by countries for populations in poverty. over 80% of cardiovascular disease deaths, that totaled 17.5 million people globally in 2005, occur in low- and middle-income countries. according to the who,13500 people die from smoking every day, and soon it will become the leading cause of death in developing countries, just as in high income countries. (mathers & loncar, 2005). infant and maternal mortality also reveals disparity in health between nations. there exist great inequalities in infant death rates within and between countries, ranging from 20/10000 births in columbia to 120/10000 in mozambique. in 1985, the world health organization estimated that maternal mortality rates were 150 times higher in developing countries than developed nations. urban the location where people live affects their health and life outcomes, which means impoverished people's health outcomes are especially determined by whether they live in a metropolitan area or rural area. in the 19th and 20th century, slums developed in cities and the ensuing crowding, poor sanitation, and inadequate dwellings brought infectious disease and illnesses, causing public health concerns. with the prevalence of inner city ghettos and slums around the globe in cities, with approximately 1 billion people living in slums globally, living situation is an especially strong determinant of health in poverty. urban areas present health risks through poor living conditions, limited food resources, traffic accidents, and pollution. urbanization is immensely altering public health problems, particularly for the poor, by directing it towards non-communicable diseases, accidental and violent injuries, and death and health impacts from ecological disaster. (capbell & campbell, 2007; yusuf et al., 2001). daily living conditions enormously impact health equity too. equity in living conditions, such as access to quality housing and clean water and hygiene, have been greatly degraded in urban areas by increasing car dependence, land use for roads, inconvenience of non-car transportation, air quality, greenhouse gas emissions, and lack of physical activity (nhf, 2007). the challenges of urban areas, such as high population density, crowding, unsuitable living conditions, and little social support, provide a special challenge to disabled people and populations in low and middle income countries (frumkin et al., 2004). obesity: obesity is a paramount problem, especially among the poor and socially disadvantaged, in cities worldwide, according to the who (hawkes et al., 2007; friel, chopra & satcher, 2007). the increased amount of obesity can be contributed to the nutrition transition that describes how people are now increasingly turning to high-fat, sugar, and salt food sources because of their availability and price. this food transition has fueled the obesity epidemic. this nutrition transition tends to start in cities because of "greater availability, accessibility, and acceptability of bulk purchases, convenience foods, and 'supersized' portions" (dixon et al., 2007). physical activity and exercise is strongly determined by the design of cities, including density of homes, heterogeneous land uses, the extent to which streets and sidewalks connect, the walkability, and the provision of and access to local public accommodations and parks for recreation and play. these factors, along with increasing reliance on cars, results in the shift of the population toward physical inactivity, which damages health (friel, chopra & satcher, 2007). crime: violence and crime are major urban health challenges. worldwide, 90% of the 1.6 million annual violent deaths occur in low and middle income counties (who, 2002). a large number of deaths and injuries occur because of crime, which affects health. traffic: individuals in ghettos and urban areas are the most affected by traffic injuries and vehicle-created air pollution, which causes 800,000 annual deaths due to air pollution, and 1.2 million from traffic accidents. (roberts & meddings, 2007; prüss- üstün & corvalán, 2006). this results in greater health risks, like death, for impoverished populations in cities. mental illness: living in a ghetto increases the likelihood of developing a mental illness, especially in children. people in this environment are less likely to receive effective mental health services. children exposed to ongoing poverty, present in a ghetto, present a high level of depression, anxiety, social withdrawal, peer conflict and aggression. mental health symptoms are increased in the ghetto due to exposure to community crime, gang induced violence, neighborhood drug infestations, and substandard housing conditions. other: in the united states, hiv is more prevalent in cities along the east coast, with prevalence among african-american women in cities 5 to 15 times higher than for women in all areas of that state. "inner-city women are the most likely of all in the united states to birth dead or extremely sick babies, partially because the massive erosion of prenatal care availability in their area. slums, made up exclusively of extremely poor populations, provide a particularly strong threat for poor health. child mortality in the slums of nairobi, which 60% of the population inhabits, is 2.5 times greater than in other areas of the city. in the slums of manila, 39% of children have tb, which is twice the national average. the term 'housing instability' describes a condition in which people have been or will be homeless in the future. people facing such instability have poorer health care access and more acute health problems than the rest of the population. a city populations grew and rents rose, those receiving section 9 housing vouchers could no longer afford the rising rents and were forced to move away. rural living in a rural community, whether in the united states, or around the globe, reduces access to medical services, health insurance, and changes health culture. differentials exist between rural and urban communities, and some health disadvantages exist for impoverished rural residents. since health of a population increases in geographical locations that have a higher prevalence of primary care physicians, rural areas face worse health. according to certain studies, measures of health and well-being indicate that rural populations have worse health outcomes. rural residents have a greater rate of premature mortality (less than age 75 at death) than urban residents. according to certain studies in the united states, the death rate of individuals age 1–24 years was 31% higher than those in urban counties. the death rate of adults 25 to 64 years old was 32% higher among rural residents than those of suburban counties and of urban counties. these higher death rates were contributed to unintentional injuries, suicide, and chronic obstructive pulmonary disease. in 1997 in the united states, 18% of adults in rural areas had chronic