3.1. Socio-Territorial Processes in Saint-Louis
Here we highlight the distinct profiles of the four selected urban sites. Their histories, recent patterns of urbanization, and social, economic, and political arenas demonstrate the heterogeneity that characterizes mid-sized cities in West Africa.
Saint-Louis was created as a colonial trading fort in 1659. It quickly became an economic crossroads and served as the capital of French West Africa until 1902. After serving as the capital of Senegal and Mauritania, it remained a major urban colonial hub until independence in 1960. During this period, the four neighbourhoods we selected for our study developed varying relationships with the colonial administration.
3.1.1. Guet Ndar, from Fishing Village to Economic Hub of Saint-Louis
Guet Ndar, located on the Langue de Barbarie between the Atlantic Ocean and the Senegal River, is the oldest district of the city. It was originally a Wolof fishing village and fishing-related activities remain the major source of income. The village existed prior to colonial rule and its residents resisted the imposition of French law. Once complete resistance to the colonial authorities was no longer possible, residents made strategic compromises with the French administration that guaranteed them greater autonomy and jurisdiction over neighbourhood affairs than most other colonial subjects [19
]. This historical legacy is evident in the present. Guet Ndar remains a distinct neighbourhood with a clear social, economic, and political boundary separating it from the rest of the city.
Guet Ndar, among other unique characteristics, is renowned for being one of the most densely populated and densely built districts in West Africa. The significantly higher number of households in each plot is a revealing sign of this density (see Figure 4
). Several attempts to alleviate the highly congested neighbourhood by moving Guet Ndarians to housing projects elsewhere in the city have failed. At the time of writing, youth in Guet Ndar were in violent conflict with city police after the demolition of neighbourhood buildings as part of an urban planning project, “Projet Assainissement Concerté Total Intégré du quartier Guet Ndar.” Their livelihood as fishermen requires proximity to their fishing boats and the sea, and their place of residence is inseparable from their collective identity. They simply cannot be Guet Ndarian any place else. According to our survey, almost all residents were born and have always lived in the neighbourhood (98.5% vs. 17.1% in Pikine Sor Diagne for example, Figure 2
). As a result, ever-expanding families occupy a very small strip of land between the Senegal River and the Atlantic.
There are several ways that the high population densities in Guet Ndar materialize in the urban landscape. Many buildings appear to be dilapidated and in various states of decay. The number of adults and children in each concession means that there is inadequate space for the numerous tasks of production and reproduction. A casual tour of Guet Ndar reveals that many domestic tasks, including meal preparation and laundry, take place in open areas and lanes between tightly packed houses. These domestic tasks compete for space with other individuals and activities: animal husbandry (largely sheep and goats), children seeking space for recreation, and other neighbourhood economic activities including the repair of fishing nets and pirogue engines. The physical appearance of the neighbourhood gives the impression of collective economic deprivation and urban disorder.
Similarly, according to the socio-economic index that we developed based on material wealth, almost 58% of the Guet Ndarian households surveyed were classified as being economically disadvantaged. Despite these findings, tremendous amounts of capital circulate through Guet Ndar, and the fishing economy, though increasingly threatened by overfishing and the allotment of concessions to other countries, is still one of the strongest economic sectors in the city. Contrary to the obvious lack of investment in home maintenance and the high number of people living in tight quarters, Guet Ndar has long been the major economic hub of Saint-Louis [19
]. Prior research in Guet Ndar has found a strong preference for consumption of fishing profits or their reinvestment in fishing equipment, rather than investment in property (possibly due to precarious ownership and unclear lines of inheritance) [25
]. If the landscape appears dilapidated, it is the result of a unique social history and urban political ecology rather than poverty.
Given the economic focus on fishing in Guet Ndar to the near exclusion of all other livelihood strategies, affluence does not necessarily coincide with levels of schooling. According to our survey, around 70% of Guet Ndar residents have never attended school. In line with the fishing economy, children are often recruited at early ages to work on the family boat, though in recent years more children are attending school for longer periods of time. The family unit is the basic unit of production and children are of great economic value to their families. The dependence of Guet Ndarians on fishing may as yet prove to be untenable in the future. Young men from Guet Ndar, concerned about overfishing, the increasing costs of boats and motors, and their long-term prospects as fisherman, have been at the epicentre of clandestine migration to Europe [26
]. It may be that Guet Ndar is on the cusp of significant socio-economic shifts.
