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Urban Health

David Vlahov, Ph.D., R.N.Center for Urban Epidemiologic Studies

Public Health Challenges for the 21st Century

� Urbanization

� Aging

� Climate Change

“In 2007, for the first time in world history, half of the world’s population is urban”

UN HABITAT, 2003

1950

2007

2030

Urban

29%

Rural

71%

Rural

50%

Urban

50%

Urban

59.9%

Rural

Rural

40.1%

Total Population

2.5 BillionTotal Population Total Population

Global Population Growth Trends

6.6 Billion 8.2 Billion

(United Nations, 2005)

Urbanization trends and projections

Source: World Urbanization Prospects: the 2001 Revision. New York, United Nations, 2002.

0

500

1000

1500

2000

2500

3000

3500

4000

1950 1970 1990 2010 2030

Urb

an p

opulation, m

illions

More developed countries

Less developed countries

Urban and rural populations in less developed countries

Source: World Urbanization Prospects: the 2001 Revision. New York, United Nations, 2002.

0

500

1000

1500

2000

2500

3000

3500

4000

1950 1970 1990 2010 2030

Population, m

illions

Rural

Urban


� Urbanization

� Aging

� Climate Change

Global Age Friendly Cities

� "Today around 75% of all older people living in

the developed world are urban dwellers -

expected to increase to 80% in 2015.

� More spectacularly, in developing countries the

number of older people in cities will increase

from 56 million in 2000 to over 908 million in

2050."

Dr Alexandre Kalache, Former Director of the WHO Ageing

and Life Course Programme


� Urbanization

� Aging

� Climate Change

Unsustainable global change: Temperature rise

Annual average, 2020s, 2050s and 2080s vs. 2007

2080s

2050s

UK Hadley

Res Centre

2020s

The climate change challenge for cities

Air pollutionlevels

Contaminationpathways

Transmissiondynamics

Natural ecosytems& Agriculture

HEALTH EFFECTS

Temperature-related

illness, death

Extreme weather-related health effects

Air pollution-relatedhealth effects

Water- and food bornediseases

Vector- and rodentborne diseases

Effects of food & watershortages

Effects of Populationdisplacement

Adaptationmeasures

Moderatinginfluences

GLOBALCLIMATE CHANGE

REGIONALWEATHERCHANGES:

- heatwaves

- extreme weather

- temperature

- precipitation

Climate and human health

Urban heat-island

Heat Island Group. Available at: http://geography.about.com/library/weekly/aa121500a.htm Accessed on October 24, 2005.

Heat wave mortality …. the heat island effectNew York City, 1966

Global Climate Change Model: Impact on New York City – Storm Surge

New York City: Storm Surge


� Urbanization

� Aging

� Climate Change

What do we mean by “urban health”?

The Components of Urban Health

�Social Determinants

� Inequity

�Metrics

�Governance

Viewed through the Urban LensUrban Lens

First Forum on Urban Health, Mexico City, 2008

The Urban Lens

� Size

� Density

� Diversity

� Complexity

Definition of an Urban Area (UA) U.S. Census

� Size: a minimum of

50,000 persons.

� Density: at least 1,000

persons/sq. mile

AIDS incidence rates by size of metropolitan

area1993-2000, U.S.

0

10

20

30

40

50

60

1993 1994 1995 1996 1997 1998 1999 2000

Year

Ave

rag

e i

nc

ide

nce

rate

pe

r 10

0,0

00

po

pu

lati

on

500,000 - 999,999

1,000,000 - 1,999,999

2,000,000 or more

Definition of an Urban Area (UA) Brazil

� The legal definition of urban in Brazil included, until 1988, the area (and population) within a perimeter

around a municipal headquarter – cidades – and

municipal district headquarters – vilas.

� Therefore, NOT size and density, but rather defined as political administrative units.

The Urban Lens

� Size

� Density

� Diversity

� Complexity

Non-white population, by population size of urban area, England and Wales

Source: Denham C, White I. Differences in urban and rural Britain. Population Trends.

1998; Office for National Statistics.

