Understanding the varied effects of urban environments on our health have arisen through centuries of observation and analysis. Various units of observation, when compiled spatially or linearly, have provided considerable understanding of the causal pathways between environmental exposures in cities and associated mortality and morbidity. With growing urban agglomerations and a digital age providing timely and standardized data, unique insights are being provided that further enhance the understanding of urban health. No longer is there a potential lack of urban data; over the 2010–2020 decade alone, the resolution and standardization of satellite and street imagery, for example, alongside methods of artificial intelligence such as self-supervision methods, have meant that technology and its capacity have surpassed the accuracy and resolution of many administrative data collections typically used for urban health research. From Bills of Mortality in 1665 to 20th century surveillance systems to the innovation and global reach in the period of “big data,” data has been the mainstay of decision support systems over the centuries. This new world of big data characterized by volume, velocity, variety, veracity, variability, volatility, and value is paramount to answering the significant urban health challenges of the 21st century.
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Big Data and Urban Health
Mark Stevenson, Jason Thompson, and Thanh Ho
Article
Burn-Related Injuries
Ashley van Niekerk
A burn occurs when cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissue due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns. Globally, burns have been in decline, but are still a major cause of injury, disability, death and disruption in some regions, with about 120,000 deaths and 9 million injuries estimated in 2017. Low-to-middle-income countries carry the bulk of this burden with the majority of all burn injuries occurring in the African and Southeast Asia regions. Thermal injuries are physically painful and may leave disabling scars not only to the skin or the body, but also impair psychological wellbeing. Severe injuries often impose significant psychological, but also educational consequences and social stigmatization, with the consequent adjustments exacerbated by a range of factors, including the circumstances of the burn incident, the severity and site of the injury, the qualities of the affected individual’s personality, and the access to supportive interpersonal and social relationships. The contributions of: economic progress, enhanced environmental and home structures, energy technology, and safety education interventions have been reported as significant for burn prevention. Similarly, legislative and policy frameworks that support access to modern energies such as electricity, govern domestic appliances and heating technology, and control storage and decanting of fossil fuels are important in energy impoverished settings. The recovery of burn survivors is affected by the availability of specialized treatment, physical rehabilitation and psychosocial support to burn victims and families, but which is still limited especially in resource constrained settings.
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Changing Open Defecation Behavior
Mark Radin
Open defecation (OD) remains a persistent problem in many low-income countries. The international community, through the Sustainable Development Goals (SDGs), has committed itself to eliminating OD by 2030. While access to and use of latrines has steadily increased, much is unknown on how to eliminate OD. The history of the elimination of OD in high-income countries offers potential lessons for achieving the sanitation targets of the SDGs. A desk review of sanitation literature revealed a well-documented effort to eliminate OD in the United States, which faced many of the same obstacles as those encountered in low-income countries in the 21st century. One of the important lessons is that eliminating OD takes sustained efforts over decades and substantial resources. The international efforts to eliminate OD have evolved through numerous phases within the global development agenda. To eliminate OD will require continued investment in new and ongoing programs, which are often led by national governments in partnership with international organizations, civil society, and the private sector. Many successful programs have utilized numerous approaches for eliminating OD as the barriers to sanitation use are different across societies and for each individual. Access to sanitation in institutions such as schools and health care facilities as well as public facilities remains a problem in both high- and low-income countries. Finally, the international community will need to deploy more resources and develop effective approaches for ensuring that latrine adoption and use is sustainable.
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Cities, Health, and Intersectorialities
Marco Akerman, Gabriela Murillo Sancho, and Samuel Jorge Moysés
Cities have been considered in many places and times a cornerstone of innovation and wealth creation in society, fostering the privilege of more comfortable lives, with existential dignity and producing healthier generations, as well as an important source of pathogenic determinants. The concept of health in cities and its intersectoral relationships unfolds in a new era of urban sociability, mediated by technologies that connect citizens in social networks and in many services provided by digital platforms. All changes have their respective economic and cost-effective impacts. Healthy cities, or smart and sustainable cities, intend to express well-being and the fulfillment of good health among people who enjoy social inclusion, effectively using policies and services concentrated in the most developed cities. However, the extent of the challenges that permeate the current urban civilization cycle is also related to the social inequities manifested in health problems and public mismanagement in cities around the world. It is necessary to think about the integration of the intersectoral habitus of conceptualizing health promotion, considering all its inclusive scope of diversity, without leaving any social and identity group out, with a view to the full realization of healthy cities. There is an ethical, political, and cultural imperative to urgently adopt an ecosocial approach to promoting the health of populations in cities around the world, recognizing the interactions between ecological determinants (all planetary systems and living species) and the very internal dispositions of what constitutes human health.