Regarding access to medical care, a public health post is available for residents in the southern part of Guet Ndar and is mainly visited by women and children (see Figure 2
). Residents from the northern part tend to seek care at the health post of “Ndar Toute,” the neighbouring district to the north. The regional hospital is located in very close proximity on the Island, on the other side of the bridge. Despite its population density, housing shortage, and congested and waste-strewn public spaces, Guet Ndar has a relative abundance of medical facilities in close proximity compared with the other neighbourhood sites in Saint-Louis.
3.1.2. Ndioloffène and Léona: Two Colonial Neighbourhoods, Two Distinct Histories
In contrast to the pre-colonial fishing village of Guet Ndar, Ndioloffène and Léona were the product of urban sprawl during the colonial period [19
]. Increasing population density on the Island and the Langue de Barbarie led residents to emigrate to the continent. Ndioloffène developed during the 1830s as a result of this urban expansion, and it also received urban migrants from other parts of the continent, including from the Djolof region of Senegal (hence the neighbourhood name) and from Mali at the end of the 19th century. Historically, Ndioloffène was a mixed neighbourhood whose residents included colonial officials, African civil servants, and mixed-race (métis) families.
Léona was originally an uninhabitable part of Ndioloffène due to flooding and wetlands. In the 1930s, the city government filled in Léona’s marshland with sand mined largely in Pikine Sor Diagne (not yet a municipal district at this time). Many dwellings, including public housing, were built in this district to accommodate new residents who came from all corners of the city and beyond to work as civil servants in the French colonial administration.
These two districts were both subject to colonial urban planning and are presently characterized by large familial homesteads, wide streets and good access to various public infrastructures (running water and electricity). Although neither Ndioloffène nor Léona has a public health post, access to medical care does not pose a geographic problem for neighbourhood residents: their neighbouring districts (Diamaguène and Eaux Claires) each have a public health post in which residents seek care. In addition, a variety of private medical facilities are available (see Figure 5
Léona and Ndioloffène have the most highly educated residents among the four study sites in Saint-Louis. The first settlers of Ndioloffène, who came from rural regions, interacted with the French colonial population and generally sent their children to school. Most current residents went at least to primary school (70% to 80% according to our survey) and these neighbourhoods are considered the intellectual hub of Saint-Louis. However, slight differences can be observed regarding their social composition. According to the socio-economic index, the share of affluent households is higher in Ndioloffène than in Léona (50.8% vs. 41.9% respectively), whereas Léona has a larger middle class compared to Ndioloffène (38.6% vs. 28.9% respectively) (see Table 2
). Numerous famous elected officials and political figures live in Ndioloffène, whereas Léona counts among its residents civil servants and middle-class merchants.
3.1.3. Pikine Sor Diagne, the Face of Urban Sprawl
Pikine Sor Diagne, now a peripheral district of Saint-Louis, was a remote, rural village of farmers and fishermen for most of the 19th and 20th centuries. It was largely isolated from and irrelevant to the colonial administration, whose headquarters were on the island of Saint-Louis (next to Guet Ndar). In the 1970s, the Senegalese state annexed agricultural lands at the city’s periphery to address urban congestion. Nevertheless, the original population of Pikine Sor Diagne was granted titles as owners of their property. Pikine Sor Diagne officially became part of the Saint-Louis municipal district in 1982.
Due to this late integration into the city and lack of formal urban planning, most of the neighbourhood has no household access to water or sanitation services. Most residents rely on public water taps or itinerant water sellers. As for health care access, there is a small dispensary available for the neighbourhood that offers some essential medicines and first aid (see Figure 5
). According to our interviews, residents tend to consult at the health post of Pikine Sor Daga which is about two kilometres away.
Today, Pikine Sor Diagne remains spatially landlocked: the lack of public infrastructure and the low population and built densities give the impression of an unplanned area. In actuality, the neighbourhood will become part of an ambitious urban development project led by the state which has not started yet in this part of Pikine. This situation led to land speculation: in recent years, the earliest neighbourhood residents sold their lands at a low price to newer residents who were attracted by this opportunity. The relative small number of residents who were born and still live in the neighbourhood is illustrative of this phenomenon (see Figure 2
and Table 1
). Today, although Pikine Sor Diagne is still sparsely built, there are no remaining plots for sale. The neighbourhood is currently undergoing significant changes, especially regarding the social composition of the population: according to our socio-economic index, the households surveyed are equally distributed between the three categories of socio-economic status (disadvantaged/middle class/upper class). This social diversity is also illustrated by their education levels: around 50% of residents have never attended school. Social reconfiguration is also tangible in the urban landscape as mud brick houses now coexist with luxurious hostels. Many residents desire to stay in the neighbourhood, probably in view of the planned improvements to the neighbourhood.