0

3

6

9

12

15

<2,000 2,000-4,999 5,000-9,999 10,000-

19,999

20,000-

49,999

50,000-

99,999

100,000-

199,999

200,000-

499,999

500,000-

999,999

1,000,000+

Population size (residents) of urban area

% of resident population

in non-w

hite gro

ups

Queens, New York City (n = 2,229,379) :

138 Languages Spoken, top 10:

� English (vast majority)

� Spanish

� Chinese

� Korean

� Italian

� Greek

� Russian

� Tagalog (Filipino)

� French

� French Creole

The Urban Lens

� Size

� Density

� Diversity

� Complexity

Organizational Chart , Saanich, British Columbia, Canada (n=108,000)

Organization Chart: New York City

(n= 8,274,527)

The Urban Lens

� Size

� Density

� Diversity

� Complexity

Components of Urban Health

� Social Determinants

� Inequity

� Metrics

� Governance

WHO Commission on the Social Determinants of Health, 2008

The main social causes of ill health include:

• Poverty

• Social exclusion

• Poor housing and

• Poor health systems.

WHO Knowledge Network for Urban Settlementsfrom “Our Cities, Our Health, Our Future” - 2008



� Inequity

� Metrics

� Governance

Urban Neighborhood Characteristics

that define

Areas of Concentrated Disadvantage

Median household income, New York City

Average educational attainment, NYC, 2000

Unemployment, New York City

Occupied housing units with mice or rats, NYC

Urban Areas

of Concentrated Disadvantage:

Health Outcomes

Births to teenagers, NYC, 2000

Homicide rate, NYC, 2000

Poor health and lifestyles by area deprivation, Amsterdam

Note: least deprivation as referent; models also adjusted for age and gender..Source: Reijnevald SA. The impact of individual and area characteristics on urban socioeconomic differences in health and smoking. Int J Epidemiol. 1998; 27: 33-40.

0 .5

1 .0

1 .5

2 .0

2 .5

Odds Ratio

I n te rm e d ia ted e p r iv a t io n

M o s td e p r iv a t io n

Poor self-ratedhealth

5 or more physical

complaints

1 or morelong-termphysicallimitations

Obesity(BMI > 27)

Cigarettesmoking

Poverty Health

Where we are

Downstream approach

Upstream approach



� Inequity

� Metrics

� Governance

Urban Health Observatories

UN HABITAT: GLOBAL URBAN OBSERVATORY (n=164 cities)

MISSION:

� To improve the collection, management, analysis and use of information in formulating more effective urban policies;

� To improve information flows between all levels for better urban decision-

making;

� To stimulate broad-based consultative processes to help identify and

integrate urban information needs;

� To provide information and analyses to all stakeholders for more effective participation in urban decision-making;

� To share information, knowledge and expertise using modern information

and communication technology (ICT);

� To create a global network of local, national and regional platforms for

sharing information about the implementation of the Habitat Agenda and

Agenda 2.

UN HABITATGUO: Indicators

Sanitary District

Health Basic Unit Catchment area

Census Tract

Slums: Vilas/favelas

Green area

TERRITORIAL DIMENSIONS FOR PLANNING AND INTERVENTIONS ON HEALTH IN BELO HORIZONTE

Index of Health Vulnerability (IQVU)

• % household without water

• % household without sewage

• % household no garbage collected

• % of provisional household

• % household density

• % illiteracy and <4 y.o. school

• % household <2 minimum wage

• % head of the family 10-19 y.o.

• Cardiovasc death rates (30-59 y.o.)

• Proportional mortality < 70 y.o.

• Infant/child mortality

Metrics

Human Development Index (1990)

� Life expectancy

� Knowledge (schooling)

� Income (GDPpc)

Gender Related Development Index

Human Poverty Index

Human Development Index: New York City

Source: The Global North and South in New York City: In the Shadow of the UN. Forthcoming study by the Women of Color Policy Network, Wagner School of Public Service, New York University, 2008

Demographic and Health Surveys (DHS)Infant mortality rate (per 1,000 live births) for the combined Africa, Asia, and Latin America

� 86 for rural areas,

� 75 for the urban poor

� 56 for the urban non-poor.

Metrics: Urban Advantage vs. Penalty

Intra-urban analyses:

Multi-level modeling Community Level Factors for Low Birth Weight (LBW)

Individual Level Factors: Income, Race, Maternal Health Condition

Structural Factors: SES composition, Race,

Population Density, Residential Stability

Social Resources (Capital): Social Ties and Engagement

(Reciprocal exchange, Voluntary Associations)

Sources of Stress and Disorder : Violent crime

(Morenoff 2003)

Results: Community Level Factors for Low Birth Weight (cont’d)

LBW = Individual poverty (income), race, maternal health condition,

Structural factors: neighborhood residential stability

Mediated by: Social Stress: violent crimeSocial Resources: combined reciprocal exchange and participation in voluntary associations.

