Urban Health Symposium

Urban Health: State of the Science

By Carly Berke

On Thursday, December 6th, the Boston University School of Public Health (SPH), the Initiative on Cities, and the Yale Institute for Global Health co-hosted an Urban Health Symposium that examined the intersection of public health and urban development. Over 30 scholars from around the world participated in a series of six panels that discussed the implications that massive global urbanization has on public health. Some speakers discussed methods that are used to advance urban health scholarship, while others presented on case studies from cities where public health policy has been formulated. The day was full of thought-provoking and engaging discussion, and a number of key ideas emerged as trends to consider in the future of urban health.

The symposium commenced with a warm welcome from Sandro Galea, SPH Dean and Professor, and David Vlahov, the Associate Dean for Research at the Yale School of Nursing and a Professor of Epidemiology at the Yale School of Public Health.

“Having the occasion to bring together experts from all over the world about understanding cities and understanding how we can create healthier cities is really an intellectual high point for us,” said Galea, citing urban health as one of the four key research areas within the School of Public Health.

Vlahov highlighted the fact that more people are living in cities now than ever before – by 2030, two-thirds of the world’s population will live in an urban setting.

“The urban environment is a ubiquitous exposure for health,” said Vlahov. “Cities shape what we eat, what we drink, what we breathe, the level of noise we hear, the amount of exercise we get, our social networks, the safety of our neighborhoods, and many other exposures that are core to health. How we create health in urban contexts will do much to decide how healthy the global population will be.”

The panels varied in scope and discipline, with speakers covering a range of diverse topics, from approaches to urban health, to resources available, to specific case studies from cities around the world.

The final panel, entitled The Past, Present, and Future of Cities, was moderated by Katharine Lusk, the Executive Director of the IOC. The speakers covered topics including migration, city leadership for development, regional planning, and healthy and safe spaces.

Lusk opened the panel with a brief introduction to the IOC’s Menino Survey of Mayors, which interviews over 100 mayors across the U.S. each summer. The 2018 report will be published come January, but Lusk mentioned some prominent statistics from this past year’s Survey, including the fact that only 13% of mayors believe that their housing availability and affordability is well-matched to the needs of their residents, 70% of mayors support expansion of bike infrastructure, and 84% of mayors believe climate change is caused by human activities. Among other issues, an overwhelming majority of mayors are also extremely concerned with those living in poverty in their communities. 

The Menino Survey not only uncovers priorities and concerns of mayors in urban spaces across the country, but it also reveals gaps in knowledge, explained Lusk.

“[The Survey] is also a measure of misperceptions,” said Lusk. “It’s a measure of knowledge gaps and knowledge deficits.”

One problem which few mayors understood is the relationship between the built environment and discrimination and racism, that is, the difference between parks, neighborhoods, roads, and transit in white neighborhoods and neighborhoods of color. This discrepancy is one of the several indicators of a lack of health literacy in urban settings and an urgent need for public health scientists and researchers to establish concrete partnerships with policymakers.

She highlighted the “three legs to the stool” of a healthy, vibrant community, according to mayors with whom the IOC converses – physical infrastructure, economic infrastructure, and social infrastructure.

“[This panel] will focus on how we get levels of government working together, how we get government and community working together, and how collectively as allies in the public health community we can overcome some of the key challenges to implementation and impact,” finished Lusk.

The first to take the podium was Sabrina Hermosilla, a Research Scientist in the Global Mental Health Program at the Vagelos College of Physicians and Surgeons at Columbia University. Hermosilla spoke of the impact that both domestic and international migration have on urban development; with over three million migrants moving to cities each week, cities have become diverse centers of cross-cultural influence and transformation. Cities like Dubai and Brussels, for instance, are composed of an 83% and 62% foreign-born population, and these percentages continue to rise in other cities like them.

Hermosilla made note of the barriers currently facing migrants and how they can be turned around into opportunities, like lack of access to healthcare and other effective services, which must be linguistically and culturally accessible to migrant populations.

Lastly, Hermosilla provided a multisectoral example of progress being made using the Johannesburg Migrant Health Forum, a collection of NGOs, universities, and policymakers in Johannesburg, South Africa. The forum brings together scholars, professionals, and leaders from many disciplines to monitor migrant discrimination in the public sector, link community members with policymakers, and facilitate collaboration between service providers and migrant-oriented NGOs.

“Migrants are central to urban spaces,” said Hermosilla. “Migrant issues and challenges provide us a unique opportunity.”

Next to speak was Renée Boynton-Jarrett, an Associate Professor of Pediatrics at the Boston University School of Medicine. Her discussion focused primarily on making cities safe spaces to live and play for children, an age group that will constitute the majority of urban residents by 2030.

She compared and contrasted the development of public health and urban planning as fields of discipline; both emerged as reactions to similar issues, like ways to control disease and infection. But the two fields of work then developed parallel to each other, disconnected and unaligned.

“Some of the threats that rapid urbanization pose to population health exist because of this parallel evolution of fields that truly, if aligned and coordinated, could benefit to work toward the same goals,” said Boynton-Jarrett.