These particular historical legacies leave their imprint on neighbourhood landscapes. Each of these neighbourhoods reflects a unique confluence of social, economic, political, and environmental factors that have shaped the social identities, social cohesion, and potentially the health of their inhabitants. The city of Saint-Louis is not one place, but a constellation of highly distinct places.
3.1.4. How Politics Materialize in Physical Space: The Example of Local Development
Since the 1990s, the municipality of Saint-Louis has implemented a decentralized model for local development at the neighbourhood scale. As a consequence, each neighbourhood was required to create local councils in order to manage local development projects under the authority of the municipality. However, this model was not taken up equally by the various locally based actors, which has led to inequalities in local development [27
]. In this section, we offer two relevant examples illustrating these distinguishing processes in Léona and Pikine Sor Diagne.
In Léona, as detailed previously, the majority of inhabitants are well-educated and several of them have gained expertise in project management. Social cohesion seems to be relatively strong as local actors work together for a variety of ends. The powerbrokers have proven to be masterful at securing external funding for local development projects from a variety of international donors. At the time of our research, Léona was the recipient of significant development assistance: a German association supported the creation of a social centre for uneducated youth; another NGO based in Luxembourg funded a kitchen in which to teach food service in the same centre; and two different Spanish associations financed a prevention campaign and the renovation of the local health centre. In short, the locally elected neighbourhood council has become proficient in financial solicitation.
This ability of Léona’s elected officials to raise external funds proved unpopular with city government, which attempted to collect a portion of Léona’s development financing. To circumvent the ability of the municipality to collect its share of the revenue, elected leaders in Léona created an independent association (comprised of exactly the same representatives as those who serve on the neighbourhood council) that operates outside of the elected neighbourhood councils that are part of the municipal government. This committee now operates independently and free of the municipality’s oversight. Thanks to this tremendous mobilization, Léona has a great degree of financial and political autonomy from the municipality. It can initiate project ideas, solicit donors, and implement projects free of the municipality’s oversight.
While Léona benefits from health promotion projects due to this exceptional ability to fundraise for local development projects, other districts are far from attracting such resources. As an example, the only health project conducted at the time of the research in Pikine Sor Diagne and funded by external financing was the building of a small dispensary. In this neighbourhood, the few local development projects generally stem from community associations mostly composed of poorly educated residents. Residents of Pikine Sor Diagne also remain on the margins of the local council whose responsibilities encompass a larger area of Pikine. As a result, they struggle to capture the attention of international donors as well as their own local representatives.
These varying levels of participation and success in the quest for external investment produces unequal infrastructure in different neighbourhoods. These unequal dynamics in local development may in turn influence health inequalities.
3.2. Spatial Variations in Health Status and Statistical Associations
Given the distinct socio-territorial processes at work in the four studied neighbourhoods in Saint-Louis, we hypothesized that residents in these sites experience different levels of vulnerability to a variety of health conditions. In Table 3
we present our clinical findings for adults (age 35–59) in each of the four neighbourhood sites on being overweight, having high blood pressure, and being hyperglycaemic.
While we are cautious about arguing that socio-territorial processes have a direct causal effect on individual health status, our data reveal significant neighbourhood variation in the percentages of adults who were overweight and who registered high blood pressure and hyperglycaemia. Guet Ndar appears to have a significantly high percentage of adults who are overweight (77.1%), whereas the percentages of overweight adults in the other three neighbourhoods were all below 60%. The findings on high blood pressure demonstrate less variation. Nonetheless, there was a 14-point difference between the highest and lowest percentages of adults with high blood pressure: 42.5% in Guet Ndar vs. 28.5% in Léona. Our findings concerning adults with hyperglycaemia (a potential indication of type II diabetes) were the least variable by neighbourhood. Despite the fact that spatial variations are not statistically significant for hyperglycaemia, Guet Ndar had the highest percentage of adults whose fasting blood glucose levels were equal or higher than 110 mg/dL (12.6%), and Pikine Sor Diagne had the lowest percentage (6.8%).
