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Health as if everybody counted blog

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The different worlds of metropolitan health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
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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Small steps toward walkability

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 26 April 2012
in CHNET-Works!

Toronto’s Department of Public Health, a leader in such areas as publicizing the conflict between eating a healthy diet and keeping a roof over your head when living on a low income, has issued a new report with important recommendations for improving health by promoting walking and cycling.

Among the recommendations: reducing speed limits to 30 km/h on residential streets and 40 km/h on most others, and installing “leading pedestrian signals” at major intersections.  (These are signals that give pedestrians a walk signal a few seconds before the light turns green for vehicle traffic, improving drivers’ ability to seen them.)  The report also notes the need for more investments in pedestrian and cycling infrastructure, and for working with Metrolinx (the regional public transportation authority, now facing drastic funding shortfalls as a consequence of provincial austerity measures) to promote active transportation.

The report is based on a longer study that undertook an extensive review of the evidence on active transportation and health, emphasizing the equity dimension.  It noted, in particular, that “low-income families often live in high-rise neighbourhoods in Toronto’s suburbs,” which are hostile to pedestrians and cyclists.  Roads are wide; marked pedestrian crossings few and far between; pedestrian collisions are more frequent even though pedestrian volumes are lower; and three-quarters of parents do not feel comfortable letting their children walk unaccompanied in their neghbourhoods.

creative-commons-licencePhoto: Richard Drdul,
reproduced under a Creative Commons licence
The longer study also argued for traffic calming strategies: engineering measures to slow down traffic, like speed bumps and curb extensions, which have resulted in major reductions in injuries and fatalities when implemented in Europe.  A more extensive review of traffic calming and health was published late last year by Canada’s National Collaborating Centre for Healthy Public Policy, and will be the topic of a CHNET-Works Fireside Chat on May 10.
Predictably, the Toronto Public Health recommendations were greeted with howls of outrage from some of Toronto’s more retrograde politicians, but as readers of a previous posting (and the longer Toronto study) will know, such measures are either already in place or under serious consideration in many European cities.  This is, literally, an issue of street-level politics: will the “right to the city,” in Henri Lefebvre’s frequently cited phrase, favour pedestrians and cyclists or people protected by two tons of steel and airbags?  In many other Canadian cities, we’re still waiting for Toronto-style public health leadership.

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HEST: A new frontier for action on health equity? *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 28 February 2012
in CHNET-Works!

In December 1995, Cynthia Wiggins was hit by a dump truck while crossing several lanes of traffic in suburban Buffalo, New York; shortly afterward, she died from her injuries. The 17-year-old African-American woman had to cross the arterial road from her bus stop because the bus that took her from downtown to her job in the posh Walden Galleria mall was not allowed on mall property. It was later revealed that the local public transportation authority had for years tried, unsuccessfully, to get permission to stop in the mall's parking lot. In 1999, a lawsuit charging the mall's owners with racial discrimination was settled for $2.55 million (to benefit Ms Wiggins' son) without admission of liability.

Ms Wiggins' death is an especially dramatic example of the connections between transportation policy and social exclusion: specifically, support for a form of apartheid in the United States long after it was challenged in legislation and jurisprudence. In Los Angeles, The Bus Riders' Union has used a variety of tactics, including litigation under national civil rights legislation, to seek improvements in a transit service that mainly serves a darker-skinned, subaltern population unable to afford the costs of driving in a car-oriented metropolis. Although we are not (yet) familiar with similar extremes in Canada, an important and neglected 2009 report prepared for Human Resources and Social Development Canada on mobility and social exclusion in Hamilton, Toronto and Montréal concluded that "the evidence uncovered in terms of mobility and accessibility patterns is suggestive of social exclusionary processes that may prevent various vulnerable groups," specifically low income people, seniors and single parent households, "from accessing the places required for their daily needs." Since social exclusion functions as a social determinant of (ill) health, the role of transportation in social exclusion should automatically be of concern to the public health community.

There are more immediate reasons for concern. One involves the health consequences of transport-related (mainly automotive) air pollution, reviewed among many other places in a 2005 WHO-Europe report and in the same year by the Ontario College of Family Physicians. It is also likely that an inverse relation exists between income and exposure, although the relation is complicated both by the limitations of measuring exposure based on residential location (most people don't spend most of their time at home) and by the "particular social geography" of cities like Montréal. (I would be delighted if readers can identify useful literature reviews on this topic.)

A second issue is the relation between metropolitan form and injuries and deaths from road accidents, where data on the socioeconomic gradient are hard to find and primary data are often collected by law enforcement agencies, using categories that have limited relevance to population health. (Again, readers are invited to contribute sources to the conversation.) A 2003 article by Reid Ewing and colleagues developed a "sprawl index" for 448 metropolitan counties in the United States, matched this against "all-mode" traffic fatality statistics, and concluded that "sprawl is a significant risk factor for traffic fatalities, especially for pedestrians." In the ten counties with the most compact urban form, fatality rates averaged 5.6 per 100,000 population; in the ten counties with the least compact form – that is, the most sprawling ones – the average was 26.3 per 100,000 population. However, hazardous environments for pedestrians are common even in cities that are relatively compact by North American standards.

hest-picture-1-1-of-1Hazardous environments for pedestrians are common, as shown in this picture taken from the University of Ottawa’s downtown campus.

