Rapid Urbanization and mental illness Professor Kwame McKenzie MD

Trends in urbanization Globalization brought with it rapid urbanization Percentage increase greater in low income countries By 2030 90% of urban dwellers in low income countries  

Urbanization challenge to government Make cities more hospitable venues for economic development Make social environment of cities suitable for people

Urban environment and mental illness Social capital Outline of talk 4 parts to talk Urban environment and mental illness Social capital Impact of urbanisation on social capital Social capital, urbanisation and mental health

Urban environment and mental illness

Urban environment and mental illness The research not consistent Increased rates urban vs rural areas in high income countries: depression, psychotic disorders, substance misuse and some eating disorders 68–77% greater risk of psychosis 12–20% increased risk of depression (Blazer et al., 1987;Kessler et al., 1994; Marcelis et al., 1998; Robins & Regier, 1991; Romans- Clarkson et al., 1990; Van Os et al., 2001, 2002, undquist et al., 2004).).

Urban environment and mental illness Increased rates not due to drift alone Eg, for psychosis: Being born and brought up in a city are risk factors. The risk increases as the size of the city increases. Longer you live in a city when you are young, the higher your risk for developing psychosis (Boydell and McKenzie, 2008).

Urban environment and mental illness Urban environment changes the exposure to risk: Malnutrition and infection during pregnancy Drug use Life events and chronic daily hassles Social isolation And action of risk factors Clustering of individuals with schizophrenia in deprived areas occurs only in urban environments Genetic vulnerability amplified (McKenzie 2007)

Urban environment and mental illness May be more stressful social environment Social structures such as social networks may not be as active However, more services available and potentially higher standard of living

Rapid urbanization and mental illness Rapid urbanization adds 3 other dimensions migration impact of rapid socio-cultural change Development of new environments with new risks

Rapid urbanization increased migration Migration – 3 impacts on health Pre-migration, migration, Post-migration

Rapid urbanization and rapid social change Individual: identity, anomie, Family strain: breakdown of families – isolation and domestic violence Community: competition for resources social exclusion of marginalized groups inadequate community support

Rapid urbanization produces new environments Environments more likely to be characterized by: (poor housing, crowding) Poor working conditions, underemployment, Food shortage, Human rights violations Inadequate social infrastructure (health & education) (World Bank, 2000).

Problems due to migration Problems due to rapid socio-cultural change A perfect storm Problems due to migration Problems due to rapid socio-cultural change Development of a toxic environment

How can we build better environments? A way forward? How can we build better environments? Planning infrastructure important but also planning social structures What social structures are needed for communities to survive and promote health? One concept that is increasingly being proffered as a way of understanding social structures is social capital

Social capital and mental health

Theory: What is social capital? Social capital is a way of describing social processes that shape communities or groups of people. There are a number of competing definitions It is a complex variable

Theory: Popular definitions “By social capital I mean features of social life – networks, norms and trust – that enable participants to act together more effectively to pursue shared objectives” Putnam Attempts to describe the forces that shape the quantity and quality of social interactions and institutions “the glue that holds society together” Kawachi.

Theory: Sub-definitions Structural Roles, rules, behaviours, networks, institutions Eg numbers of groups, membership, participation Cognitive Values, attitudes, beliefs that produce co-operative behaviour Eg – trust, community spirit, efficacy

Theory: Sub-definitions Bonding Between individuals in families Bridging Between different groups in a society

Theory: Sub-definitions Horizontal Between individuals and groups at similar levels in a society Vertical Between different strata in society and ability to control government etc.

Social capital in US High social capital: Low High all cause mortality morbidity crime drug misuse/ underage pregnancy/ deviance High Life expectancy Government performance Funding of social safety net Educational achievement

De Silva et al J Epi Comm Health 2005 Systematic review No. of estimates inverse none positive Cognitive CMD 11 7 (18140) 4 (2608) Structural CMD 3 (56971) (23832) 1 (222) Combined 2 (5952) Cognitive Child (1008) 5 (3429)

Specific impacts on mental health from literature Social capital’s relation to mental health is complex Social capital associated with CMD, risky behaviour and psychosis Different types of social capital impact on health in different ways Bridging social capital is particularly important Cognitive social capital particularly important

Rapid urbanisation and social capital Rapid urbanization impacts structural social capital High migration leads to fewer relationships, networks, associations and institutions that link people and groups together. Governments in low income countries are struggling to develop social safety nets and infrastructures in the face of rapid changes in need.

Rapid urbanization and social capital Cognitive social capital also undermined Values, norms of reciprocity, altruism and civic responsibility all need to be re-evaluated and renegotiated. In the meantime, trust is the victim. Retreat into highly bonded sub-communities or families is a common response

Rapid urbanization and social capital Decreases social networks and bridging social capital and increases the level of responsibility of the immediate family. The strain that this puts on families is significant. Increased domestic violence, family break up and abandonment. Social isolation is not an infrequent result. This leads to further fractured networks and undermines the development of local social capital

Building social capital? Civic identity is difficult to build and takes time. Also takes a belief that your community is efficacious. Lack of material social infrastructure undermines the development of civic identity. But the development of cognitive social capital is necessary in order to build community spirit and to help organize people to advocate for better facilities

International research has stressed the importance of vertical social capital and access to power Urbanization is characterized by movements of people who do not have access to power and whose access has been lost in the transfer from better networked rural or semirural communities to much more anonymous urban conurbations. The lack of power, social efficacy and bridging makes these communities very vulnerable

Urbanization, social capital and mental illness

Social capital urbanization and mental health Social capital linked to social determinants of mental health in the urban environment. Higher levels of social capital linked to fewer risks Bridging social capital may produce social supports and safety nets which buffer the effects of life events on mental health High levels of collective efficacy are better able to acquire and hold on to educational, health, and housing resources

Social capital is easy to breakdown but slow to generate. It takes time to develop trust and build structures that enable cooperative working and social efficacy.

Rapid unplanned urbanization undermines the development of social capital. Breaks existing cognitive and structural horizontal bonds that existed in pre-migration settings.

Urbanization may occur without regard for the development of the vertical integrative structures required to develop a sense of community efficacy and participation. Low levels of these sorts of social capital predictably produce an environment with more in the way of social risk factors for mental illness but less in the way of supports and buffers that decrease the impacts of these risk factors.

Action on promotion of mental health Enhanced by effective public health interventions Collective action depends on shared values Promoted by a climate that respects civil rights and freedoms Needs inter-sectoral linkages Social environment that promote economy depends on mental health

Rapid urbanization is with us Conclusion Rapid urbanization is with us The urban environment may not be good for mental health Using the lens of social capital may help planners to develop urban environments that promote mental health Economic development linked to mental health There is no wealth without mental health