Historically, children have not been taken into serious consideration during urban planning and design, and they are often perceived as a nuisance rather than a beneficiary. The primary concern regarding children is strictly safety, which has inhibited the way children can engage with urban spaces. 

Additionally, disparity and poverty in urban areas disproportionately affect children during an integral developmental stage. Boynton-Jarrett also highlighted the fact that risk for illiteracy, malnutrition, early marriage and early pregnancy are higher for girls living in slums.

But Boynton-Jarrett is hopeful for the future of children’s public health in urban spaces. Child-friendly cities are considerations that are now entering discourse surrounding urban planning and public health, a trend particularly exemplified at Habitat III, the United Nations Conference on Housing and Sustainable Urban Development, which included a commitment for children in the decision making-process.

“There’s a renaissance around the importance and understanding of the impact of where you live, learn and play, the ecosystem wherein your health develops, has on your life course health outcomes, and it is motivating changes in our work,” she said.

Boynton-Jarrett concluded by urging her colleagues to consider the role and voice of children in urban planning and the ways in which both the built and social environment affect their wellbeing and development.

David Siscovick, a Senior Research Scientist at the New York Academy of Medicine and Professor Emeritus in Medicine and Epidemiology at the University of Washington, discussed his experience with the Regional Plan Association of metropolitan New York (RPA), an independent, nonprofit, nongovernmental planning agency for the tri-state area (New York, New Jersey, and Connecticut). Some of its services include researching and identifying major challenges to regions and offering potential solutions, sharing ideas and plans with policymakers, and advocating for implementation.

Siscovick became involved with the RPA when he moved to New York in 2014 and began engaging with urban planners, learning as much as he could about regional development after a lifetime in medicine.

From 1929 to 1996, the RPA drafted and published three Regional Plans for the tri-state area. The First Regional Plan was focused on automobiles, the Second Regional Plan, published in 1968, focused on suburbanization, and the Third Regional Plan, published in 1996, focused on transit-related challenges.

The turn of the millennium brought issues like climate change and income inequality to the forefront of public discourse, and, following the recession of 2008 and Hurricane Sandy in 2012,  the RPA began to consider launching a Fourth Regional Plan to address crumbling infrastructure, economic disparity, and vulnerability to natural disasters.

In 2012, the RPA outlined four goals for the Fourth Regional Plan:

-Create a dynamic, customer-oriented transportation system

-Rise to the challenge of climate change

-Make the region affordable for everyone

-Fix the institutions that are failing us

What these goals failed to encompass, however, was health or equity. But shortly thereafter, the RPA received a grant to write a paper on urban health in New York, the results of which revealed huge variations in public health between differing neighborhoods, counties, and even states. The white paper forced the RPA to address public health as a key issue in their Fourth Regional Plan, and they redesigned the plan under four guiding values: equity, prosperity, sustainability, and health.

“[This commitment] says a lot about the commitment of this organization – it’s not a health organization, it’s a planning organization committed to integrating health and equity into plans and into their assistance of government in making decisions with regard to investments,” Said Siscovick.

Agis Tsouros closed out the day with a motivating call to synthesize the science behind public health through partnerships and collaboration. With over thirty years of experience at the World Health Organization, Tsouros currently serves as an International Advisor on Healthy Policy and Strategy at the WHO, after previously serving as the Director of the Global Healthy Cities initiative.

Tsouros was tasked with developing a European Healthy Cities project in the beginning of his career, in 1988, when the concept of urban public health had not been explored in depth. Tsouros discovered very quickly that health policies were of major interest to city leaders – within one year, 200 cities had joined his healthy cities project, and the basis for the project quickly spread across the globe. 

In 1998, Tsouros, along with Michael Marmot, released an influential publication exploring the social determinants of health that offered policy advice for city leaders regarding public health strategy. Although millions of dollars have been poured into public health research since then, Tsouros claims that the evidence for change remains isolated in academia, circulating the public health sphere of influence but never reaching those with the power to implement policy.

“Today we are drowning in evidence, but still action is very limited,” said Tsouros.

As a result, Tsouros reiterated a theme that was expressed consistently throughout the day: that public health is an issue that transcends scientists and researchers and must be brought to the forefront of the political agenda. What’s necessary to advance public health policy is political statements that create legitimacy and commitment for action. The key to unlocking action and policy implementation are global partnerships that translate the science into digestible content for city leaders and policymakers and that connect advocates from all disciplines.

“Modern approaches to address public health require whole-of-government approaches. The public health sector alone can’t do it,” said Tsouros. “Our agenda of social determinants and the determinants of health is an agenda that should be discussed in political party platforms. This kind of information should shape policies.”

Overall, the symposium was a spectacular day of diverse, insightful, and impactful approaches to public health in cities. The issue was tackled from several different focal points – from education to incarceration, from the children to the elderly, from healthy foods to housing affordability, and everything in between. Several themes emerged across all of these issues, including the connection between the built environment and the social and economic environments, multidisciplinary approaches to solutions, and the importance of integrating public health research and results with legislative action and policy formation.

To see the full list of speakers at the event and watch a livestream recording of each panel, you can access the School of Public Health’s website here.