This blog is the first of the health in urban development blog series. View also:
Gaza: Cage Politics, Violence and Health

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They may be small, but don’t let their size mislead you. Secondary centres form a significant—though underappreciated—part of the global urban landscape. Drawing on my doctoral research in Karonga, a small town in Malawi, I explain why achieving a healthy urban future will depend increasingly on how urban growth occurs outside the largest cities.

Haphazard densification of a previously planned settlement, Karonga Town, Malawi. Photo credit: Donald Brown (2017)

It is widely proclaimed that we now live in an urban age, with more than half of the world’s population living in ‘cities’. While impressive, this statistic does not tell the whole story. It is widely assumed that most of the world’s urban population live in the largest cities and that they are the fastest growing. But there are relatively few mega cities (with more than 10 million residents) and they account for less than 10% of the world’s urban population. Many are also not growing especially fast.

Far more urban dwellers live in small and intermediate centres (with less than 1 million inhabitants), many in Asia and Africa. These ‘secondary’ centres constitute the bottom and middle of the urban hierarchy, where a large and typically growing share of the world’s future urban growth is expected to occur. But this is also where the capacity to plan and manage urban growth, provide services, and reduce environmental risks is so often lacking.

If the growth of secondary centres in Malawi and other sub-Saharan African countries is to contribute to a healthy urban future, research and action is required on several fronts:

The dynamics of in situ urbanisation

Most accounts of Africa’s urban transition have focused on the causes and patterns of urbanisation and peri-urbanisation. Much less attention has been paid to in situ urbanisation—the placed-based transition from a rural area into an urban one. These dynamics are of growing importance in sub-Saharan Africa given its low urbanisation level and moderate urbanisation rate, meaning that many small settlements have yet to emerge.

Karonga exemplifies the process of in situ urbanisation: it grew from a small trading post in the colonial era into a sub-regional service centre under the current national planning framework. The town’s population increased nearly four-fold from around 11,000 in 1966 (the first census year) to over 40,000 in 2008 (the last census year). Karonga is now the second largest centre in the Northern Region following Mzuzu.

Despite its size and growth, Karonga has no local government and so lacks the capacity to effectively plan and manage its growth. Numerous environmental hazards have subsequently emerged, ranging from poor sanitation, to seasonal floods, to large-scale disasters, posing major health risks.

Flooding in and around the central market, Karonga Town, Malawi. Photo credit: Wisdom Bwanali (2017)

The need for disaggregated urban data

Most demographic and health data is aggregated to provide averages for urban populations, obscuring widespread health disparities within and between urban populations. Basic health data is especially limited in sub-Saharan Africa in the absence of vital registration systems, disease surveillance sites and electronic health records, even though the region bears the brunt of the world’s deadliest epidemics, including HIV/AIDS, malaria and tuberculosis.

Where available, local information sources can be used to generate disaggregated data at the urban scale. Among the most valuable sources are hospital records, which provide information on the causes of disease in populations. To generate this information for Karonga, nearly 3,000 inpatient records from Karonga District Hospital (located in the town) were collected over a 12-month period (August 2016 to July 2017) to produces estimates of the prevalence of environmental disease.

While the sample is not completely representative of the town’s population, the findings reveal alarming patterns:

• 63% of all recorded diseases were environmental (i.e. related to factors in the physical environment);
• 64% of environmental diseases were infectious and parasitic; and
• cholera outbreaks during the rainy season are recurrent in areas with the poorest sanitation.

These observations support the longstanding suspicion that smaller settlements with limited capacities can be among the most hazardous places to live, highlighting the need for urban environments far more capable of preventing disease.

The dynamics of rural governance regime change

As in situ urbanisation unfolds, villages will grow into towns, towns will be reclassified as urban (raising the urbanisation level), and modern institutions will attempt to intervene in rural governance regimes that may be resistant to change. This process is creating new governance challenges for planning authorities attempting to intervene in towns once they have already emerged.

These challenges are heightened in Karonga in the absence of a local government, meaning the balance of power has not shifted from traditional to modern institutions in much the same way the planning system has not resulted in formal urban development. Instead, customary and modern institutions have intertwined in hybridised governance arrangements in which the authority and legitimacy of the state is contested.

A chief holds a meeting in a village in Karonga Town, Malawi. Photo credit: Donald Brown (2017)

Understanding the place-based dynamics of rural governance regime change in emerging towns such as Karonga is at the forefront of planning research on in situ urbanisation. Case studies of this kind have significant potential to reveal the possibilities and obstacles for planning healthy towns at the bottom of the urban hierarchy. This is where many of the future challenges facing public health will be increasingly concentrated, but where little scholarly or practical attention has been paid to this and other important urban development issues.

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Donald Brown is an urban planner and researcher interested in the nexus between urban development planning, public health and (disaster) risk reduction in sub-Saharan Africa and other urbanising regions. His doctoral research focused on environmental health in smaller African urban centres as increasingly important to overall urban population health.

While only lasting for a few weeks, the field research trip is an intense experience that provides in-depth learnings that go beyond the research outcomes themselves. One of the key highlights for me was how a good field research technique is about combining learnings from human interactions as well as using planning and organisational tools to reduce the uncertainty that surrounds field research.