Inference: Violent crime affects women with weak social ties;Without social capital, stress of violent crimes isolates pregnant women affecting nutrition, contributing to low birth weight children.

(Morenoff 2003)

Ecometrics

Science of measurement of neighborhoodsshould capture unique features of urban landscape:

� Per capita ratio of public space (e.g., parks, playgrounds,

pedestrian zones, amenities and entertainment,

local services, public transportation).

� Size and conditions of buildings and streets.

� Neighborhood disorder (e.g. graffiti, vandalism, noise,

density of liquor stores, abandoned buildings).

We have validated scales of perception of disorder, but few measures of environmental disorder

(Raudenbush and Sampson, 1999)

“Broken Windows”

“Broken Windows” and Gonorrhea Rates

Cohen et al, 2000

0.50

0.70

0.90

1.10

1.30

1.50

1.70

1.90

2.10

2.30

2.50

% buildings dilapidated % buildings

deteriorating

% external wall

problems

% window problems % stairway problems

Odds Ratio

External environment and depression, New York City neighborhoods

Note: model adjusted for neighborhood income, individual income and income squared, age, race, and sex

0.50

0.70

0.90

1.10

1.30

1.50

1.70

1.90

2.10

2.30

2.50

% toilet

breakdown

% non-functioning

kitchen

% 4+ heat

breakdowns

% needed more

heating

% large area

peeling

plaster/paint

% water leakage

Odds Ratio

Internal environment and depression,New York City neighborhoods

Note: model adjusted for neighborhood income, individual income and income squared, age, race, and sex



� Inequity

� Metrics

� Governance

Governance

Governance Government

“Steering” “Driving”

“Power to” “Power over”

Worldwide Governance Indicators: (World Bank)

• voice and accountability,

• political stability and lack of violence,

• government effectiveness,

• regulatory quality,

• rule of law,

• control of corruption.

Approaches to Addressing Urban Health Problems: Examples

Conditional Cash Transfer(incentives to individuals)

Participatory Budgeting (building community)

Urban Design

Belo Horizonte

Challenge for Urban Health: Outreach into Favella

BH Master Plan

BH Citizen

and Social

Inclusion

Program

Specific

Global Plan

for Vilas and

Favelas

Participatory

Budgeting

Sectorial Directions

Program of the Pampulha

Basin Recovery

The Master Drainage

Plan

Municipal Sanitation

Plan

PARTICIPATORY BUDGETING: INTERSECTORAL PROCESS

Participatory Budgeting

� Municipal Intersectoral Council - coordinate the priorities

� Regions (9) –Assemblies collect & pre-select range of projects� Includes voted delegates for Planning Units

� Inspection of project demands identified by assemblies

� Caravan of Priorities (Delegates visit worksites)

� Final selection of projects in Regional Forum

� Election of Follow-up and Control Commission – COMFORÇA at

Regional Forum

� Municipal Meeting of Budget Priorities

� Planning units - 81 homogeneous areas sorted on IQVU. Citizens make

application for specific projects funds that fit the criteria of the region (weighted

toward the most disadvantaged) and elect Planning Unit delegates in the assemblies.

PARTICIPATORY BUDGETING: Step 1. Municipal & Regional

Sanitary District

Health Basic Unit Catchment area

Census Tract

Slums: Vilas/favelas

Green area

TERRITORIAL DIMENSIONS FOR PLANNING AND INTERVENTIONS ON HEALTH IN BELO HORIZONTE

Index of Health Vulnerability (IQVU)

• % household without water

• % household without sewage

• % household no garbage collected

• % of provisional household

• % household density

• % illiteracy and <4 yo school

• % household <2 minimum wage

• Cardiovasc death rates (30-59 yo)

• Proportional mortality < 70 yo

• Infant/child mortality

• % head of the family 10-19 yo



� Regional PB (9 regions) – Includes voted Delegates from Planning Units

� Regional Assemblies collect and pre-select range of projects

� Inspection of project demands identified by assemblies

� Caravan of Priorities (Delegates visit worksites)


� Elections at Follow-up and Control Commission –

COMFORÇA at Regional Forum


� Planning units - 81 homogeneous areas based on IQVU.

