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The World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) has posed a provocative question for public health: “Why do we keep treating people for illnesses only to send them back to the conditions that created illness in the first place?”1 For the WHO Centre for Health Development (WHO Kobe Centre), hub of the Commission’s Knowledge Network on Urban Settings (KNUS), this represents a challenge to the public health sector not only to acknowledge the pervasiveness of urban poverty as a critical pathway to ill health and health inequities, but to address this as an urgent public health issue affecting a billion people living in informal settlements, or “slums.”1
People who live in informal settlements are often systematically excluded from opportunities, decent employment, security, capacity, and empowerment3 that would enable them to gain better control over their health and lives. As noted in the Interim Report by the Millennium Development Goals (MDG) Task Force, which focuses on improving the lives of urban slum dwellers:
Much of urban poverty is not because of distance from infrastructure and services but from exclusion. They are excluded from the attributes of urban life that remain a monopoly of a privileged minority—political voice, secure good-quality housing, safety and the rule of law, good education, health services, decent transport, adequate incomes, access to goods and services, credit—in short, the attributes of full citizenship.4
The issue of urban poverty is not new, but it is often narrowly viewed as an economic issue that is best addressed by economic policies and interventions. Urban poverty today, as driven by globalization and rapid uncontrolled urbanization, also needs to be recognized as a social, political, and cultural process that has profound impacts on public health. Exclusion of the urban poor from the benefits of urban life fosters discontent and political unrest. Within the broader context of health and human development, rapid urbanization of poverty and ill health have been characterized as a new human security threat.5
Rapid uncontrolled urbanization results from the interaction between global and local forces. The interconnectedness of cities through trade, business, industry, tourism, international travel, information technology, and media is reshaping social determinants of health that are manifest at the city level. On the other hand, local and national governance capacity in relation to health systems, housing, transport, property rights, migration, land use policy, working conditions, and employment may be unable to cope with the speed of change brought about by global economic restructuring. Inequity in cities that leads to urban poverty, and poor health, therefore, are also products of global and local forces in the urban setting. Public health can play an important role in ameliorating urban poverty through social processes (participation, social capital, social accountability, and social inclusion) that influence urban governance at multiple nodes6 of power. Addressing urban poverty as an urgent public health issue opens a policy space for fairer health opportunities and healthier and more equitable cities.
Today, for the first time in history, half of the world’s population lives in cities. The United Nations estimates that the number of urban residents will increase by more than two billion people by 2030, whereas the rural population will decline by about 20 million.7 Of the many risks to health that are linked to rapid urbanization, none is more compelling than the rise of urban poverty, manifested by the growth of informal settlements. Whereas rising urban poverty is evident in the developed world, this trend is more pronounced in developing countries.
UN-HABITAT states that the global urban slum population is expected to double from one billion (estimated in 2002) to nearly two billion by 2030 (from 32% to 41% of the world’s urban population), and to approximately three billion by 2050.8 Among the one billion people who live in informal settlements today, one-third of households are headed by women. Hundreds of millions of children and youth live and work in depraved conditions in urban areas.9 According to the latest Global Report on Human Settlements, 43% of the urban population in developing regions lives in slums. In the least developed countries, 78% are slum-dwellers.10 The scale and speed of this phenomenon pose serious and compelling risks and challenges to health—in sum, it is a crisis of unprecedented magnitude.
When disaggregated according to the regions of the World Health Organization, as depicted in Figure 1, the largest numbers of impoverished people living in poor conditions in urban settings are found in the Western Pacific Region (around 233 million), followed by the Southeast Asian Region (217 million) and the African Region (156 million).8 Whereas the Western Pacific Region has the highest number of urban slum dwellers, they represent a relatively lower one-third of the total urban population of approximately 700 million, on a par with the developing countries of the Americas Region.2 The rapid expansion of urban areas in South and East Asia is creating megacities of unprecedented size and complexity that present new challenges to providing a decent environment for the poor: the urban slums of the South-East Asia and Eastern Mediterranean Regions account for almost half of urban populations there. Worst affected is the (largely sub-Saharan) African Region, where two-thirds of its urban inhabitants live in informal settlements. It is also experiencing the world’s fastest rates of urbanization. Northern Africa is the only developing region where the quality of urban life is improving: here, the proportion of city dwellers living in slums has decreased by 0.15% annually.10
The urban setting in a globalized world is increasing exposure to unhealthy environments, disasters, climate change, violence and injuries, tobacco and other drugs, and epidemics including HIV-AIDS. Without access to adequate shelter, health care, and resources, the urban poor face the greatest threat. Given current demographic trends, the majority of all urban inhabitants in years to come will suffer disproportionate exposure to the triple burden of ill health: injuries, communicable diseases, and noncommunicable diseases.19
Over the past 12 months, the Knowledge Network on Urban Settings has worked with researchers, local communities, academia, development organizations, donors, and practitioners from local, national, regional, and global organizations to distill what is known about social determinants,3 health and health inequities in urban settings.
