African mortality and the new `urban penalty'
Introduction
Differences in health and demographic indices between rural and urban areas are familiar in all societies and over most time periods, though the differences are not always in the same direction or to the same extent, for they depend on the very different sets of conditions affecting mortality, morbidity and health in rural and urban areas. The extent and causation of rural/urban differences and their variation over time broadly reflect the larger processes in the geography of any area, of relative levels of incomes and development and of service provision. The geographies of mortality and morbidity at local and national scales are directly linked to the variable economic, environmental and social context in which a population seeks its livelihood.
This paper seeks to set rural/urban childhood mortality differences in Sub-Saharan Africa (SSA) in historical perspective as part of a larger concern for changing urban mortality conditions in the continent more generally1. The substantial reductions in mortality experienced almost everywhere in Africa over the second half of the 20th Century have now slowed, and in some cases have even been reversed, but everywhere mortality levels remain considerably above those currently found in the more developed parts of the world. This is a disappointing outcome that raises important issues primarily for the well-being of the populations of SSA, but also for both population theory and development theory. Is this a temporary blip in the long-term downward trend, or will the expected (i.e. on the basis of classical demographic transition theory) lower levels never be reached? Is Africa fundamentally different from other major world areas in the ways in which mortality responds to changing economic and environmental conditions?
The principal objective of this paper is to review the changing patterns and explanations of rural/urban differentials in under-5 mortality in contemporary SSA generally, exploring the experience of Kenya in particular, and to set these findings in the broader context of growing national planning and policy problems associated with rapid urbanization. The argument of the paper proceeds in three major sections. In the first of these the African experience of the rural/urban mortality gap of the last 100 years is compared with the very different European, and particularly British, mortality experience from 1850, which was characterized by an `urban penalty'. This is then followed by a more detailed consideration of urban mortality change in SSA since ca. 1950, and the third section focuses on the Kenyan experience, where the available under-5 mortality indices for Nairobi, its capital and largest city, all indicate a potential reversal of its long-standing advantage over the rest of the country.
Section snippets
The urban penalty in 19th Century England and Wales
Mortality in late 19th Century Europe was categorized by an `urban penalty'2: mortality was substantially higher in urban areas than in rural areas, and particularly for infants and children. Infant
A narrowing rural/urban differential?
Mortality decline has been fairly widespread and consistent in Africa since the 1920s, but particularly since 1950. The effects have been evident in both urban and rural areas, but can be attributed to rather different mixes of the basic causes. In urban areas there were public health measures and a curative health care, providing initially and primarily for a rich and politically powerful colonial elite and, after independence, a predominantly national elite. Improved sanitation and a clean
Rural/urban under-5 mortality differentials in Kenya
For most of the last 50 years there has been continuous mortality decline in Kenya. This trend has been well recorded in official census and survey reports, most recently by the published reports of the 1989 Census including a volume on `Mortality' (Kenya Government, 1996), and by a stream of more specific analyses (e.g. Anker and Knowles, 1980; Van Vianen and Van Ginniken, 1984), and most authoritatively by Brass and Jolly (1993)in their NSF volume on Kenya. While there are some problems with
Conclusion
There does seem in recent years to have been a broad but by no means regular or universal trend towards a narrowing of the rural/urban mortality gap in Sub-Saharan Africa, but its causes are now different from those of earlier decades. In the earlier period of narrowing in the 1950s and 1960s both rural and urban rates were falling, but the rural rates were falling much more rapidly than the urban as rural incomes rose, food supply was more assured and more comprehensive health services spread
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