� Citizens in Planning Units make application for specific projects funds that fit the criteria of the region (weighted toward the most disadvantaged) and elect Planning Unit delegates in the assemblies.

PARTICIPATORY BUDGETING: Step 2. Citizen Application



� Regional (9 regions) – Includes voted Delegates from Planning Units

� Regional Assemblies collect and pre-select range of projects

� Inspection of applications for projects

� Caravan of Priorities (Delegates visit worksites).


� Elections at Follow-up and Control Commission –

COMFORÇA at Regional Forum


� Planning units - 81 homogeneous areas based on IQVU. Citizens make application

for specific projects funds that fit the criteria of the region (weighted toward the most

disadvantaged) and elect Planning Unit delegates in the assemblies.

PARTICIPATORY BUDGETING: Step 3. Process and Vote

PARTICIPATORY BUDGETING: RESULTS IN BELO HORIZONTE

Type of Project N %

Infrastructure 494 41.7

Development of vilas 308 26.0

Health Centers 123 10.4

HC 38

Education 118 10.0

Schools 33

Social 39 3.3

Sports 47 4.0

Housing 16 1.4

Culture 19 1.6

Environment 20 1.7

TOTAL 1,184 100.0

Progress of Projects

1,184 projects completed

6,068 housing units approved

2,183 housing units completed

Participation

372,785 participants 1994 - 2007

503,266 votes in Digital PB

Source: SMAPL- PBH

Participatory Budgeting: from Strip Mine to Physical Academy

PARTICIPATORY BUDGETING: EFFECTS ON URBAN HEALTH

Outcomes: ecological association with:

• Reduced infant mortality rates in Porto Alegre (Goldani et al,2002)

• Reduced Under 5 y.o. MR from 80 to 25 per 1,000 (BH)

• Higher standard of living

• Longer life expectancy (WHO, 2007; Menegat, 1998)

PARTICIPATORY BUDGETING: EFFECTS ON URBAN HEALTH

Theoretical advantages at several levels:

Addressing of social determinants of health:

- provision of utilities and upgrades in housing.

- allocation of space for cultural and recreational pursuits.

- addressing health needs for the most disadvantage.

Demonstrate community capacity and feasibility to

International NGOs for scale up funds.

� Governance innovations and development interventions are not always articulated in terms of effects on public-health outcomes.

� Lack of adequate data sources to monitor changes in specific health outcomes over time. Effects examined using publicly available “gross” indicators (e.g., Life Expectancy, IMR).

� Ecological Fallacy: For some cities, changes in life expectancy or infant mortality may be ascertained, but it is not always obvious how these relate to specific interventions or programs.

LIMITATIONS FROM MODELS OF URBAN HEALTH PROGRAMS

� Lack of rigorous health specific quantitative data to evaluate he effectiveness of the models and applications of participatory budgeting. Data available are generally on distal (to health) outcomes, such as percent of budget allocated to certain sectors or projects as well as service provision or infrastructure generated (such as number of households with access to water and sanitation services, or number of health centers built).

� Few intra-urban comparisons available for program implementation and health indicators directly (morbidity and mortality) or indirectly (participation, satisfaction with participation, social capital).

� Qualitative Evaluations: Necessity of more cases reports that go beyond description of a single initiative; rather, efforts should be directed at comparing pre- versus post-implementation, between program and non program areas.

LIMITATIONS FROM MODELS OF URBAN HEALTH PROGRAMS

Approaches to Addressing Urban Health Problems: Examples

Conditional Cash Transfer


Urban Design

SUMMARYComponents of Urban Health


� Inequity

� Metrics

� Governance

SUMMARYThe Urban Lens

� Size

� Density

� Diversity

� Complexity

International Society for Urban Health

http://www.isuh.org

The New Urbanism

� Public realm.

� Multifunctional urban places.

� Human scale architecture.

� Regional character.

� Mixed use shop/houses.

� Compact urban fabric.

� Cellular city structure.

� Balanced, integrated transportation.

� Controlled regional plan.

� Ecological & social sustainability.

The Portland City Repair Project

Overview of The City Repair Project

� The City Repair Project is an urban intervention to

revive an existing urban city layout with novel urban

features and amenities that help to create healthy

urban environments that foster healthy social

environments.

