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.