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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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Getting real about intersectoral action

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Wednesday, 23 November 2011
in CHNET-Works!

Many policies that affect social determinants of health, and therefore the prospects for reducing health inequity, are outside the control (and sometimes beyond the competence) of government ministries, departments and agencies responsible for health protection and public health. Advancing health equity therefore requires what is variously described as a health in all policies approach (which was the theme of Finland's presidency of the European Union in 2006), a whole of government approach, or intersectoral action.

In parallel with the work of the WHO Commission on Social Determinants of Health, the Public Health Agency of Canada produced a synthesis of 18 country case studies of intersectoral action. The level of detail varied considerably, and to their considerable credit the authors of the report warned about the lack of a standard reporting format, and further that "the majority of case studies were written from one perspective only in most cases from the perspective of a representative of the health sector. The tone of the case studies was often positive (rather than critical)," as might be expected from what were essentially self-reports, "and we had no opportunity to determine what the opposing views, if any, might be." Indeed, a cynic might observe that intersectoral action is far easier to talk about than to carry out with demonstrable improvements in outcomes.

A new series of monographs produced by WHO in Geneva, in collaboration with the WHO Regional Office for the Western Pacific, now offers valuable resources for moving beyond rhetoric in intersectoral action, drawn from experiences in countries rich and poor alike. Reports produced so far address housing, education and transportation: three of the most important social determinants of health, with special importance from an equity perspective.

The key message of the housing monograph is that health equity can be a guiding principle and catalyst for sustainable housing and development policies, organized around advancing the right to housing for all citizens. It identifies numerous opportunities for intersectoral action to achieve eight objectives: sound construction, safety and security, adequate size, availability of basic services, affordability, accessibility, tenure, and protection from climate change. Several of these are directly relevant to Ontario, where waiting times for affordable housing can be measured in years and where – in pre-recession 2007 – 13.9 percent of urban households (17.2 percent of Toronto households) were in "core housing need" as defined by Canada Mortgage and Housing Corporation. This means that their housing requires major repairs, lacks enough bedrooms for the size and composition of the household, or costs more than 30 percent of before-tax household income; the core housing need concept does not take into account problems related to neighbourhood characteristics or inadequate transportation, so understates the opportunities for creative policy initiatives.

cat-1The education monograph is organized around recognition that universal access to education opportunities is one of the most powerful determinants of child well-being, health equity and development. Critically, the monograph recognizes that "disparities in educational attainment among learners are often based on living conditions outside the realm of schools," taking the imperative for intersectoral action to a new level. We may think that such problems are not a serious issue in Canada, but the work of such researchers as Human Early Learning Partnership scholar Paul Kershaw at the University of British Columbia provides an urgent wake-up call. Kershaw has advocated a New Deal for Families that would combine increased income support with flexible working hours (flextime) and drastically expanded access to affordable quality child care services. As one of those childless-by-choice individuals whose cohabitants are quadrupedal and furry, I more than most people need this kind of reminder about the financial and logistical stressors involved with raising children on wages that are stagnating while housing costs and other daily expenses are skyrocketing.

The road transport monograph focuses on multiple health impacts and inequities associated with reliance on private automobiles for transportation. These include both the obvious (reduced physical activity, environmental pollution, injury risks that are disproportionately borne by those who cannot afford vehicles) and the less obvious, like the high costs that car-oriented transportation planning imposes on working class families. (An important US study found that such families in 28 metropolitan areas were spending, on average, 28 percent of their incomes for housing and 29 percent for transportation.) This monograph is especially rich in examples of policies that have been implemented successfully, on scales ranging from the local to the national. These include road safety measures, road tolls and congestion charges, integration of traffic injury data and health and sustainability criteria into municipal transport policy, and a variety of improvements to public transportation. It is fair to say that Canada is far from the cutting edge in applying many such measures. In a country where more than three out of every five commuters drive to work in every metropolitan area, scope for local initiatives abounds.

stree-cap-3In this vein, a thoroughly parochial example shows the obstacles to making intersectoral action happen. Following several fatal and nearly fatal road accidents involving pedestrians and cyclists, my local councillor in downtown Ottawa (Diane Holmes) convened a well attended "sidewalk Summit" on how to improve pedestrian safety. In particular, participants complained about the danger of crossing Bronson Avenue, a four-lane arterial road connecting the city centre with the airport that will undergo a costly reconstruction starting this winter. Ms Holmes told Summit participants that engineers on city staff have so far rejected proposals to make the street more pedestrian-friendly because the suggested changes would mean a 60-second delay for drivers on the 1.1 kilometre downtown segment of Bronson, bisecting a neighbourhood that is far from wealthy – this despite abundant evidence of the health benefits of improving the walkability of cities.

This is far from an isolated case. Intersectoral action to advance health equity requires, first of all, improving information flows within and across organizations that develop and implement policies that affect health. Okay, we already knew that, but the "how-to" often remains elusive, and I hope that readers will post comments about both their successes and their frustrations. Perhaps more basically, we need to address questions of leadership and accountability: Who elected the engineers? To whose priorities do they respond, and why? In local planning decisions and in national policies, health equity means that everyone has to count.

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