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Urban health

Global perspectives on urban health

21 April 2021
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11 min read

Our report explores how cities around the world are addressing health inequalities and shares their real-world solutions to pressing urban health issues.

Overview

Cities sit at the centre of modern life. They act as engines driving society, and their ability to generate wealth and opportunity shapes our health.  Furthermore, they have the potential and resources to provide positive benefits to people of all ages. For example, access to education, jobs, health services, supportive communities and transport. However, not all city residents experience or can access these benefits equally. Many positive attributes of cities mask the inequalities that exist within them.

Living in urban areas, like inner-city London, carries distinct health challenges. Many of these start early in life and are influenced by the wider determinants of health and wellbeing. For example, if you live in an inner-city area in the UK, you are more likely to have low-paid employment or be unemployed, be exposed to high levels of air pollution and live with multiple long-term health conditions from an earlier age.

At Impact on Urban Health, when we speak about health equity in the context of cities – the places across the world where the greatest health inequities are found - we mean fair and equal access to the opportunities a city has to offer and protecting the city’s most disadvantaged residents from its harmful health impacts.

Urban health in cities across the world

These health inequalities are not unique to London. So we began to look at similar cities and neighbourhoods to ours around the world. We started by identifying comparable cities with a view to understanding what urban health equity (or lack thereof) looked like globally. Health challenges associated with density of population, overcrowded housing, poor air quality, social isolation, ethnic and cultural diversity, precarious employment and income inequality are present in the majority of urban communities. This shared context means we believe there is huge potential for cities across the world to learn from each other.

By focusing our attention on understanding health in urban areas, looking at what works and what creative ideas can be used to tackle what doesn’t, we gain valuable insight which can then be applied in other places. Moreover, by sharing our knowledge, expertise and vision with others, nationally and internationally, we can begin to remove the barriers to achieving health equity.

Together, we can build an understanding of the barriers to living healthier lives and how to collectively remove them, reducing health inequalities. Of course, what is most important is that health equity cannot be achieved by one organisation or sector alone. Solutions must be multifaceted. Though improved health may be the end goal, they do not always need to start with healthcare.

Our Chief Executive, Kieron Boyle, comments: “This report explores how cities around the world are addressing health inequalities. It finds real-world solutions in how they are shaping the built environment, devolving power, building cross-sector collaborations, centring the voice of urban communities, using new data and technologies, and tackling systemic issues of racial and economic segregation. Through these examples, we can see a clear picture of how to unlock the potential for cities to be healthier.”

We need to take a broad view of what drives all our health. We need to work in wide partnerships that bring a range of perspectives. And, crucially, we need to ensure that the process of building health equity is equitable itself. These global insights are shaping our own work. We hope they are of interest to yours too.

Kieron Boyle
Kieron Boyle Chief Executive, Impact on Urban Health 

The methodology

The UN Habitat’s City Prosperity Initiative (CPI) is a composite index. It measures a city’s overall achievements in key areas, including prosperity, infrastructure development and quality of life. This was used to identify urban places across the globe with similar characteristics to London in the UK. For example, population density, diversity and income. So this provided a consistent and carefully constructed sample of cities and their characteristics.

To find cities around the world that might have comparable neighbourhoods to Lambeth and Southwark, Euclidean distance analysis1 was then applied to the UN’s open cities dataset. Based on this CPI data, cities were ranked for closest comparison to London, the boroughs of Lambeth and Southwark and the specific neighbourhoods Impact on Urban Health works in.

However, the CPI data did not allow us to compare and measure diversity and cultural mix at a global level. What is considered diversity in London and the UK, may not look the same elsewhere in the world.  Therefore, we focused on ethnic and cultural diversity and proxies that looked at the percentage of foreign-born populations and number of non-native languages spoken.2

Footnotes:

1 Generally, distance metrics is used in both supervised and unsupervised machine learning to calculate the similarity between data points. Euclidean Distance represents the shortest distance between two points.

2 We looked at the differences between migrant and indigenous populations. In the case of countries like America and Australia, this was the difference between the migrant white-European populations (ethnic majority) and the migrant and indigenous non-white populations (ethnic minorities).

The cities and approaches we explored

This data analysis gave us a list of ten cities from across the world, each undertaking interesting urban health initiatives. Some were close comparators to London, others specifically to our home in Lambeth and Southwark. Though not an exhaustive list, we identified initiatives designed to have a positive impact on urban health in each city.

Click on the cities below to explore how they approach urban health.

Building on our findings

Overall, three consistent themes emerged as we explored each city:

1. Urban health is about far more than healthcare

Complex health issues rarely have a single cause. Often, these are driven by many interconnected factors. Through different cultural and political contexts, we’ve explored the commonalities between health and the places people grow up, live and work. This has helped deepen our understanding of what drives positive health outcomes for all. Shaping our cities to improve urban health requires a collective effort. This goes much wider than the healthcare system, clinical interventions and public health authorities. And it includes urban planners, civic institutions, investors, employers and residents.

Our commitment: a dedicated taskforce

In 2021, we are creating an urban health taskforce. This two-year project will convene a broad spectrum of voices from urban communities, academia, business, statutory and third sector organisations. Thus driving the urban health debate in the UK. The taskforce will focus on evidence gathering and consultation to establish the key challenges around urban health and to develop recommendations that can be implemented to improve health in our cities. We will use this platform to help to raise the profile of urban health in the UK and to influence key thinkers working in this space.