health conditions, compared to only 13% of suburban adults. the national health interview survey indicated that in 1998, 16% of rural adults reported poor health. poor rural residents have only 21% medicaid coverage, while poor urban populations report 30% coverage. demographic and socioeconomic factors vary between rural and urban areas, which contributes to some health disparities. for extremely poor rural communities, variables in the community, like ecological setting, including climate, soil, rainfall, temperature, altitude, and seasonality greatly impact health. "in rural subsistence societies, these variables can have strong influence on child survival by affecting the quantity and variety of food crops produced, the availability and quality of water, vector-borne disease transmission" governance/policy type and structure of governments and their social and economic policy more deeply affects the health of the impoverished than other populations. every component of government- from finance, education, housing, employment, transportation, and health policy- affects population health and health equity. life expectancy variation between countries can be partially attributed to the type of political regime, whether that be fascist, communist, conservative, or social-democratic. it is suggested by who that those who are the most vulnerable and affected by policy changes that influence their quality of health should have a direct hand in the construction and adoption of these same policies. this power in contribution would have a positive impact on their health outcomes, due to their ability to participate autonomously in policies that influence their health. however, changing the status of government regime does not always end the type of policies in place, as seen in south africa. the end of south africa's apartheid regime has still not dismantled the structures of inequality and oppression, which has led the persistent social inequality to perpetuate the spread of hiv, diminishing population health. also, the political economy, encompassing production organization, physical infrastructure, and political institutions play a large role in determining health inequalities. social service and healthcare availability no usual source of healthcare due to weak social safety net the social environment that impoverished people dwell in is often a precursor to the quality of their health outcomes. without equitable access to basic social needs, it is difficult to have a quality standard of health while under a significant financial burden. the commission of social determinants of health, created in 2015 by the world health organization, was a pioneer in the push for more focus on "creating better social conditions for health, particularly among the most vulnerable people". these basic social needs that influence social environment include food security, housing, education, transportation, healthcare access and more factors that can affect health. social services and social service programs, which provide support in access to basic social needs, are made critical in the improvement in health conditions of the impoverished. impoverished people depend on healthcare and other social services to be provided in the social safety net, therefore availability greatly determines health outcomes. since low living standards greatly influence health inequity, generous social protection systems result in greater population health, with lower mortality rates, especially in disadvantaged populations. a successful example of such social service program is the senior companion program, an extension of the united states federal program senior corps. the program provides assistance for adults who have physical and mental disadvantages. it pairs up senior volunteers with patients who come from low-income background to help them increase their social capability, ability to live independently and more accessibility to healthcare. a mixed-method study explores that the program does target various social determinants of health and have positive effects on enrolled elders' health status (although less positive correlation long-term). it concludes that the program does have enthusiastic impacts on clients and volunteers' overall wellness. the result is homogeneous with conclusions from other studies, with emerging themes include: companionship, reduced depression, access to healthcare, isolation, and increased social network. another example of a utilized social service program in northern california is the ucsf benioff children's hospital oakland find program. this program employs a method of addressing the social determinants of health, liaison work, contextualized by their predominantly impoverished patient population. this liaison work involves caseworkers in the clinic connecting patients to basic social needs resources. similar positive results have been found, suggesting that this liaison work is effective in bettering the health status of those in marginalized positions of society. nations that have more generous social protection systems have better population health (lundberg et al., 2007). more generous family policies correlate with lower infant mortality. nations that offered higher coverage and reimbursement for pensions and sickness, unemployment, and employment accident insurance have a higher leb (lundberg et al., 2007), as well as countries with more liberal pensions have less senior mortality. (lundberg et al., 2007) access to healthcare the health care system represents a social determinant of health as well as it influences other determining factors. people's access to health care, their experiences there, and the benefits they gain are closely related to other social determinants of health like income, gender, education, ethnicity, occupation, and more. for poor people, systematic barriers in the social structure are formidable, especially financing. medicaid and maternity coverage structures have complex and time-consuming registration processes, along with long waits and unsure eligibility. a study of the emergency department found that the majority of patients presenting with mental illness were those on medical (20.4%) and medicare (31.5%), whereas only 12.4% of privately insured patients presented with mental illness. california has expanded its eligibility of medi-cal under federal law to cover as many people as possible. inequalities in health are also determined by these socioeconomic and cultural factors. health care is inequitably distributed globally, with pronounced inequality for the poor in low- and middle-income countries. one study demonstrated that doctors treat poor populations differently, showing that disadvantaged patients are less likely to receive the recommended diabetic treatments and are more likely to undergo hospitalization due to the complications of diabetes (agency for health care research and quality, 2003). according to