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Climate Change and Water-Related Diseases in the Mekong Delta Region
Nu Quy Linh Tran, Des Connell, Trung Hieu Nguyen, and Dung Phung
The Mekong Delta Region (MDR) in Vietnam, located at the downstream end of the Mekong River, is highly affected by climate change and extreme weather events, such as floods, droughts, soil erosion, and salinization. Due to the specific characteristics of climate, topography, river systems, and population, water-related diseases (WRDs) have been a disease burden in the Mekong Delta. This article aims to critically review the evidence of existing studies on the association between climatic conditions and WRDs in the MDR. Dengue was found to be most sensitive to the changes in ambient temperatures, humidity, and rainfall at a lag of 2 months. The climate-based prediction model was recommended for an early warning system to enhance dengue prevention. Diarrheal diseases are highly correlated with extreme weather events such as high temperatures and floods, but the evidence on the association between climatic conditions and cause-specific WRDs is limited and inconclusive. Despite the preliminary evidence for the development of climate change adaptation strategies in the MDR, studies on other WRDs (i.e., water-washed, water-scarce, and water-contaminated diseases) should be conducted. In addition, future studies should investigate the effects of interaction between climatic factors and sociodemographic, household, and individual factors in predicting climate-sensitive diseases. How to translate and integrate the scientific evidence to the policy and practices that protect the MDR residents from the elevated extreme weather events due to climate change should be warranted.
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Customer Assistance Programs and Affordability Issues in Water Supply and Sanitation
Joseph Cook
Concerns about water affordability have centered on access to networked services in low-income countries, but have grown in high-income countries as water, sewer, and stormwater tariffs, which fund replacement of aging infrastructure and management of demand, have risen. The political context includes a UN-recognized human right to water and a set of Sustainable Development Goals that explicitly reference affordable services in water, sanitation, and other sectors. Affordability has traditionally been measured as the ratio of combined water and sewer bills divided by total income or expenditures. Subjective decisions are then made about what constitutes an “affordable” ratio, and the fraction paying more than this is calculated. This measurement approach typically omits the coping costs associated with poor supply, notably the time costs of carrying water home. Three less commonly used approaches include calculating (a) the expenditure related to procuring a “lifeline” quantity of water as a percent of income or expenditures, (b) the amount of income left for other needs after water and sewer expenditures are subtracted, and (c) the number of hours of minimum wage work needed to purchase an essential quantity of water.
Lowering water rates for all customers does not necessarily help those in need in low- and middle-income countries. This includes tariff structures that subsidize the price of water in the lowest block or tier (i.e., lifeline blocks) for all customers, not just the poor. Affordability programs that do not operate through tariffs can be characterized by (a) how they are administered and funded, (b) how they target the poor, and (c) how they deliver subsidies to the poor. Common types of delivery mechanisms include subsidizing public taps for unconnected households, subsidizing or financing the fees associated with obtaining a connection to the piped network, and subsidizing monthly bills for poor households. Means-tested consumption subsidies are most common in industrialized countries, whereas subsidizing public taps and connection fees are more common in low- and middle-income countries.
A final challenge is directing subsidies to renters who are more likely to be poor and who do not have a direct relationship with a water utility because they pay for water through their landlord, either included as part of their rent or as a separate water payment. Based on data from the 2013 American Housing Survey, approximately 21% of all housing units in the United States are occupied by this type of “hard to reach” customer, although not all of them would be considered poor or eligible for an assistance program. This ratio is as high as 74% of all housing units in metropolitan areas like New York City. Because of data limitations, there are no similar estimates in low-income countries.
Instead of sector-by-sector affordability policies, governments might do better to think about the entire package of services a poor person has a perceived right to consume. Direct income support, calculated to cover a package of basic services, could then be delivered to the poor, preserving their autonomy to make spending decisions and preserving the appropriate signals about resource scarcity.
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Environmental Health Concerns From Unconventional Natural Gas Development
Irena Gorski and Brian S. Schwartz
Unconventional natural gas development (UNGD), which includes the processes of horizontal drilling and hydraulic fracturing to extract natural gas from unconventional reservoirs such as shale, has dramatically expanded since 2000. In parallel, concern over environmental and community impacts has increased along with the threats they pose for health. Shale gas reservoirs are present on all continents, but only a small proportion of global reserves has been extracted through 2016. Natural gas production from UNGD is highest in the United States in Pennsylvania, Texas, Louisiana, Oklahoma, and Arkansas. But unconventional production is also in practice elsewhere, including in eighteen other U.S. states, Canada, and China. Given the rapid development of the industry coupled with its likelihood of further growth and public concern about potential cumulative and long-term environmental and health impacts, it is important to review what is currently known about these topics.