A third reason for concern involves the relation among transport policy, the built environment, and overweight and obesity, which are now recognized as one of the most urgent public health challenges. The idea of obesogenic environments has gained widespread acceptance, and represents an essential challenge to the emphasis on 'lifestyles' or 'healthy choices' that characterizes many health promotion efforts. Isolating the specific contribution of transport policy is complicated by the fact that in the metropolitan environment, many things are going on at once. For example, neighbourhoods may be more conducive to physical activity ('walkable'), but may also have few full-service grocery stores but lots of convenience stores and fast-food outlets, or neighbourhoods where the built environment is conducive to walkability may also be those where crime is highest. However, some evidence shows a direct link between settlement patterns or transportation and obesity. For example, a 2004 study using a sprawl index – not the same one used by Ewing and colleagues – and self-reports of Body Mass Index (BMI) found that each 1-point increase in the sprawl index (on a scale of 100, values for large US metropolitan areas ranged from 6 to 100) was associated with a 0.5 percent increase in the risk of obesity, after individual-level variables like income, gender, age and education were controlled for. Almost by definition, urban sprawl implies a high reliance on automobiles for transportation, as shown in a classic graph produced by Jeffrey Kenworthy

hest-picture-2-1Source: P. Newman and J. Kenworthy, “‘Peak Car Use’: Understanding the Demise of Automobile Dependence,” World Transport Policy and Practice 17 (June 2011), reproduced with permission.

Finally, there is the need to shift transportation patterns in order to limit climate change, which itself is likely to have substantial adverse health impacts that will be inequitably distributed, falling first and hardest on people and regions that contributed least to the buildup of greenhouse gases. A 2009 article in The Lancet pointed out that transport emissions are rising faster than all other categories, and argued using scenarios for London and Delhi that there would be substantial health benefits from moving to "sustainable transport" including both lower-emission motor vehicles and more walking and cycling, quite independent of the effects on climate change. Elsewhere, a recent assessment of the effects of reducing automobile usage for short trips (1.6 km or less) in the Midwestern United States came to similar conclusions, and further projected several billion dollars a year in health care cost savings. As with other studies cited here these are only selections from a very large literature, but the pattern is clear.

So far as I know, the acronym HEST (for Healthy, Equitable and Sustainable Transportation) is my own invention. There is no shortage of useful information about how to begin, starting with a WHO evidence review mentioned in an earlier posting that identified transportation as an important area for action to reduce health inequity. Kenworthy has listed "ten key transport and planning decisions for sustainable city development," including de-emphasis of freeway and road; planning for employment and housing growth in the city centre and sub-centres; and – critically – a planning process that "is a visionary 'debate and decide' process, not a 'predict and provide,' computer-driven process." (A recent Toronto Star commentary on how the city's planning is now driven by the "pseudo-science" of traffic engineering made a similar point.) Ewing and colleagues have described the "five D's of development": density, diversity, design destination accessibility, and distance to transit. This source is one chapter in an excellent book called Making Healthy Places published by Island Press. World Streets, a web site specifically devoted to "equity-based transport," is another valuable and provocative resource.

Some Canadian organizations have taken up the challenge. I've already mentioned the work of the Ontario College of Family Physicians. In 2007, Toronto Public Health produced a report on air pollution, traffic and health that concluded: "Given there is a finite amount of public space in the city for all modes of transportation, there is a need to reassess how road space can be used more effectively to enable the shift to more sustainable transportation modes" like "walking, cycling and on-road public transit." (I don't think the city's current mayor has read it.) And Alberta Health Services has produced a well researched and hard-hitting fact sheet on urban sprawl and health. Doubtless much more is going on, and I hope readers will post appropriate news, citations and links. 



Predictably, our colleagues in other countries have been less polite and more proactive. Margaret Douglas and colleagues in Britain's NHS (including the Director of Public Health for a primary care trust in Manchester) wonder whether cars are the new tobacco, pointing to the multiple negative effects on health and sustainability of auto-oriented transport systems and the influence of the "car lobby." Also from the UK, writing in the December, 2011 issue of Public Health Today Philip Insall calls for a 20 mph speed limit in residential areas, noting that some continental cities have already made this move and that it would eliminate up to 580 child deaths and serious injuries each year. (Lower speed limits are just one kind of traffic calming measure; many others involve design changes, as noted in an important review by the Canada's National Collaborating Centre for Healthy Public Policy just released last November.) And Andy Jones, writing about obesogenic environments, says: "Maybe we just need to force society to change. Excluding traffic from city centres, radically increasing parking charges, forcing employees to walk at least part of the way to work by removing workplace car parks" as well as taxing high-fat foods.

Forcing society to change can be difficult when we have things like elections, and that's as it should be. Canada's public health community could, however, be much more energetic in advocating for such changes, and providing leadership to ensure that their equity and health benefits are part of the public debate during and between elections.

* Unfortunately, as with previous postings some hyperlinks lead to sources that are not available on an open-access basis. I have tried to find open-access materials wherever possible.

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