Urban Primary Health Care

Urban Noise 1

TITLE: Sleeping in the midst of chaos: Does urbanization lead to “noise related sleep disorders in developing countries”? (Urban Problem Solving Worksheet)

Step Activity Response

Step 1

• Identify a specific urban area in the developing world.

• Identify one specific public health or health- related problem facing that urban area.

• Explain why this is a public health problem.

• Support your choice with reference to at least one article

Mumbai, India, has approximately 18 million inhabitants, and is four times densely populated than New York. Due to ‘’urban sprawl’’ around 7 millions of the residents are slum dwellers. Slums (UN definition) are those communities which have insecure residential status, poor structural quality of housing, overcrowding, inadequate access to safe water, sanitation, and other infrastructure. In Mumbai, slums are located near airports, along railway tracks, underneath high transportation bridges and near factories. Besides being poor and living in substandard conditions, slum dwellers are also exposed to one of the most annoying environmental factor – NOISE leading to Noise related sleep disturbance. It is a public health problem. It is well known that sufficient sleep is not a luxury—it is a necessity—and should be thought of as a “vital sign” of good health. 1. There is a growing body of evidence that Sleep disorders can have substantial impact on public health through the disruption of education, work, school performance in children, accidents and quality of life in those affected. 2. Sufficient sleep is increasingly being recognized as an essential aspect of health promotion and chronic disease prevention in the public health community. 3. Sleep disorders can cause severe disability, suffering, mental illness and stress leading to crime. Thus noise related sleep disorders does not affect the individual only but incurs a substantial burden to community and the population. 4. As sleep disorders in urban cities occur widely, and may be clustered in slums because of noise, it should be an area of public health research to know patterns of exposure, disease relationship. Interventions directed at community or population level may play an effective role in prevention. Reference. Barbara Griefahn, Environmental noise and sleep. Review – need for further research: Applied Acoustics 32 , 1991, 255-268

Urban Noise 2

Step Activity Response Step

2 Determine the magnitude of the problem Describe those affected Support your information with reference to at least one article

According to estimates by UN-HABITAT about one third of current 3.3 billion urban residents live in slums. This demographic shift is reshaping health profile of individuals and society around the globe, especially in resource poor developing countries. Recent evidence suggests that rapid population growth in urban areas creates negative economic, social and environmental consequences. One of these environmental influences is Noise induced sleeping disorder. Environmental noise (both community and industrial) causes sleep disruption and affects both the quantity and quality of sleep. Scientific literature suggests that the cumulative long-term effects of sleep loss and sleep disorders have been associated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, heart attack, stroke, increased acidity and peptic ulcer formation, deafness, depression and mental agitation Noise induced sleep disorders affects both gender and is prevalent in all ages and can lead to decreased performance and work efficiency. It is estimated that approximately 20 percent of all serious car crash injuries in the general population are associated with driver sleep disturbance, independent of alcohol effects. As per National Institute of Urban Affairs study, in India children less than 15 years and women make up the majority of the urban poor population and this disorder is linked with poor school performance in children and has harmful effects on pregnant women. A recent study titled Survey of community annoyance due to traffic noise exposure in Calcutta metropolis (Chakraborty D, Kalyani University School of Environmental Studies) reported that more people are annoyed by traffic noise than any other source of noise pollution. In this study 27.5 % of those surveyed were highly annoyed and 4.91% reported severely disturbed sleep.

Reference: Wolfgang B: Transportation noise and cardiovascular risk: Updated Review and synthesis of epidemiological studies indicate that the evidence has increased. Federal environmental agency, Berlin. Noise & Health, Jan-March 2006, Volume 8

Urban Noise 3

TITLE: Sleeping in the midst of chaos: Does urbanization lead to “noise associated sleep disorders in developing countries”? Step Activity Response Step

3 Explore the social, physical and other determinants of the problem Support your analysis with reference to at least one article