The environmental impacts from UNGD include chemical, physical, and psychosocial hazards as well as more general community impacts. Chemical hazards commonly include detection of chemical odors; volatile organic compounds (including BTEX chemicals [benzene, toluene, ethylbenzene, and xylene], and several that have been implicated in endocrine disruption) in air, soil, and surface and groundwater; particulate matter, ozone, and oxides of nitrogen (NOx) in air; and inorganic compounds, including heavy metals, in soil and water, particularly near wastewater disposal sites. Physical hazards include noise, light, vibration, and ionizing radiation (including technologically enhanced naturally occurring radioactive materials [TENORMs] in air and water), which can affect health directly or through stress pathways. Psychosocial hazards can also operate through stress pathways and include exposure to increases in traffic accidents, heavy truck traffic, transient workforces, rapid industrialization of previously rural areas, increased crime rates, and changes in employment opportunities as well as land and home values. In addition, the deep-well injection of wastewater from UNGD has been associated with increased seismic activity.
These environmental and community impacts have generated considerable concern about potential health effects and corresponding political debate over whether UNGD should be promoted, regulated, or banned. For several years after the expansion of the industry, there were no well-designed, population-based studies that objectively measured UNGD activity or associated exposures in relation to health outcomes. This delay is inherent after the introduction of new industries, but hundreds of thousands of wells were drilled before any health studies were completed. By 2017, there were a number of important, peer-reviewed studies published in the scientific literature that raised concern about potential ongoing health impacts. These studies have reported associations between proximity to UNGD and pregnancy and birth outcomes; migraine headache, chronic rhinosinusitis, severe fatigue, and other symptoms; asthma exacerbations; and psychological and stress-related concerns. Beyond its direct health impacts, UNGD may be substantially contributing to climate change (due to fugitive emissions of methane, a powerful greenhouse gas), which has further health impacts. Certain health outcomes, such as cancer and neurodegenerative diseases, cannot yet be studied because insufficient time has passed in most regions since the expansion of UNGD to allow for latency considerations. With the potential for tens of thousands of additional wells across large geographic areas, these early health studies should give pause about whether and how UNGD should proceed. Citing health concerns, several U.S. states and nations in Europe have already decided to not allow UNGD.
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Environmental Health in Latin American Countries
Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss
The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions.
The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.
Article
The Evidence Base for Cognitive, Nutrition, and Other Benefits From Water, Sanitation, and Hygiene Interventions
Jennifer Orgill-Meyer
Cost-benefit analysis of WASH (water, sanitation, and hygiene) interventions have traditionally focused on two primary benefits: improved health outcomes, usually measured as reduced diarrheal disease incidence, and reduced time burdens from collecting water, treating water, or traveling to open defecation or shared sanitation sites. However, there are also many other important benefits of water, sanitation, and hygiene interventions for policymakers and researchers to consider, such as improved nutrition and decreased stunting, improved cognitive development and educational attainment, and quality-of-life improvements for women.
Reduced fecal exposure from improved WASH may decrease not only diarrheal disease incidence but also the risk of environmental enteropathy, a condition that reduces the nutritional absorptive capacity of the gut. Environmental enteropathy results in a range of outcomes associated with malnutrition, such as wasting, stunting, and anemia. A growing body of literature has explored the direct relationship between improved sanitation environments and stunting. There are mixed findings from these research studies, suggesting that intervention adherence and baseline sanitation conditions may be important to realizing any potential stunting benefits. The economics literature has documented a strong inverse relationship between childhood stunting and lifetime earnings.
Reduced absorptive capacity from environmental enteropathy may also hinder cognitive development in children. Recent research documents a strong relationship between improved sanitation environments and cognitive development in children, though some studies find no relationship. Beyond cognition, improved health from reduced fecal exposure may also affect a child’s ability to attend school, and research shows a relationship between WASH environments and school attendance and enrollment. Monetizing the benefits of improved schooling in a low-income country context is challenging due to high variation in school quality as well as high rates of self-employment.
Quality-of-life benefits for women are a third category of benefits that are often omitted from WASH cost–benefit analyses. Mostly qualitative research highlights that poor sanitation and water insecurity is associated with safety, security, privacy, and dignity concerns for women. While these concerns and experiences are difficult to quantify in many cases, they should not be ignored when considering WASH benefits.