� Community organizing in urban neighborhoods has

the potential to reverse alienation and foster a sense

of responsibility that counteracts urban blight,

encouraging residents to take initiative against social

disorder and physical deterioration.

Semenza JC. Building healthy cities: a focus on interventions. In: Galea S, Vlahov D (Eds). Handbook of Urban Health: Populations, Methods, and Practice. Springer Science and Business Media, New York. 2005, 459-478.

1

Community outreach

2

Interested people

contact City Repair

3

Information meetings

4

Receive and review

RFPs

5

RFP

supportable?6

Encourage

continuation

7

Design process

8

Need BDS

Permit?

9

PDOT

approve?

10

Joint PDOT/BDS

process

11

Construction plan

development

12

Village building

convergence

13

Project completion

14

Evaluation and

documentation

Yes

Yes

YesNo No

No No

Methods. Flow-diagram A health promoting neighborhood intervention

Flow-diagram. A health promoting neighborhood intervention


Intersection Repair

� Intersection Repair, one of many projects of The

City Repair Project, aims to retrofit the urban

orthogonal grid to create public gathering

places for human interactions

� Two underlying ideas:

� Taking public participation into account in

neighborhood design is critical

� The importance of urban amenities and art to

improving the qualities of urbanity


Case study: Sunnyside Piazza

� In 2000, Sunnyside neighborhood in Portland,

OR was greatly affected by a large transient

population, social disorder, street litter, noise,

and parking violations.

� The neighborhood responded to these social

disruptions using The City Repair Project to

create a pedestrian-friendly public square.


Social outcomes of Sunnyside Piazza

� The neighborhood collaboration in the creation of Sunny-

side Piazza had a number of positive social outcomes:

� Working together helped neighbors build social capital.

� A public square was created where neighbors and by-

passers can interact to get to know each other.

� New social relationships and mutual cooperation

around collective problem solving.


Neighborhood outcomes

of Sunnyside Piazza

With the creation of Sunnyside Piazza a number of social disruptions within Sunnyside neighborhood decreased:

� Burglary

� Assault

� Vehicle theft

� Robbery

� Drug abuse and trafficking

� Traffic speed


SUMMARYComponents of Urban Health


� Inequity

� Metrics

� Governance

SUMMARYThe Urban Lens

� Size

� Density

� Diversity

� Complexity

International Society for Urban Health

http://www.isuh.org

Conceptual Framework for Urban Health

Building the Urban Health Advantage

A conceptual framework for urban health

IV.

Outcomes

Enduring structures: e.g., economic systems, religion, government, culture

Immigration, suburbanization, changes in the

role of

government, globalization

Government: Policies and

practices of all

levels

I. Major national and international

trends

II. Municipal level

determinants

III. Urban

characteristics

Health and

social services: Formal and

informal

Health outcomes

Non-health

outcomes

Markets: Food, housing, other

goods

Civil society:

Community organization, community

capacity, social movements

Public health intervention

and

research: Intentional

public health activities

Population:

Demographics, socioeconomic

status, ethnicity, employment

status, attitudes, behaviors

Physical

environment: Housing,

climate, density

Social

environment: Social networks, social support,

social capital

Freudenberg, Galea and Vlahov, 2005

Work ability (%) as a function of WBGT (degr.C) at

4 work intensities (Watts), acclimatized

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20 25 30 35 40

Temperature C

Wo

rk A

bil

ity % 500 Watts

400 Watts

300 Watts

200 Watts

The “HOTBODS” effect (High Occupational Temperature

Burden Of Disability Study)

The HOTBODS concept:High Occupational Temperature

Burden Of Disability Study

� Effects of high temperature and high humidity on daily life:

� If the temperature reaches 40 degrees and it is 80-90% humidity,

can these normal activities be sustained? :

� Work outdoors or indoors (poor countries generally do not have air conditioned factories or offices)

� Home handyman activities

� Home gardening

� Physical exercise, sports, commuting (walking, bicycling, etc)

� Children’s play

� Other normal activities at home or in the community

� More night time activities?

� Impact on Burden of Disability?

21 09 15h45 DAVID VLAHOV - epi2008.com.brepi2008.com.br/apresentacoes/MESA_REDONDA_21_09... ·...

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