At the scale of the full sample, these analyses reveal that age and sex are the factors most associated with high blood pressure, hyperglycaemia and overweight (see Table 4
). We remain cautious about the importance of sex as a factor, since women represent 80% of our sample. Age was not statistically relevant in Guet Ndar or in Pikine for being overweight. Regardless of age, women’s diets seem to be quite similar in both places. However, for hyperglycaemia, age is associated with the rate of the disease only in Léona. Becoming older appears to be a risk factor of hyperglycaemia, specifically for residents of this area.
Sex had no effect on high blood pressure and hyperglycaemia at the scale of neighbourhoods (except for Pikine for hypertension), whereas it is very significant for overweight in every studied place. For the full sample, no education is associated with being overweight but not with hypertension and hyperglycaemia. This statistical linkage disappears when the hypothesis is tested at the neighbourhood scale.
Finally, socio-economic status does not influence the rates of three studied health conditions (hypertension, hyperglycaemia, and overweight), in any significant way to health status in the four neighbourhoods, except in Pikine Sor Diagne for hyperglycaemia (the more upper-class the household, the higher the rate hyperglycaemia). Certainly, disadvantaged populations are more affected by hypertension in Guet Ndar, but proportionally to the share of this socio-economic group in the area.
3.3. Health Inequalities and Care-Seeking Behaviour
We found few statistical associations between measured factors and rates of hypertension, hyperglycaemia, and being overweight. Despite this, disease rates vary significantly in the study neighbourhoods.
We have several hypotheses about how socio-territorial processes may contribute to this variation in morbidity by neighbourhood. At the individual level, being overweight, having high blood pressure, and having hyperglycaemia are reflections of diet, tobacco use, and levels of physical activity [28
]. There was remarkable consensus about the etiology of hypertension and diabetes in our interviews with individuals who had been diagnosed with these conditions. In over two-thirds of our interviews, respondents mentioned the overconsumption of sugar, refined carbohydrates, animal fat, and oil, combined with a lack of physical activity, as the primary causes. The Senegalese diet, whose focal point is the noon meal of fried fish and fried white rice, also includes white bread, sugar-laden tea, and soft drinks. Nearly all respondents cited these items as the source of growing cases of hypertension and diabetes.
While the main staples of the urban Senegalese diet are fairly consistent across social groups irrespective of economic status, residents of Guet Ndar asserted that their diet is particularly rich in oil and fried fish. As such, Guet Ndar provides an illustrative example of how neighbourhood processes, particularly livelihood strategies and territorial identities, may shape individual diet and levels of physical activity. Our interviews demonstrate that residents of Guet Ndar report a particular affinity for overeating and for a diet rich in fat and oil that has become part of their collective identity. “The things we eat here in Guet Ndar, it is only us who eat them,” explained a 54-year-old diabetic woman. Another woman in her fifties who is also diabetic asserted, “If you are from Guet Ndar you love very oily ceeb u gen (fried fish and rice). It is our main dish. And if you are diabetic they forbid you to eat rice, and we love rice.” “In this neighbourhood we love sugar, oil, and too many spices, especially the (salty) bouillon we put in our meals” asserted a woman in her sixties with hypertension.
It was clear in our interviews that overconsumption is a particular mark of distinction for residents of Guet Ndar. This overconsumption is possible due in part to the fishing economy, arguably the most robust economic sector in Saint-Louis. Most households have reliable access to fresh fish for their own consumption and cash from the daily sale of fish. Additional territorial factors include the occupational trajectory of most Guet Ndarians, and the population density of the neighbourhood. Men who work as fishermen tend to retire from the intense physical labour on the fishing boats by age 50. Similarly, women engaged in domestic labour are relieved of their household tasks by their unmarried adult daughters or their daughters-in-law (who join their household upon marriage due to cultural norms and the shortage of available housing in the neighbourhood) by the time they are 50. These patterns lead to long periods of relative sedentariness starting in early middle age during which vulnerability to hypertension and diabetes may increase. Again, while we would not point to these factors as directly causing Guet Ndar’s high rates of overweight adults, and the higher percentages of adults with high blood pressure and hyperglycaemia, they seem to indicate a confluence of enabling socio-territorial dynamics. Although there are unique socio-territorial features in the other three neighbourhood sites, none of them seem to have produced health outcomes as distinctive as the patterns we found for Guet Ndar.
