Big city blues: health disparities within the world's largest urban centres.

The enormity of the challenge — and the gulf between rhetoric and reality — was immediately evident. A well-heeled British delegate stepped up to the microphone at the World Health Summit in Berlin, Germany, and chided Dr. Hans Dohmann, municipal secretary of health for the city of Rio de Janeiro, Brazil, for having taken more than a decade to begin implementing his federal government’s dictum to expand primary health care to all citizens. Dohmann bristled at the suggestion that Rio had been lax in delivering primary care in its slums, where only 3% of denizens had ready access to a doctor, health worker or health facility. It’s one thing to implement the “very romantic” notion that a “gaucho with a stethoscope” can just ride into a rural area or a small city and cure everyone’s ills, Dohmann said. But it’s another thing altogether to build the health infrastructure and hire the health workers needed to provide primary and dental care for the more than one million people living in the city’s often-violent hillside slums, while also improving care for its remaining 11.6 million residents. “It takes time,” Dohmann stressed, expressing pride that primary health and dental care will be extended to 16% of slum residents by the end of this year and that 30% will have access by 2012. Therein lies an enormous dilemma for the world’s so-called “megacities,” (which are typically defined as metropolitan areas with a total population in excess of 10 million people): how to provide health care for the everincreasing number of poor and the marginalized people in the world who are born, or are flocking, to oftenunstructured urban environments. It’s not as onerous a task for megacities in the wealthy industrialized world, such as Tokyo, Japan (33 million residents) and New York City, New York (about 18 million residents), as it is for those in developing or emerging countries. Dohmann says Rio’s challenge was nothing short of “immense,” and ranged from finding new homes for slum tenants who were displaced by the construction of new health facilities to finding health care workers willing to toil in the dangerous slums. “There’s a long list of difficulties but I think the major ones were the cultural aspects (attitudes) of professionals, and from the communities — to understand the new model, and how to work in this model. The other was the bureaucracy. We were fighting a lot with the bureaucracy to implement this plan.” The plan basically involved divvyingup the city into “micro-regions,” in which primary health care would be contracted from, and managed by, a private not-for-profit organization. The goal was to create a walk-in clinic or family health unit for every 30 000 residents and a “municipal reference hospital” for every 150 000 residents. Dohmann earlier told the summit session that because of the cultural and social conditions of the slums, there was a need to hire a community liaison person to convince residents to use facilities and “take pride in their health.” So it was decided that a “health agent” had to be hired for each of the local clinics. Recruiting those agents, along with pediatricians willing to venture into the slums, has been the biggest staffing obstacle, he says. Then there was the cost. Over a three year period, “to implement the program we’re spending about 1.5 billion reals ($908.2 million) per year,” he says. “At the beginning, people didn’t believe that it was possible. Now they’re beginning to believe.” Rio’s challenges are not unique, delegates to the “Megacities: Opportunities and Challenges for Health” session were told. The health disparities and inequities within segments of cities are often enormous, said Ricky Burdett, director