Over 70% of the population of the World Health Organisation (WHO) European Region live in towns and cities. Heavy traffic, pollution, noise and violence are among the factors that can make urban living unhealthy. People in towns and cities also experience increased rates of noncommunicable diseases – such as cardiovascular diseases, cancer and chronic obstructive respiratory diseases – associated with unhealthy diet, low physical activity, mental stress and living in disadvantaged neighbourhoods. And, as is now painfully evident, the close contact between people in urban areas makes cities hot spots for the rapid spread of infectious diseases, such as Covid-19. This disease is already hitting those earning low wages and in less secure jobs harder, deepening urban health inequity.
As Manuel Franco an epidemiologist at the University of Alcalá in Madrid, Spain, writes in SINC (Servicio de Información y Noticias Científicas), confinement due to the coronavirus crisis is magnifying inequality. The measures to control transmission affect different population sectors in different ways, often putting those who can least afford care at greatest risk of transmission and of dying from the virus.
“Health inequality is a growing problem in cities”, says Hanneke Kruize, Environmental Epidemiologist at the Dutch National Institute for Public Health and Environment (RIVM). “Despite a lot of research and policies in this area the differences in life expectancy between socio-economic groups do not decrease and may even increase”.
Tackling urban health equity requires cross-sectoral collaborations because the solutions do not lie only in the healthcare sector. They involve decisions made by local government departments (e.g., education, housing, social services) and urban planners on the investment in and the design of infrastructure projects that affect citizens’ health, such as medical centres, parks, transport routes and sports facilities.
According to Mathew White, an Environmental Psychologist at The European Centre for Environment & Human Health in the UK, health and wellbeing should be a goal that is built-in to all urban infrastructure projects. As part of the European BlueHealth project, he has been part of a large interdisciplinary, international team exploring the effects of exposure to blue spaces, which include fountains, rivers, canals and the coast, on health.
Data gathered from projects that improve access to blue spaces indicate that in addition to mitigating some of the effects of climate change, by reducing heat stress for example, they can encourage physical activity and improve social cohesion.
“We are finding that it is the poorest communities that benefit the most from exposure to blue spaces near their homes,” Mathew White says. “We would argue that investing in blue spaces can reduce health inequalities, while also potentially protecting fragile environments.”
Another project that has been exploring ways of making European cities more sustainable and healthier for all is INHERIT (INter-sectoral Health and Environment Research for InnovaTion). Among the outcomes of this project are fifteen ‘triple-win’ case studies that describe innovative approaches to improve health, increase health equity and have a positive impact on the environment.
“We are looking for solutions that can tackle more than one problem at once,” explains Kruize. For example, introducing initiatives such as ‘Meat Free Monday’ and ‘Green Gym’ (outdoor sessions involving practical activities such as planting trees and growing vegetables) into schools are encouraging children to have a healthy diet and do more physical exercise. They also aim to reduce health inequalities arising from unhealthy food choices associated to low-income groups.
As Kruize outlines, a combination of top-down high-level policy changes and bottom-up initiatives are required to see real improvements in urban health equity and environmental sustainability. The roles and responsibilities of citizens themselves, community groups and businesses should not be underestimated in the process. Companies will have to start expanding the perception of ‘value’ beyond its economic monetary meaning and develop business models that deliver sustainable social and environmental value. Citizens and community groups need to be brought into the decisions that affect their lives. Engaging with lower socio-economic groups is vital to ensure that the pro-environmental and healthy behavioural choices or measures are affordable and easy.
“We are starting to see promising behavioural changes in food consumption for example, but I am curious whether this is happening in the lower socio-economic status groups,” says Kruize.
The effects of implementing the sustainable practices identified in the INHERIT project more widely and on future generations remain to be investigated. But Kruize is optimistic – as the health-related impacts of climate change become increasingly apparent, people are more aware of the need for climate adaptation measures and willing to take action.
The WHO-initiated European Healthy Cities movement has been working to reduce health inequalities for over 30 years, providing technical and strategic support to the efforts of their member cities and creating national networks for sharing best practice and innovations.
As the joint WHO and United Nations Human Settlements Programme (UN-HABITAT) global report points out, the price of failing to take action is too high. Further urban health inequity will translate into even more avoidable suffering from infectious and other diseases and prevent cities from meeting multiple societal goals, in line with the UN Sustainable Development Goals (SDGs).