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Impacts of Climate Change on Workers’ Health and Safety
Barry S. Levy and Cora Roelofs
Climate change has increased the risk to workers’ health and safety. Workers, especially those who work outdoors or in hot indoor environments, are at increased risk of heat stress and other heat-related disorders, occupational injuries, and reduced productivity at work. A variety of approaches have been developed to measure and assess workers’ occupational heat exposure and the risk of heat-related disorders. In addition, increased ambient temperature may increase workers’ exposure to hazardous chemicals and the adverse effects of chemicals on their health. Global warming will influence the distribution of weeds, insect pests, and pathogens, and will introduce new pests, all of which could change the types and amounts of pesticides used, thereby affecting the health of agricultural workers and others. Increased ambient temperatures may contribute to chronic kidney disease of unknown etiology among workers. Global warming is increasing ground-level ozone concentrations with adverse effects on outdoor workers and others. Extreme weather events related to climate change pose injury risks to rescue and recovery workers. Reducing the risks of work-related illnesses and injuries from climate change requires a three-pronged approach: (1) mitigating the production of greenhouse gases, the primary cause of climate change; (2) implementing adaptation measures to address the overall consequences of climate change; and (3) implementing improved measures for occupational health and safety.
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Public Health and the UN Sustainable Development Goals
Claire E. Brolan
The COVID-19 crisis—the most catastrophic international public health emergency since the Spanish influenza 100 years ago—provides impetus to review the significance of public and global health in the context of Sustainable Development Goal (SDG) achievement. When countries unanimously adopted the 17 SDGs in September 2015, stakeholders had mixed views on global health goal SDG 3 (Good Health and Well-Being). Concern arose over the feasibility of achieving SDG 3 by 2030 when countries pursued its nine targets and four means of implementation with sixteen other ambitious global goals. Nonetheless, health surely cuts across the SDG framework: for instance, the underlying health determinants are expressed in many goals as is urban and planetary health. Although health (and its different constructions) is central to overall SDG achievement, SDG success depends on a paradigm shift toward whole-of-government policy and planning. Indeed, the 2030 Agenda echoes calls for a Health in All Policies (HiAP) approach to public health programming. This depends on another paradigm shift in public health tertiary education, practitioner training, and policy skills development within and beyond ministries of health. Added to this are the underlying problematics around SDG health financing, human resources for health, health target and indicator localization for equitable country responses that leave no one behind, strengthening civil registration and vital statistics systems for inclusive and accountable health implementation, and the sidelining of human rights from SDG metrics. While COVID-19 has derailed SDG efforts, it could also be the ultimate game changer for intergenerational human and environmental health transformation. Yet strong global health governance and rights-based approaches remain key.
Article
Street Science: Community Knowledge for Global Health Equity
Jason Corburn
Street science is the processes used by community residents to understand, document, and take action to address the environmental health issues they are experiencing. Street science is an increasingly essential process in global urban health, as more and more people live in complex environments where physical and social inequalities create cumulative disease burdens. Street science builds on a long tradition of critical public health that values local knowledge, participatory action research, and community-driven science, sometimes referred to as “citizen science.” Street scientists often partner with professional scientists, but science from the street does not necessarily fit into professional models, variables or other standards of positivist data. Street science is not one method, but rather an approach where residents are equally expert as professional scientists, and together they co-produce evidence for action. In this way, street science challenges conventional notions in global health and urban planning, which tend to divorce technical issues from their social setting and discourage a plurality of participants from engaging in everything from problem setting to decision-making. Street science does not romanticize local or community knowledge as always more accurate or superior to other ways of knowing and doing, but it also recognizes that local knowledge acts as an oppositional discourse that gives voice to the often silent suffering of disadvantaged people. At its best, street science can offer a framework for a new urban health science that incorporates community knowledge and expertise to ensure our cities and communities promote what is already working, confront the inequities experienced by the poor and vulnerable, and use this evidence to transform the physical and social conditions where people live, learn, work, and play.
