urban settings. Yet Kenya is urbanizing at a rate of seven percent per year, and more than 70 percent of the growing Nairobi population lives in urban slums that bear many similarities to what I had grown used to seeing in Dhaka. I thought that any program that sets out to assess burden of disease and risks for emerging infectious diseases must include an urban slum site, as well as at least one rural site. So, in 2005, we began population-based infectious disease surveillance in Kibera, one of the 20 largest slums (with 77,000 people per square kilometer) in Africa and in Lwak, in rural Kenya (about 300 people per square kilometer) in the western part of the country next to Lake Victoria.

What are current health and development challenges in urban slums? Where do you see the potential for a massive public health emergency in slums?

Because of dense population and sub-optimal sanitation and safe water, there is immense potential for the introduction and spread of a variety of pathogens. You can imagine that a highly transmittable respiratory virus, once introduced in this setting, would spread like a flame in a tinderbox. Endemic typhoid rates are incredibly high in this setting—children have a one in five chance of developing typhoid fever during the first 10 years of life, and cholera outbreaks have occurred in Kibera and in other urban slums in Nairobi. Given the close proximity of a variety of animals (including rodents) to humans in these crowded settings, the potential for pathogens to jump from animals to human and spread rapidly is also substantial. With urbanization and industry comes deforestation which brings animals, like bats, which carry many highly dangerous pathogens. Again, the potential of hazards in an urban slum is of particular concern if one of these pathogens then can be easily transmitted from person to person.

These settings are not very resilient—the minimal infrastructure can easily be overwhelmed by extreme events, so floods can be hazard as can be droughts (when it becomes exceedingly difficult to access drinking water). One unexpected finding was the high incidence of burn injuries (often associated with cooking and affecting toddlers) and the risk of fire. Fire spreads very rapidly in the slum, and there are no roads for emergency vehicles to access and no way to get water in to put fires out.  I have been in Kibera when fires have broken out, and these are very scary events—not only is it hard for fire crews to get in to respond, but there is essentially no way out.

Security is also a problem in these areas, especially at night, so even though there are clinics and hospitals in much closer proximity for urbanites than for people living in rural areas, people in emergencies (like mothers going into labor) are often not willing to venture out at night.

What disciplines and organizations do you think should be involved in addressing issues in urban slums? What units or departments here at Emory could be potential partners in these efforts?

While there are many public health interventions that are needed, like influenza, typhoid, cholera and other vaccines, safe water, hand hygiene, safe stoves and others, the principal problem is the informality of these settings. They are disadvantaged by minimal government services, the lack of a sustained effort to raise the standard of living (which would dramatically reduce the public health risk), and also the paucity of formal employment (with adequate salary and benefits) for nearly all of the residents. As things stand now, most slum residents have the cards stacked against them for improving their lives, creating businesses, extending education for their children and building better living environments. So, I believe that the primary public health advances for the growing issue of urbanization (and slum proliferation), especially in Africa, are not only traditional public health efforts, but they will involve creating opportunities for business, and for locally grown innovations, and may require input from business, law, and political science, as well as from religious, social science, environmental health, and IT sectors.

There is much to learn from history as well—how did the US and Europe ultimately address the challenge of urbanization? Integrating experts from a variety of disciplines to focus on an overarching problem is one of the things that EGHI is designed to do. In addition to engaging faculty from around the university to come up with novel and scalable approaches, we also will bring fresh young minds—students—to the discussion and the experience so that, as their careers develop, a cadre of future global health scientists and leaders will have this foundation and can contribute. I believe that this also will require building a wide stream of students from the developing world who will join existing Emory students in training and in sharing experiences and ideas. In addition, EGHI has the advantage of being in Atlanta, where partners at places like Georgia Tech, Georgia State, Morehouse, University of Georgia, CARE, The Carter Center, the Task Force for Global Health, and the CDC will have exciting ways they can contribute to an integrated, comprehensive approach. Urbanization in low- and middle-income countries is fast becoming one of the major issues of the 21st century. Emory and its partners are ideally suited to make an immense positive impact.