In addition to examining how socio-territorial processes may produce variable environmental exposures and disease vulnerability, our study aimed to determine if these processes shape the possibility of successfully managing hypertension and type II diabetes. We explored the diagnostic experiences and therapeutic itineraries of men and women living with hypertension and type II diabetes in each neighbourhood site. Our analysis highlights two key concepts: healthscapes and treatability.
Healthscapes builds upon the classic understanding of medical pluralism and aims to convey how people understand and navigate their therapeutic options. A healthscape is therefore, “an individual’s subjective vision of a landscape’s medical resources and institutions, limited by costs and accessibility …” [30
]. This idea moves our analysis beyond the presence or absence of medical infrastructure to suggest that access to medical care and treatment decisions are embedded in socio-territorial processes. Importantly, the notion of healthscape gives equal analytic weight to the landscape of health resources and “the social experience of that landscape as it is viewed and experienced by different actors working and living within it” [30
In our interviews, we posed questions about individuals’ experiences with diabetes and hypertension, their understanding of etiology, their initial medical consultations and first medical diagnosis of these conditions, the medical recommendations they had received, and their therapeutic itineraries and health-seeking practices. Although the number of interviews was modest (approximately 20 per neighbourhood), we sought to determine if there are shared healthscapes for individuals living in the same neighbourhood, and if there are distinctive healthscapes for people who are hypertensive or diabetic.
A number of important themes emerged in our interviews. In nearly all cases, individuals were diagnosed with hypertension or diabetes after the onset of life-disrupting symptoms (weight loss, frequent urination, headaches, dizziness, fatigue, blurred vision, partial paralysis). Fewer than ten of our respondents were diagnosed in the course of receiving routine medical screening or an annual medical exam. Once individuals began to experience symptoms, there were four factors that most frequently influenced their choice of location for an initial consultation: perception of urgency, proximity, cost, and referral by a trusted individual. Many individuals reported that the perceived seriousness of their symptoms (fainting, mild paralysis, severe vomiting, inability to speak) meant that they went to the Saint-Louis Hospital, a Level 1 medical facility that serves the region of Saint-Louis. For those who did not initiate care at the hospital directly, some reported that they went to the medical facility that was closest to them. In most cases, after they were screened for high blood pressure or diabetes, they were immediately referred to the specialists at the Saint -Louis Hospital for follow-up care. Others cited high prices and long wait times as reasons to avoid the Saint-Louis Hospital, so they chose facilities that were “within their means” and where the work ethic was “serious, where they treat you well and you don’t have to wait.” Some individuals reported that they made their initial choice of medical venue on the basis of a recommendation from someone in their social network.
While space does not allow for more detailed analysis here, we found that among our interview participants, healthscapes, or the perception of available and accessible medical options, do not have a significant territorial dimension. While proximity did matter in some instances, the perception of accessibility was not limited to options in the neighbourhood or even by the boundaries of the city itself. Even residents of Pikine, who we found had the fewest number of health facilities in close proximity, did not have healthscapes that were different from residents of other neighbourhoods. A small number of our interview participants were treated for acute episodes in the capital city Dakar, and some continue to seek regular care there. We found no identifiable pattern of care-seeking by neighbourhood. We suspect that because untreated hypertension and diabetes produce dramatic symptoms, individuals seek care at the limited number of facilities that are deemed appropriate for serious health conditions. For more routine care and for less serious problems (vaccinations, pre-natal care, diarrhoea, malaria), territorial factors such as proximity may weigh more heavily in patients’ therapeutic itineraries.
Our interviews about illness experiences in the four neighbourhoods also sought to understand potential variations in the treatability of diabetes and hypertension. As health research in sub-Saharan Africa increasingly addresses the emerging challenge of non-communicable diseases (NCDs), the idea of treatability conveys the presence or absence of health policies, funding, biomedical expertise and tools, and people’s knowledge of particular pathologies [33
]. Whyte’s analysis of the treatability of hypertension and diabetes in Uganda points to a lack of public health resources and infrastructure, and she highlights the challenges facing patients who are proscribed pharmaceutical regimens and diet and lifestyle changes [34
Saint-Louis offers insight into the treatability of hypertension and diabetes in a setting where biomedical infrastructure for monitoring NCDs and local knowledge of these pathologies is relatively robust. As a result, treatability of hypertension and diabetes reflects access to available medical care, the ability to purchase relatively expensive pharmaceuticals (most patients spend between US$20–$50 per month on prescription medications), and the tension between recommended dietary changes and deeply held notions of food culture and sociality. We identified a number of key themes in patient accounts of how they managed hypertension and diabetes. The most significant themes were: the expense of medications, the high cost of dietary recommendations, the difficulty of following dietary recommendations due to food preferences, and the reliance on family members, particularly siblings and children, to help pay medical costs.
