Marrakech is a beautiful, lively and highly diverse city. It is home to more than a million people. Considering the rural settlements in its surroundings, it is also a center for significant numbers of commuters to the city, to work there and also to access services.
Our research project in Marrakech – which is a partnership with the Higher Atlas Foundation – aims to provide a preliminary mapping of the priority health needs of the residents in the city and its outskirts, who face challenges with deteriorating conditions that are rooted in systemic, rural causes.
Life expectancy in Morocco is similar to other countries in the surrounding region (such as Tunisia or Turkey) and stands at 76 years, which is higher than Egypt (72 years old) or South Africa (63 years old).
Yet, the infant mortality rate in Morocco (per 1000 live births) is one of the highest in the MENA region. As already noted, though Morocco has improved its control over several health risks such as childhood diseases, social fragmentation is evident and consequently, health inequities still exist.
According to the Human Development Index Morocco ranks 121 out of 189 countries; this is mainly due to illiteracy, education and health indicators. According to Dadush and Saoudi there is some improvement in health in the city, which is a result of economic and social development as well as poverty reduction policies.
Within Morocco, Marrakech is the poorest city with the lowest standard of living. Yet, poverty and neglect characterise some parts of the city while others enjoy a better quality of infrastructure and service. A walk along Avenue Mohammed V that crosses the central districts of Marrakech uncovers these intra-city disparities. One can observe considerable gaps in infrastructure, housing conditions, public spaces and social status.
A telling illustration of this is the comparison between the Medina district (the historical city centre) and the district of Gueliz (the modern district of the city) – a one hour walk only. According to Sebti et al. in Gueliz, there are 2.5 times more high-school graduates and 3.5 times more homes with a bath or shower in Gueliz.
Furthermore, infant mortality (which is one of the most important indicators of health inequalities) is higher in the Medina (40 deaths before age one per 1,000 births) than in Gueliz (34 per 1,000 births).
While intra-city disparities certainly exist, it is suggested that the inhabitants of Marrakech are in a slightly better situation than those living in the rural surroundings, where standards of living are significantly lower. This urban-rural gap that characterises many cities in MENA is a catalyst of rural migration that is significant to many cities in Morocco, including Marrakech.
The rural-urban interconnections highlight our argument that it is time to think about health in urban territories rather than in cities. By using the term ‘urban territory’, we point to the necessity to involve a wider understanding of the rural-urban nexus as a unit of analysis and intervention. As noted by Yacobi and Milner, urban territories are about the operationalization of places, often located far beyond dense population centres, to support the everyday activities and socioeconomic dynamics of urban life.
The production of such operational landscapes, as suggested by Brenner and Schmid, results from what we have observed in Marrakech. These are the most basic socio-metabolic imperatives associated with urban growth: the procurement and circulation of food, water, energy and construction materials; the processing and management of waste and pollution; and the mobilization of labour-power in support of the various processes of extraction, production, circulation and management.
Indeed, if we want to understand what the health challenges are in Marrakech, we need to look through the lens of its wider rural-urban territorial perspective. The case of Marrakech falls into this category, not solely from a spatial perspective, but also from economic, cultural and social angles, as well as by virtue of the use of services by the rural community including health, employment, transportation and welfare.
A Study of the Kingdom of Morocco National Human Rights Council on the right for development in Morocco further reconfirms our argument suggesting that the health services have significant shortcomings, often exacerbated by geographical and categorical inequalities.
Geographical categories include the differences between regions and areas (urban, sub-urban and rural), mostly in the allocation of human resources, provision of health facilities, as well as in government funding that, we suggest, are also intersecting with local conditions including the lack of water and sanitation infrastructure, deteriorating housing conditions, and unemployment.
Importantly, such geographical vulnerabilities always intersect and hence produce a cluster of determinants of health located in a given site that cause health risks, especially within vulnerable groups such as children, the elderly and women.
This brings us to one of the central observations we have made while visiting Marrakech: there is an explicit commitment to implementing women’s rights measures and promoting gender equality. This is a central channel of work of the Higher Atlas Foundation that aims to empower women to achieve the lives they want, while providing tools to advocate and act on women’s needs and goals.
A good example of this initiative are the literacy workshops for women arriving in the surrounded villages. In these workshops women are trained to teach other women Arabic in their own villages. Nevertheless, as already reported, women in distant and vulnerable areas face difficulties including housing unevenness and poverty, with their corresponding outcomes, such as illiteracy, limited access to services and poor infrastructure.
It is reported that the rates of maternal and infant mortality in Morocco are among the highest in the world, with obvious disparities between urban and rural areas. Many women give birth at home, without medical supervision, and the poorest women, especially in rural areas, have a limited, and often a lack, of access to health care services.
Additionally, there is an accessibility problem with health care services for Non-Communicable Diseases including diabetes, cancer, mental health and cardiovascular diseases. Inaccessibility is not solely due to a lack of infrastructures such as roads and transportation, but is also affected by socio-economic gaps.
The rich, mainly in urban areas, benefit from public hospitals about seven times more than the poorest urban populations; whereas rural populations use more health facilities where treatment is free. Importantly, the report states, this situation is aggravated by other external factors associated with illiteracy, poor housing, unemployment, and gender discrimination.
To sum up, the case of Marrakech illustrates the World Health Organization’s (WHO) approach to analysing and understanding health beyond the biomedical gaze, and to considering the Social Determinants of Health as central to positive and negative impacts on public health. These include housing, transportation, open spaces, education, employment, access to food, income level, social inclusion, and health services.
All these elements are shaped by public policy and planning and address a variety of causes that shape the health of communities living in urban territories.
Achieving better, and hopefully equal health conditions for urban dwellers in Marrakech should be linked to initiatives for human development; where the reduction of social inequalities in turn reduces health inequities. Hence, we further suggest that it is time to proactively think about an urban health justice agenda for the city and its surroundings.
