Frequently asked questions
1. There seems to be a large focus on cities in 2010 — from the World Expo “Better City, Better Life”, to the World Urban Forum in Rio, and the WHO World Health Day’s theme of “Urban Health Matters.” Now WHO and UN-HABITAT are launching this report, which focuses on urban health. Why is there so much emphasis on cities this year?
The sheer number and increasing proportion of people living in cities today means that urban health issues directly affect more than half of the world’s population, and virtually all population growth over the next 30 years will be in urban areas. Urban settings create particular health issues. For example, due to the close proximity of people living and working together, there are obvious implications for communicable diseases, and there are also more surprising issues such as the greater inequities in health within cities between the rich and poor. With the launch of this unique joint report, “Hidden cities: Unmasking and overcoming health inequities in urban settings,” the WHO and UN-HABITAT hopes to call greater attention to the need for concrete action to be taken in order to address these urgent health matters.
2. Why is this report called “Hidden cities?” / What are the “hidden cities?”
While urbanization has brought countries opportunity, prosperity and health, at the same time it has created large and unfair differences in the health status of different city dwellers. In Glasgow for instance, there is a 28 year gap in life expectancy between residents of different parts of the city. Very little is known about these health differences that exist within cities, and this report is an attempt to talk about the urban health inequities that have been largely hidden from view.
3. How have you managed to bring these “hidden cities” into view?
Available health information is usually aggregated to provide an average of all urban residents—rich and poor, young and old, men and women, migrants and long-term residents—rather than disaggregated by income, neighborhood or other population characteristics. As a result, the different worlds of city dwellers remain in the shadows, and the substantial health challenges of the disadvantaged go overlooked. Understanding urban health begins with knowing which city dwellers are affected by which health issues, and why. To that end, available information must be disaggregated according to defining characteristics of city dwellers, such as their socioeconomic status or places of residence, just as examples.
4. Why have you attached so much importance to the issue of “health inequities”?
Health inequities are the result of the circumstances in which people grow, live, work and age, and the health systems they can access. All of these things, in turn, are shaped by broader political, social and economic forces. They are not distributed randomly, but rather show a consistent pattern across the population, often by socioeconomic status or geographical location. Understood in this way, urban health inequities are systematic, socially produced (and therefore modifiable) and unfair.
5. Can you provide some examples of the types of urban health inequities to which you are referring?
Hidden cities illustrates that the urban poor suffer disproportionately from a wide range of diseases and health problems. Families with the lowest incomes in urban areas, for example, are most at risk for adverse health outcomes such as early childhood death, have less access to health services such as skilled birth attendance, and are also disadvantaged in terms of their living conditions, such as access to piped water. Disadvantage and disease also cluster within certain neighborhoods, and city dwellers’ odds of being healthy depend very much on their “place” within the city. Beyond socioeconomic status and neighborhood, some city dwellers have poor health outcomes because of the way societies marginalize and discriminate against them for aspects of their identity they cannot change, such as their age, sex, or disability. These are but a few broad examples and more details can be found in the report.
6. I’m not sure that those examples are relevant to my city…
No city—large or small, rich or poor, east or west, north or south—has been shown to be immune to the problem of health inequity. In fact, there are many urban-specific health issues that all cities around the globe share in common.
7. Is this report really about the health of the urban poor?
Although it is clear that the urban poor suffer disproportionately from a wide range of diseases and health problems, ultimately, urban health inequalities are detrimental to all city dwellers. This will vary from country to country, but even cities in developed countries have urban health issues such as life expectancy differences between socioeconomic groups in the same city, lack of access to medical services for certain groups, lack of access to physical activity facilities, lack of protection from air pollution, tobacco use etc. Similarly, disease outbreaks, social unrest, crime and violence are but a few ways that urban health inequities affect everyone. These threats can spread easily beyond a single neighborhood or district to endanger all citizens and taint a city’s reputation.
8. Urban health interventions should be targeted at which populations exactly?
The target population of an intervention must be considered carefully. Three main approaches are (a) targeting disadvantaged population groups or social classes; (b) narrowing the health gap, meaning focusing only on the best-off and worst-off urban residents, or the extremes of the social scale; and (c) reducing health inequities across the entire urban population, meaning focusing on all urban residents, including the middle class. Most agree that health equity can be achieved best through using the third approach: reducing inequities throughout entire urban populations, though caution must be exercised because interventions that have a positive influence on general population health might not reach vulnerable groups, thereby potentially increasing health inequities.
9. The report mentions MDG targets in relation to urban health. I thought those were national issues?
Urban health inequities threaten the achievement of many health-related Millennium Development Goal (MDG) targets by 2015. For example, more than 80% of low- and middle-income countries examined for Hidden cities will fail to meet MDG-related benchmarks for childhood stunting and childhood deaths among their urban poor if they continue at current rates of progress. This will undermine countries’ ability to meet national targets, and will prevent the realization of the international community’s vision of health and development for all.
10. So what are the main health threats that urban residents face?
In the Hidden cities report, reference is made to a triple-threat of urban diseases and health conditions that consists of: (a) infectious diseases such as HIV, tuberculosis, pneumonia and diarrhoeal infections; (b) noncommunicable diseases and conditions such as heart disease, cancers and diabetes; and (c) injuries (including road traffic accidents) and violence.
11. What should the first step be when attempting to reduce health inequity in urban settings?
The starting point would be to gain a clear picture of the health issues and their determinants in the city, and this can be done through the use of disaggregated data. Once information is assembled, it can be organized to identify the population subgroups and health issues that reveal the greatest urban health inequities. It also can be used to see how these issues are developing over time, or compare between cities. Data can be sourced from local or national levels, but in all cases it should meet high standards of reliability, transparency and completeness.
12. Who should be involved in setting policies to address urban health inequities?
Acting on urban health inequities requires involvement of organized communities and all levels of government—local, provincial and national. It is important to secure political commitment across a wide range of local leaders, developing a common vision for health and health equity, creating supportive institutional arrangements, and connecting with others who can support the work.
13. More specifically, what sectors should be involved in addressing urban health? Isn’t the health sector already equipped to deal with these issues?
The specific sectors for involvement will depend on the nature of the health inequity and the organizational arrangement of the government, but typically will include representatives from municipal government departments, national-level ministries, civil society and the private sector. Vertical partnerships among national, regional and local governments must be complemented by horizontal partnerships of stakeholders within cities. These can include, but are not limited to, transport, parks and recreation, education, environment, and agricultural sectors as well as the private sector and community groups. Solutions lie beyond the health sector and require the coordinated engagement of many different areas of government and society.
14. Are there any existing tools available to help local leaders address these urban health issues?
WHO’s Urban HEART (Urban Health Equity Assessment and Response Tool) is a simple and user friendly tool, and can be used by a wide range of people to assess and respond to urban health inequities. It promotes the use of already-available data, which are then disaggregated into socioeconomic groups, and geographical areas or neighbourhoods. Urban HEART considers health determinants and their interactions in multiple domains of urban life, and encourages policy responses and interventions that will be sustainable in the long term. Similarly, UN-HABITAT’s UrbanInfo is a software tool that helps users store, analyse and communicate results for an array of urban indicators, both global and user defined. It also helps users develop tables, graphs and maps, in multiple languages and with customized names, logos and graphics. Additional resources and tools are referenced in Hidden cities.