While KNUS research is ongoing, the following findings are of particular relevance to public health:
The need for intersectoral action and policy to address social determinants of health is not a new concept. The challenges and difficulties of mobilizing intersectoral support for policy and resources are known. In its review of 80 case studies, KNUS has discovered that “health” can unite individuals, communities, institutions, leaders, donors, and politicians from divergent sectors, even in complex and hostile contexts where structural determinants of health are deep and divisive. Some of the case studies are highlighted below.
Whether it is getting a local community to design a health plan for themselves (Dar es Salaam, Tanzania’s Healthy City Programme31), or enabling citizens to vote for priorities in local resource allocations for health (participatory budgeting in Porto Alegre, Brazil32), decreasing dengue incidence (Marikina Healthy Cities Programme, Philippines33), or involving the entire community in designing shared spaces that encourage walking and cycling (Healthy by Design, Victoria, Australia34), public health is an effective rallying point for achieving greater health equity in the urban setting.
While debate and discourse inevitably arise on methods, terminology, resources, and priorities for achieving better health, invoking health as a social goal and the imperative for “fairer health opportunities for all” has been a powerful lever for addressing social determinants of health in urban settings. The research and analysis also point to the critical importance of social processes in achieving more equitable health outcomes. Preliminary findings from the thematic papers of KNUS4 suggest that:
Primary health care and its emphasis on community action and social process in the urban setting is a key strategy in achieving better health equity for the urban poor.46 Sharpening the focus on social processes throughout the entire public health arena paves the way for scaling up interventions that work.
The case studies of KNUS describe a range of actions that contribute to strengthening and supporting the role of public health:
How can we do a better job of linking disadvantaged people living in cities to the human and financial resources, policies, programs, and actions that would enable them to gain control over their health and their lives? How can we mobilize the resources to enable this process to happen at a scale that will make a difference for the world’s urban poor? What is the link between social processes and urban governance?
Social capital, as part of social processes, is a critical means of changing power relations in cities. Public health can provide the “glue” to link, network, and bind the growing groups of poor and marginalized populations to nodes of power.
The urban setting is a social determinant of health in itself. Public health gains in disease prevention and control in our cities can easily unravel with the growth of physical and social environments of extreme deprivation. In an interconnected world, our cities can continue to be “engines of economic growth”48 and “centres of culture.”49 The question is whether public health can use the interconnectedness of cities as a positive pathway to enhancing equity in health between and among cities and nations.
1UN-HABITAT defines “slum” as: “A heavily populated urban area characterized by substandard housing and squalor”.2
2These numbers are based on country reports from UN-HABITAT in 2001, which were subsequently organized as WHO regional statistics.
3Former WHO Director-General Dr. J. W. Lee stated at the launch of the WHO Commission for Social Determinants of Health that social determinants of health are the conditions in which people live and work. They are the “causes behind the causes” of ill health. (http://www.medicalnewstoday.com/medicalnews.php?newsid=21561 accessed 21 February 2007).
4These papers have been abridged and are presented in this special supplement of the Journal of Urban Health.
Mercado is with the Urbanization and Healthy Equity Programme, WHO Kobe Centre, Kobe, Japan; Havemann and Sami are with the Health Governance Research, Urbanization and Healthy Equity Programme, WHO Kobe Centre, Kobe, Japan; Ueda is with the Knowledge Management, Urbanization and Healthy Equity Programme, WHO Kobe Centre, Kobe, Japan.