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Urban Guerrilla Gardening and Health
Alec Thornton
The benefits of gardening for mental and physical health are well known. Gardening is also recognized as a local-level or grassroots response to the negative effects of climate change and global warming. In urban areas, dense neighborhoods, limited green spaces, contaminated brownfield sites, and, at times, restrictive council regulations on the public use of parks and verges can act as barriers to gardening. In the 1970s, guerrilla gardening emerged as a clandestine, environmentally conscious, grassroots activity to reclaim and transform neglected or derelict urban spaces into healthy green spaces. Although not as subversive since its inception, guerrilla gardening in cities is as much a recreational activity as it is an ecological statement of urban activism, which effectively provides urban dwellers an entry point to engage with the outdoors for the planting of edible and nonedible plants in artificial places and spaces where natural life struggles to exist. Guerilla gardening has been impactful to city life through its contributions and controversies in improving urban ecosystems, educating neighbors on nutrition and food production where gardens crop up, and broadly to the health of humans (and other creatures) who live there.
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Urban Health in Latin America and the Caribbean
Luiz Galvão, Waleska Teixeira Caiaffa, Solimar Carnavalli Rocha, and Bernhard Liese
Urbanization can enhance the quality of life in cities and promote healthy living conditions. Unfortunately, according to the World Health Organization, 24% of urban populations live in unhealthy slums, making early intervention and public policies imperative. While urban areas have the advantage of access to essential services like transportation and healthcare, inadequate planning can lead to health issues.
Rural populations also face challenges accessing safe drinking water and sanitation, leading to unequal distribution of drinking-water quality. Climate change exacerbates these issues, resulting in conflicts, social and economic instability, and adverse environmental and public health effects. Additionally, population growth and improved water access have intensified wastewater treatment problems, and waste generation remains a significant issue in Latin America. Homeless communities in urban areas are particularly vulnerable to crises like COVID-19 and climate change. Access to healthcare is crucial for urban health, but half of the population lacks this access, leading to poverty due to healthcare expenses. Promoting social equity through healthcare access is vital.
The United Nations recognizes the devastating impact of COVID-19 and calls for a transformative approach to rebuild economies that prioritize social equity and environmental sustainability. Sustainable development policies can combat poverty, hunger, climate change, and environmental degradation. The Barcelona Institute for Global Health has developed a framework that connects healthy urban development to the sustainable development goals, emphasizing intersectoral work, health equity, and data quality. However, COVID-19 has severely affected the implementation of the 2030 Agenda.
Research in Brazil and Latin America reveals that economic segregation and inequality contribute to higher homicide rates and lower life expectancy. Effective urban policies can improve population health, and understanding the factors that impact elderly health can lead to better planning for active aging and reducing health disparities.
Successful approaches to research and addressing urban health issues involve interdisciplinary collaboration among academia, public and private sectors, and communities. Policies that impact health, with particular attention to the social, economic, and urban determinants of health in urban areas, are essential. The aim of the authors of this article, as public health researchers, is to identify targets for large-scale policy interventions in these areas.
The Belo Horizonte Observatory for Urban Health was founded in 2002 through a process led by the local university and health services to bring together academics and public sector services as part of a broader agenda to strengthen local and national health systems. This model could be a modern approach to Urban Health and play a central role in the current global health challenges.
Article
Water Safety Plans
Karen Setty and Giuliana Ferrero
Water safety plans (WSPs) represent a holistic risk assessment and management approach covering all steps in the water supply process from the catchment to the consumer. Since 2004, the World Health Organization (WHO) has formally recommended WSPs as a public health intervention to consistently ensure the safety of drinking water. These risk management programs apply to all water supplies in all countries, including small community supplies and large urban systems in both developed and developing settings. As of 2017, more than 90 countries had adopted various permutations of WSPs at different scales, ranging from limited-scale voluntary pilot programs to nationwide implementation mandated by legislative requirements. Tools to support WSP implementation include primary and supplemental manuals in multiple languages, training resources, assessment tools, and some country-specific guidelines and case studies.
Systems employing the WSP approach seek to incrementally improve water quality and security by reducing risks and increasing resilience over time. To maintain WSP effectiveness, water supply managers periodically update WSPs to integrate knowledge about prior, existing, and potential future risks. Effectively implemented WSPs may translate to positive health and other impacts. Impact evaluation has centered on a logic model developed by the Centers for Disease Control and Prevention (CDC) as well as WHO-refined indicators that compare water system performance to pre-WSP baseline conditions. Potential benefits of WSPs include improved cost efficiency, water quality, water conservation, regulatory compliance, operational performance, and disease reduction. Available research shows outcomes vary depending on site-specific context, and challenges remain in using WSPs to achieve lasting improvements in water safety. Future directions for WSP development include strengthening and sustaining capacity-building to achieve consistent application and quality, refining evaluation indicators to better reveal linked outcomes (including economic impacts), and incorporating social equity and climate change readiness.
