Does rapid urbanization aggravate health disparities? Reflections on the epidemiological transition in Pune, India

Abstract

Background: Rapid urbanization in low- and middle-income countries reinforces risk and epidemiological transition in urban societies, which are characterized by high socioeconomic gradients. Limited availability of disaggregated morbidity data in these settings impedes research on epidemiological profiles of different population subgroups.

Objective: The study aimed to analyze the epidemiological transition in the emerging megacity of Pune with respect to changing morbidity and mortality patterns, also taking into consideration health disparities among different socioeconomic groups.

Design: A mixed-methods approach was used, comprising secondary analysis of mortality data, a survey among 900 households in six neighborhoods with different socioeconomic profiles, 46 in-depth interviews with laypeople, and expert interviews with 37 health care providers and 22 other health care workers.

Results: The mortality data account for an epidemiological transition with an increasing number of deaths due to non-communicable diseases (NCDs) in Pune. The share of deaths due to infectious and parasitic diseases remained nearly constant, though the cause of deaths changed considerably within this group. The survey data and expert interviews indicated a slightly higher prevalence of diabetes and hypertension among higher socioeconomic groups, but a higher incidence and more frequent complications and comorbidities in lower socioeconomic groups. Although the self-reported morbidity for malaria, gastroenteritis, and tuberculosis did not show a socioeconomic pattern, experts estimated the prevalence in lower socioeconomic groups to be higher, though all groups in Pune would be affected.

Conclusions: The rising burden of NCDs among all socioeconomic groups and the concurrent persistence of communicable diseases pose a major challenge for public health. Improvement of urban health requires a stronger focus on health promotion and disease prevention for all socioeconomic groups with a holistic understanding of urban health. In order to derive evidence-based solutions and interventions, routine surveillance data become indispensable.

Keywords: India; epidemiological transition; health disparities; low- and middle-income countries; urban health; urbanization.

Fig. 1

Different models of epidemiological transition. The first three graphs depict the epidemiological transition concepts of Omran (2, 3), Caldwell (5, 6), and Castillo-Salgado (11). The model of epidemiological diversification has been developed based on own findings in Pune in the context of rapid urbanization and steep socioeconomic disparities within the urban society. Source: Modified from Kroll (31).