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Health as if everybody counted blog

The different worlds of metropolitan health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 14 December 2012
in CHNET-Works!

Sometime in 2008, for the first time in history, more than half of the world’s population lived in urban areas.  In Canada, as for all high-income countries, the proportion is far higher; definitional issues complicate the picture, but we know that more than 46 percent of Canadians live within metropolitan areas centred around Toronto, Montréal, Vancouver, Calgary, Edmonton and Ottawa.  A June, 2012 article on “shaping cities for health” by a group of authors convened by The Lancet and University College London sheds some light – although I think not quite enough – on what urbanization means for the future of health equity. 


The authors begin with recognition that that “rich and poor people live in very different epidemiological worlds, even within the same city.”  Finally, someone gets this!  In itself, this recognition is an advance on much current thinking about urban health, which tends to use of place of residence as a proxy for the entire range of exposures that comprise the metropolitan “riskscape.”  The concept of an epidemiological world urgently needs to be incorporated into future study designs and academic curricula on place and health.  The authors of the Lancet piece emphasize the complexity of the influences on health in cities (I prefer the term metropolitan health to the more familiar urban health, because it reflects the interaction of cities with the economics, politics and demographics of their surrounding suburbs and exurbs).  And they note the limited concrete advances resulting from the WHO-led Healthy Cities movement that began in 1984 although other authors, it must be said, are more optimistic.


The Lancet authors opt for a “more restricted” focus, “on how urban planning could shape the physical aspects of an urban environment to promote health,” concentrating on five specific sets of issues: sanitation and wastewater management; building standards and indoor air quality; transportation, mobility and physical activity; the urban heat island effect; and urban food production.  (Some of these are obviously more relevant than others to high-income countries like Canada.)   And they argue that “many people know what a healthy urban environment would look like,” although one could quibble with the generality of their list.

Lancet pic 1

Here is where, in my view, the analysis runs into trouble, because the question ‘healthy for whom?’ recedes into the background.  The authors acknowledge the significance of conflicting interests – for example, those of people who can afford to drive everywhere (and the businesses that cater to them) and the generally poorer individuals who can’t and don’t – such that “the needs of vulnerable groups in urban societies are often forgotten.”  Truer words were never written.  Yet the same paragraph refers to “engag[ing] stakeholders in detailed and problem-orientated argumentation on potential solutions,” as if the process were some kind of event in the senior common room, with “inclusion of the full range of community representatives within such deliberation and debate.”


Now it is all very well to say “that planners need to engage in widespread policy debate to instill healthy city values in the policy process,” but what about the raw power differentials that are familiar to me, and to every urban activist I have ever met, from engagement with the real world of planning processes, which are often driven by economic actors who have no need or desire to engage in public debate?  (They can buy the access they need.)  Urban planners are seldom autonomous; they usually work for one or another agency of the state.  What about the interests, resources and allegiances of those who direct their work? 


Context outside the metropolis matters, as well.  Discussing Detroit’s promising future in urban fruit and vegetable growing, the authors show limited awareness of the etiology of the city’s decline in the deindustrialization that has devastated communities throughout the high-income world.  This is a key illustration of how metropolitan economies are connected to global-scale flows and processes, a point that will be familiar to anyone even tangentially acquainted with Saskia Sassen’s work.   And there is little recognition of the role of real estate capitalism, itself a global phenomenon, in driving patterns of dispossession and exclusion and corrupting planning processes.  (One of the three best books on the political economy of New York City is called From Welfare State to Real Estate.)  


These are relatively minor disagreements with an important, multidisciplinary, and brilliantly well documented article.  Anyone concerned with metropolitan health will learn a lot from it.  At the same time, we must not forget that the metropolis is a terrain of political conflict among interests with vastly unequal resources, and that many of the most powerful influences on health equity within the metropolis may originate far outside its borders.  Against this background, how realistic is a ‘let us reason together’ approach to metropolitan health, especially if reducing inequities is a primary objective?  Better, perhaps, to start from a concept like the “right to the city,” in Henri Lefebvre’s oft-cited phrase.

Lancet  pic 2

Some additional resources: 
UN Habitat, Cities in a Globalizing World (London: Earthscan, 2001) – empirically a bit dated now, but still a classic


UN  Habitat, State of the World’s Cities 2010/2011: Bridging the Urban Divide.  London: Earthscan, 2008


World Health Organization, Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings (Nairobi: UN Habitat and WHO, 2010)

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