Within the context of urbanization in India particularly Mumbai, noise associated sleep disorders is underestimated which is related to social, economic, political and epidemiological factors. According to 2001 census report, the urban growth rate was 3% and the slum growth rate was its double at 5 – 6 % in the same period (Agarwal S. All Slums are Not Equal: Indian Pediatrics. Vol 12- March 17, 2005). Given the rapid rates of urbanization and growth, the sources of noise are also increasing. One of the recent reports indicated that Airplane noise is much greater disturbance to sleep than other noises and the number of people awakened by airplanes is about 50% greater than the number awakened by other noises. In this context, Mumbai has one of the busiest airports in the country and slums residents living near the airport have to deal with the noise disturbance caused by planes landing or taking off every 3 to 5 minutes which equates to noise levels up to 110 decibels (whereas the comfortable level of noise for sleep is 35-45 decibels). Under the situation of extreme poverty, the urban slums residents of Mumbai face multidimensional vulnerability i.e. various forms of social exclusion, discrimination and inequality. Slum dwellers are considered illegal and 49.4% slums are nonnotified or invisible in India. (NSSO 58th Round 2002). It is obvious that urban poor have lack of knowledge, but the medical community, policy makers; politicians in India also have very low awareness of sleep disorders and associated health and non- health effects. Thus, the scientific knowledge about noise associated sleep disorders is in the stages of infancy that is made worse by lack of research, data, community awareness and political commitment.

References taken from lectures 1-9 Particularly lecture 9

Urban Noise 4

Step Activity Response

Step 4 • Discuss at least two alternate solutions, their strengths and weaknesses

Support your choices with reference to at least one article

Urbanization is a fast growing problem. Given the current capacity and policy gaps in Indian healthcare system, and its primary focus on rural population, the challenges of urbanism (especially slums) is likely to increase over time. Because of the complexity among the determinants of this disorder, there is neither a simple solution nor a magic bullet. Considering the noise associated sleep disorders to be a growing problem, a multi-pronged approach combining community participation and interdisciplinary partnership might be promising public health strategy. Because of the limited recourses’ an approach to reduce the burden of this disorder should include efficient social planning at the metropolitan level and the self-help approach at the community level. The emphasis of community participation is personal growth that comes when people work together to solve the problem. Community participation may also help to facilitate operational research, health and behavior modification of the individuals; needs assessment and better situational analysis. The limitations of community participation include the commitment and intensity of participation of slum dwellers; and the tradeoff between cost benefit. Alternately, general preventive measures can be directed to attenuate noise: at its source, on its way or at the individual level. The individual level measures include earplugs, sleeping pills, insulation windows, migration and brick walled houses. This approach is costly and urban people may not seek advice or get proper care. Other approaches for sustainability of a program to succeed include political commitment, law enforcement, continuous monitoring and evaluation. Breiger W et al. Urban community health education in Africa. Int,l. quaterly of community health education 2( 2) 1981-82 pp 109-121.

Urban Noise 5

Step Activity Response Step

5 Recommend one solution and defend your choice Support your analysis with reference to at least one article

In the context of ‘Noise associated sleep disorder’ in urban slums, I strongly recommend a stepwise strategy that includes social planning at the metropolitan level and community participation. As the direct and indirect detrimental health effects of this disorder not only percolates in the urban slums but potentially crosses the boundaries of slums and spreads in the urban city, I recommend a two step strategy as follows : 1. Community participation (CP) and Awareness 2. Coalition - involving representatives from diverse groups and organizations. The first step involves CP i.e. mobilization and education of all slum residents to use resources that will improve their overall health and welfare. Active CP that makes no distinction among different members is the key to build an empowered community. Another important factor in CP is that all residents who offer themselves to community development, are actively welcomed, regardless of gender, race, level of education, occupation, handicap, religion, or any other factor. This participation facilitates exchanges, give a clear idea of the situation, educate the community and help public health professionals in needs assessment and data gathering. As the community members become fully aware about the magnitude of the ill effects of problem and the ways to reduce the burden or prevention, the next step is building a coalition aimed at “Strengthening the social fabric” in the urban city . To be efficient, the coalition must include representative organizations from all sections of the society including slums .This coalition will help management and coordination of available resources to find successful solutions and strengthen the preventive efforts. The strengths of Coalition includes continuous education and advocacy within and beyond the community to generate new public health policies, allocate resources and involve the municipal authorities to meet the needs of the society . (CP) = community participation Concepts taken from Reference. Brieger et al., Community Partners for Health: Urban Health Coalitions in Lagos, Nigeria. Int’l. Quarterly of Community Health Education, Vol. 20(1) 59-81, 2000-2001