Again, we sought to determine if there was a socio-territorial dimension to treatability, i.e., if diabetes and hypertension are more treatable in some neighbourhoods than for others. We discerned no patterns in the interview themes to suggest that treatability is linked to an individual’s place of residence in Saint-Louis. While a majority of our interview participants sought to comply with medical treatment, cost of prescriptions emerged as the main obstacle to treatability. Only six individuals in our sample had any form of medical insurance, and of those six two reported that their insurance provided them with only partial coverage. Therefore, the vast majority of people living with diabetes and hypertension must pay all of their costs out of pocket. In the best scenario, patients have uninterrupted access to pharmaceuticals and their treatment is continuous. At least half of our interview respondents cited the tremendous financial burden of purchasing medicines, and indicated that their treatment is sometimes episodic. Interviewees described running out of medications and needing several weeks to save enough money for refills, as well as delaying medical appointments and laboratory work because they had no money. A few other patients described reducing their prescribed doses to stretch out their medications, or taking their medications only when they experienced noticeable symptoms. For most of our respondents, the cost of medical treatment far exceeds their personal budgets, and they therefore receive regular financial assistance from another family member (typically a sibling or a child) for their medical care. Treatability of these conditions is therefore related not just to the presence of adequate medical infrastructure and the financial means of the patient, but also to the ability of extended families to mobilize the necessary financial resources to pay for treatment.
All of our interview participants described the dietary recommendations that are known to lower blood pressure and blood glucose levels: reduce sugar, salt, fatty foods, white rice, and other refined carbohydrates while increasing fresh fruits and vegetables, grilled fish and leaner meat. Interview participants described many obstacles to complying with their proscribed diet. Cost was a predominant concern in our interviews. Diabetes and hypertension were described as being diseases for the rich or bourgeois because of the combined expense of medications and diet. Healthy foods are said to be more expensive, and complying with dietary recommendations means that the household cook effectively has to prepare a separate meal three times a day. This additional domestic labour was simply not feasible in some households. As a result, some interviewees reported eating very small portions of the family’s meal at noon time and skipping the evening meal. The idea of an entire household changing its diet to accommodate the diabetic or hypertensive family member was absent in all of the interviews save one. One head of household in Ndioloffène with high blood pressure reported that he had imposed food restrictions on his household: less oil, less salt, and no bouillon. He was the only one of our interview respondents who had attempted to shift the entire household’s diet.
In addition to the high cost of preparing separate meals, interview participants described how “tiring” and “unappetizing” it is to eat meals that are low in salt, fat, and sugar. It would be hard to overstate the central place that ceeb u jen holds in Senegalese food culture, and some interviewees claimed that it was next to impossible to eliminate rice from their diet. Evening meals often include a meaty sauce eaten with pieces of white bread. The recommendation for those with high blood pressure to avoid salty foods and fatty meats was reported to be particularly difficult. One 80-year-old resident of Léona with hypertension explained his reaction to his physician’s recommendations, “He told me to give up meat, oil, and tea. I told him that he wanted me to die!” His incredulity at the idea of giving up food items that are central to the Senegalese diet illustrates the challenge of attempting to comply with dietary restrictions. An additional obstacle is that respecting dietary recommendations usually means eating alone while the rest of the family eats from a collective bowl. The challenge of eating in isolation appeared in 28 of our interviews.
In sum, treatability of hypertension and type II diabetes appears to be largely related to the cost of medications and the recommended diet. As such, treatability varies according to the financial means of the patient and his or her immediate household, and the social networks that can be mobilized to help pay for care. Further analysis might demonstrate more evidence that neighbourhood residence influences economic status and/or the density and social cohesion of one’s social networks. Nonetheless, the findings presented here do not support a clear socio-territorial influence on the treatability of hypertension and diabetes.