Jefe Bergenstein
Legend
The difference is the availability of magic. If you have access to druids, then we have no failed crops.
Maybe. Or maybe the druids don't meddle with magically increasing crop yields to artificially bloat a population that's already consuming too much wilderness resources for its own good. Maybe they say no to Magically Modified Organisms. This also ignores evil gods and entities that favor blight and famine. I recently ran an adventure with a disease that couldn't be magically cured. If every 3rd level cleric or 1st level paladin can undo the god of disease's work, it kind of makes them look like a chump.
In regards to the OP, I play it up depending on the campaign or character. If everyone is city born, I let it fade into the background, as it would for the characters. If the characters are more rural/woodland, I make it more known just how odious they would find the big cities. Sometimes its just for texture or to explain an encounter. Yep, the ghouls and otyughs in the sewers hang out neat the butcher district because of all the viscera that sluices down from the shop.