# Session Overview ## Learning outcomes By the end of this session you should be able to: · describe drivers of urban change, the urban transition and pros and cons related to health · explain equity issues, ‘urban bias,’ and the role of urban planning in developing healthy cities (e.g. reducing obesogenic environments) · evaluate linkages between ‘good local governance’ and policy actions from community to district and/or national level. # 1. Introduction Five percent of the global population lived in urban environments in 1800, 15% in 1900, while now approximately 50% of the global population lives in urban areas. Urbanization – the increasing concentration of people and economic activities in towns and cities – brings economies of scale and proximity to infrastructure. Services that reduce the risks of injury, illness and premature death, education provision and employment opportunities can be considered beneficial for health, although in low and middle-income countries these benefits tend to be spread more unevenly, as large sectors of society live in informal settlements where conditions can be extremely poor and health burdens consequently very high. # 2. The urban environment The urban environment can be defined as ‘the natural, built and institutional elements that determine the physical, mental and social health and wellbeing of people who live in cities and towns’. ## 2.1 Urbanization ### Activity 2 After reading pages 149-153 of the PHM106 textbook, please consider the following questions. 1. What is urbanisation? The increasing concentration of people and economic activities in towns and cities. 2. What are the main drivers for urbanisation? Economic growth, particularly where manufacturing and services are the growth areas. Economic, political and social change such as natural disasters and conflict may also contribute to migration from rural areas. 3. What are the potential problems associated with rapid urban growth? It may occur at a faster rate than infra development can cope with, particularly in LICs where social and economic conditions are often uncoordinated. The result: lack of good quality housing, water supply and sanitation. 4. What is the relationship between economic growth and level of urbanisation? - Levels of urbanisation tend to increase by country’s income - Fastest growing economies tend to be those that urbanized most - Most large cities are in the world’s largest economies 5. What is the general relationship between national economies by sector and level of urbanisation? Agricultural sector tends to decline, while the industry and services sector tends to increase in all growing economies ## 2.2 The impact of urban environment on health The role of healthy cities is pivotal for sustainable development as it is directly linked to SDG 2 (Zero hunger), SDG 6 (Clean water and sanitation), SDG 11 (Sustainable cities and communities), SDG 12 (Responsible consumption and production), SDG 13 (Climate action) and SDG 16 (Peace, justice and strong institutions) (WHO 2016). As discussed by Ezzati et al (2015), ==it is important to consider carefully the possible discourse between what an idealised ‘healthy city’ is or should be and the complex dynamics of urban development that include concurrent and dynamic changes in demographic, social, natural, built and food environments==. ### Activity 3 After reading pages 153-161 of the PHM106 textbook, please consider the following questions. 6. What are the potential health benefits of urbanisation? Think about both direct and indirect impacts on health. Easier access to health facilities Economic growth, more opportunities to build wealth and afford healthcare Better education opportunities and thus, improve the health-seeking behavior Food availability, water supply Better transportation; more [[Active commuting]] Better housing 7. What are the potential disadvantages to health? Inequality of all the advantage above Wealth does not automatically translate to better health Increased spread of communicable disease 8. Which sectors of society benefit and which do not and why? Where urbanisation has been well managed (adequate provision of good quality housing, infrastructure and services), there tend to be benefits to health and wealth. However, the converse is also true. In addition, for some global corporations who site their headquarters in urban areas where labour is inexpensive, the benefits of the resulting economic growth are not felt by the country in which they are located, but elsewhere – usually in high income countries 9. Look at Table 9.5 from the PHM106 textbook showing figures for mortality and morbidity rates in children for Nairobi. Which sectors of society benefit and which do not and why? 10. What are the health implications of obesogenic environments? Post your comments on Moodle and respond to at least one other post. # 3. Focus areas to implement strategies for healthy and sustainable cities The WHO’s Urban Health Initiative identified the following areas to implement strategies for healthy and sustainable cities (WHO nd, [link here](https://www.who.int/initiatives/urban-health-initiative)): · Energy-efficient transport · Healthy urban planning · Healthy urban diets · Slum upgrading · Healthy, energy-efficient housing · Improved urban waste management Healthy urban diets have been receiving a lot of attention, particularly in the form of municipal and community initiatives to promote healthy eating and sustainable diets. Urban agriculture initiatives and projects can help improve access to healthy foods, especially in low-income inner-city neighbourhoods. Community participation in such projects is also beneficial as it improves people’s awareness of healthy eating, food production and food hygiene and affordability of fresh food. The role of local government is crucial in implementing and supporting such initiatives (WHO nd). One such example comes from the C40 cities and the C40 Food Systems Network, which, in partnership with EAT initiative (session 13), convenes city officials to work together to achieve solutions to the most pressing food systems challenges. The Network focuses on five areas (C40 nd): Food Procurement – using food procurement for public facilities (schools’ canteens, hospitals, elderly homes, civic buildings etc.) to foster more sustainable and healthy diets. Food Environment – transforming the social and physical environment that affect the types of food available within neighbourhoods, the affordability of food, and the nutrition information that people are exposed to, including food marketing to allow better consumers' choices Food Waste – raising awareness of and addressing food loss and waste reduction, including by facilitating recovery and redistribution for people in need (food banks) and implementing food waste valorization. Regenerative Agriculture – promoting regenerative urban agriculture to decrease production emissions, close yields gaps, increase food security, support local producers, decrease food miles, mitigate urban heat island effect and reduce building energy demand (through roof and wall gardens) Governance – supporting cities in developing food strategies; including food as part of their climate action plans; and creating food boards and councils for inter-departmental and external coordination # 4. Integrating activity # 5. Summary This session provides an overview of the concept of urban development and how it can affect health. You should now be able to describe drivers of urban change and pros and cons related to health, explain equity issues and the role of urban planning in developing healthy cities (e.g. reducing obesogenic environments), and evaluate linkages between 'good local governance' and policy actions from community to district and/or national level. Local and global initiatives are discussed in more detail in later sessions. # 6. References ## 6.1 [[Essential readings]] [[@ezzatiCitiesGlobalHealth2018]] Ezzati M, Webster CJ, Doyle YG, Rashid S, Owusu G, Leung GM. (2018) Cities for global health. BMJ. 363: k3794. This paper is the first of a series of papers on the role of cities in health. It is specifically looking at the importance to take action to reduce health inequalities within cities. The authors describe the policy challenges to improve health in cities and define the role of cities in global health under the following themes: Environment; Housing; Nutrition; Addiction; Universal health coverage; Public safety and emergency response; Infectious disease outbreaks; Smart cities and emerging economies and technologies; Migrant, transient and peri-urban populations. The authors conclude with a call for action to include health and health equity in all policies. [[@pineoPromotingHealthyCities2018]] Pineo H, Zimmermann N, Cosgrave E, Aldridge RW, Acuto M and Rutter H (2018) Promoting a healthy cities agenda through indicators: development of a global urban environment and heath index. Cities and Health. 2:1, 27-45. This paper presents the development of a global index to help city leaders and practitioners understand their role in delivering health outcomes through urban environment policies and programmes. The Building Research Establishment’s international Healthy Cities Index (BRE HCI) contains 10 environment categories and 58 indicators, supported by a causal pathways framework. [[@francoPreventingNoncommunicableDiseases2015]] Franco M, Bilal U and Diez-Roux AV. (2015) Preventing non-communicable diseases through structural changes in urban environments. J Epidemiol Community Health. 69(6): 509-11. This paper provides an excellent summary of the characteristics of the urban environment and individual behavioural risk factors related to non-communicable diseases (NCDs). Hutchinson EJ and Kovats RS (2016) Environmental Health and Sustainable Development, Chapter 9 (The urban environment and health) Chapter 9 chapter discusses various dimensions of urbanisation (e.g. physical, social, economic). It focuses on health problems associated with rapid urbanisation and differences in health outcomes and policy actions to promote heathy cities. ## 6.2 [[Recommended reading]] Hutchinson EJ and Kovats RS (2016) Environmental Health and Sustainable Development, Chapter 3 (Changing pressures on health and the environment) Chapter 3 describes the demographic, environmental risk, epidemiological, urban and technological transitions. Rydin Y, Bleahu A, Davies M, Dávila JD, Friel S, De Grandis G, Groce N, Hallal PC, Hamilton I, Howden-Chapman P, Lai KM, Lim CJ, Martins J, Osrin D, Ridley I, Scott I, Taylor M, Wilkinson P and Wilson J (2012) Shaping cities for health: complexity and the planning of urban environments in the 21st century. Lancet. 379(9831): 2079-108. Satterthwaite D (2007) The Transition to a Predominantly Urban World and its Underpinnings. Human Settlements Working Paper Series Urban Change No. 4. IIED, London. This IIED Discussion paper gives an overview of urban change and its main causes published by IIED’s Human Settlements Group since 1986. It uses the new global dataset produced by the UN Populations Division on urban populations and on the populations of the largest cities to describe the dramatic changes in the size of the world’s urban population and its largest cities over the last 100 years. Satterthwaite D (2021). Do urban populations benefit from urban bias? Available at: https://www.iied.org/do-urban-populations-benefit-urban-bias (Accessed 8 October 2023). WHO (2022). WHO Urban Health Initiative in Accra, Ghana: summary of project results. Available at WHO Urban Health Initiative in Accra, Ghana: summary of project results (Accessed 8 October 2023) Greiener C and Sakdapolrak P (2012) Rural-urban migration, agricultural change and the environment in Kenya. A literature review. Population and Environment. 34 (4): 524-553. This paper provides a good discussion on the complexities between rural-urban migration and the environment in Kenya. World Health Organization (2018) Copenhagen Consensus of Mayors – Healthier and happier cities for all. WHO: Denmark. This report summarizes the consensus that was endorsed at the WHO European Healthy Cities Summit of Mayors in Copenhagen in 2018. The report provides a list of commitments from mayors of about 1400 municipalities in Europe to take action to improve the health and well-being of everyone living in their cities.