An important evolution has been things we did not consider to be part of urban health - the design of our cities, spatial justice, community bonds - all end up fitting into urban health. A city or neighbourhood that looks healthy would be one that that knows not only the very visible and palpable factors that are influencing health - such as air quality - but also the social factors, such as loneliness, which have a huge impact on health.

Gabriella Gomez-Mont Laboratorio Para la Ciudad, Mexico City

2. Tackling health inequalities will depend on cross-sector collaboration and collective responsibility

Whilst collaborative working is happening in many places it is seldom cross-sector. We need to look at how to encourage and incentivise different sectors to recognise their own influence on health and measure the health impacts of their work. This is particularly important now as we see the impact COVID-19 has had on economies all over the world.

The most impactful collective health initiatives connect local community leaders with decision makers, all of whom need to be willing to commit time to building trusted relationships and to be open to experimenting with new ways of working together.  For example, in Detroit, the Michigan Health Endowment Fund recognises that many parts of the system are doing great work. However, poor communication can lead to duplication and unhelpful competition. Therefore, the Fund takes a whole-system view, producing a services map which they analyse for gaps. Then, once identified, it seeks out grant partners who can fill those gaps, usually drawn from the community level. Also, it is beginning to bring together leaders from different sectors to leverage the work each are doing and address urban health issues, such as food insecurity, at a systemic level.

Our commitment: sharing what we learn

The COVID-19 pandemic has taught us now, more than ever, that we live in a globally connected community; that there is much we can learn and achieve by working together.

Truly understanding what works in improving health in inner cities is key to achieving impact. For instance, learning rooted in practice is our contribution to the growing body of evidence around urban health. We’re committed to sharing what we learn about what works and what doesn’t with other global cities.

We’ll continue to work with decision makers, community leaders, businesses, investors, and others to build health equity. We’ll do this here in the UK, and internationally – to build on this research and take practical action.

We’ll also continue to work with organisations and people from all sectors, from community groups to large commercial enterprises. Our collaborations with anchor organisations allow us to research issues, develop new methods, test ideas on the ground, share knowledge and evaluate the effectiveness of projects. We will continue to support anchor organisations in Lambeth and Southwark, working with them to test solutions to some of the biggest urban health challenges we face.

We don’t all know everything, but we’ve collectively developed insights that none of us could have done without the others. Knowing you’re speaking the same language and are moving in the same direction is sometimes I think more important than having rigid roles.

Anna-Maria Volkmann UCL Research Lead, Cities Changing Diabetes, Shanghai and Mexico City

3. The process of building health equity must be equitable

We can only achieve health equity through an equitable process that invests time, rebalances power and builds trust. This is critical in ensuring that a genuinely collective voice advocates for better health. Taking the time to fully understand the experiences of people living and working in cities, will keep the process of engagement, involvement and delivering action centred on the perspectives of urban communities.

We believe that community organisations can play a pivotal role in driving positive change in health. They can act as anchor organisations, offering stability and a trusted reference point for community knowledge. Our research also showed that they were best placed to build personal and collective resilience in neighbourhoods, offering trusted support for residents most at risk from poor health outcomes. But they are also flexible and willing to adapt, exploring opportunities to support communities to grow and thrive in response to changing needs.  One example of this is the way Queens Community House in New York City improved local people’s access to fresh, nutritious produce by establishing a farmers’ market with and for the community.

Our commitment: Strengthening our approach to community research and engagement

We recognise that for too long, communities experiencing the negative consequences of inequality have been the subjects of research programmes. Conversely, as demonstrated by numerous examples in this report, improvements in health which have been driven from the ground up rely on communities instead becoming partners in the design and implementation of research and active agents in developing solutions.

Therefore, Impact on Urban Health has invested in developing a Community Research approach, with our strategic partner, The Social Innovation Partnership, built upon principles of community leadership and co-ownership. It ensures that people who are living in a place and are experiencing the challenges that organisations are trying to solve are more involved in local research, and the projects and interventions that come out of that research. As a result, the Community Research team leverage their knowledge, awareness and relationships in communities in Lambeth and Southwark to deliver nuanced insight that would be inaccessible through traditional research methods.

Conclusion

We believe cities around the world can and must learn from each other if we are to achieve health equity in urban areas. Therefore, we need to rethink approaches to health. In particular, these should consider the reality of people’s lives in order to drive positive change to health in cities; to think differently, try new things and bring others with us on the journey.

Significantly, it is important that we ask questions and build relationships. This will allow us to understand the day-to-day experience of living and working in a city, rather than focusing our efforts via existing structures and professional specialisms. Additionally, listening, collaborating and adapting will give us all the best chance of tackling health inequalities.

Our overall commitment

We are committed to playing our part. With individuals and organisations across the world, we want to continue to learn from other cities and share what we discover to inform urban health approaches across the UK and globally.  Likewise, much like other organisations we have the potential to galvanise different sectors within our own nation and, internationally, to work towards our goal of urban health equity. Especially, we believe that reshaping cities so they are healthier places for everyone is not just about improving urban health, but a critical route to improving global health.

Cities themselves are fantastic assets for progress. The most successful cities are the ones that can absorb people from different backgrounds and give them a leg up in life. That’s the greatest asset - that a city provides access to education, jobs and health services, within clean streets with parks and trees, and deals with young people as well as old people.

Ricky Burdett Professor of Urban Studies, London School of Economics

Our latest research on how cities across the world are approaching health inequalities