Part 1: Learnings from the people – Disillusionment in the periphery

View from the community of Villa Lourdes Ecológico (VMT)

I’m standing here on the dark distant slopes of Villa Lourdes Ecológico, a settlement without water, sewerage or electricity access, looking down at the city of Lima that stretches as far as the eye can see. We have just had a focus group using headtorches with a group of mostly women, their kids playing at their feet. They came to meet us with hope, a hope to be listened to. They feel forgotten and right here, in this dark spot, I can relate to this disillusionment.

Since arriving in Lima, I have heard many heartfelt sentences from people who have lost hope and no longer believe in the transformative change we came here to seek. Vicente Chavez, a leader of the fog catcher initiative from this community, wants to move back to Cusco instead of “waiting here, hoping for the water to come from the sky”.

A few days before, at a march on water access, I came across the slogan “stop fighting is to start dying”. Whilst extreme for effect, I do believe that when people feel disheartened about their situation, they stop engaging and driving change.

Without pressure on decision makers, they may well be forgotten.

I can already observe the direct negative impact of the lack of hope. With the fog catchers project, people lost hope in official support and decreased engagement to the point that they were not making use of a solution that was already available to them. Some community members did not even know that they were entitled to a piece of land to cultivate using water from the fog catchers.

And yet, people’s support and buy-in are rarely mentioned in policy briefs as a key prerequisite to foster participation. It appears critical that our recommendations consider how to help restore people’s hope in the potential for transformative change in order to ultimately foster their participation and make them instrumental in their future.

Two crucial factors to regain this confidence from the people: transparency and action. Communities explicitly asked for “no more lies” about their situation. They need to understand better the short to long term plans to organise and decide accordingly. Not knowing often means that they linger in the fear of taking action that could damage their current situation. They also need to “see proofs” that improvements are made whether in the form of electricity access or small-scale infrastructure work such as stairs. When projects reach their community, people feel heard and that change is possible thereby increasing their likeliness to engage.

This gave me an additional purpose and some guidance for our research. As future planners, we have the duty not only to bring to light these forgotten realities but to also deliver recommendations that aim at overcoming people’s disillusionment when requiring their participation. In other words, the role of a socio-environmental planner is to make sure that no one is left out in the dark without hope.

Water march board

Part 2 – Learnings from the process – Networking, my ally for achieving holistic research

As Lima was my first field research trip I was aware that data collection would be the most challenging phase of the research process. As a project manager, I am used to things being planned from A to Z before a project even starts. As a result, I was fearing data collection as I viewed it as uncertain and unpredictable. Thankfully, I discovered a great ally that changed my perspective and allowed us to bring structure to data collection: networking.

I understand networking as interactions with a system of interrelated primary and secondary connections that hold different roles, views and power about a given topic. To have a holistic data gathering, it is important to network with a diverse range of actors of various opinions. However, not all stakeholders play the same role in data collection. In the field, when time is limited, it is vital to be flexible and to learn to also rely on secondary connections. While they may provide a smaller share of information, these connections can be more engaged and transparent. In our case, we met with an engineer working on the ecosanitation project from Sedapal who could be considered as a secondary connection given his operational clout in the project. His insights, provided anonymously, proved even deeper than information provided by the key project partner AguaEcosan.

Having recognised the importance of networking, it became critical to integrate it in our research process as a key planning tool for data collection. Recognising that these connections may not always happen organically, it is important to have the methods in place to foster networking and adapt it constantly in the field. Clear research objectives and actor-mapping were critical to  framing our networking. By knowing the data we needed, the current gaps and the existing actors we could interact with, it became easier to prioritise connections and make the required substitutions when needed, understanding the implications for our research.

Actors mapping

The role of networking as a planning tool for data collection was critical in achieving our research objective to understand better the eschemas model, a publicly-driven city-wide framework from Sedapal to provide water and sanitation services to 100% of the population. Making a direct connection within Sedapal had not yielded any result so we mapped potential actors that could help us gather similar data and decided to network upwards from the communities. We leveraged our existing relationship with the NGO Peruanos sin Agua to connect with a leader from an eschema committee at a water protest march. While the march itself had little importance from a data collection perspective, the contact had the potential to be the missing link we needed to connect with Sedapal as the march was organised in collaboration with the worker union from Sedapal. This allowed us to achieve our initial research goal.

First, these key learnings about the methods to network efficiently allowed me to overcome my fear of data collection by understanding that data collection can be planned and is not as uncertain as I saw it originally. Furthermore, recognising the existence of this system of interrelated primary and secondary connections enabled me to use networking as a key ally to engage with these connections and collect data in a holistic and efficient way. Ultimately, this ultimately has a positive impact on the quality of our research outcomes.

Conclusion

It is undeniable that pre-research plays a key role in research trips as it allows to gain deep knowledge about a given field of analysis and form initial hypotheses to verify during the research. However, once on the ground, the reality can challenge assumptions and reshape priorities… but after all, research is about ‘trusting the process’. While tools such as networking should be used to help reduce uncertainty, planners should remain flexible and embrace the research journey to gather findings that go much beyond pure research outcomes.