Introduction

There are opening questions that guide the structure of this article. It is assumed that they trigger a fertile debate that keeps the theme of intersectoral health in cities on the public policy agenda: What would a new generation of intersectorality be in the 21st century? What was done in the 20th century, and can it continue to be done in the 21st century? What is currently being done and should be stopped? What has not yet been done or is not currently being done, but would it be worth starting to do? This debate needs to be continued to produce consistent answers for societies that can benefit from translating scientific knowledge into everyday actions and services.

Post–Industrial Revolution, internet of things, artificial intelligence, algorithms, social networks, and techno-surveillance are all devices that express human urban way of life in some cities, mainly those from the Northern Hemisphere—the so-called cities 4.0 (Aldelaimi et al., 2020; D’Amico et al., 2020; Manimuthu et al., 2021). We are on the fringes of a new era of urban sociability mediated by technologies, with the respective economic and cost-benefit impacts. Healthy or smart and sustainable cities translate into the well-being of digitally included groups but with drastic impacts on the organization, structure, and epidemiological profiles of social clusters that reflect on health services (Puliafito et al., 2021).

Population health and equity in services and programs, however, have been noticeably absent from much of the policy agenda for smart and sustainable cities. Technology-mediated connections are vital to institutional health promotion and to remedy inequities. It is necessary to think about the integration of the intersectoral habitus of conceptualizing health promotion and healthy cities (Veenstra & Burnett, 2016), with the current interest in smart and sustainable cities (Febrer et al., 2021; Mouton et al., 2019).

Thus, all these new gadget assemblies are also used as cross-sector arrangements that involve a wide range of actors, interests, and motivations for social action, with economic, political, or cultural purposes. Not surprisingly, they can translate on social advances for the common good (Kamel Boulos et al., 2015). On the other hand, they also foster the exponentiation of panoptic on hypersurveillance (Dillard-Wright, 2019; Elmaghraby & Losavio, 2014; Guta et al., 2018; Hoven & Vermaas, 2007), being sometimes even prompted by authoritarian regimes, threatening citizen freedom, as well as providing powerful tools for social division, political hatred, conspiracy theories, and increasing inequities.

The alleged “smart” initiatives must go beyond city-level data to a higher-order understanding of cities as cross-border, multisectoral, multiscalar, socioecological-infrastructural systems with diverse actors, priorities, and solutions. There is a need to focus attention on the system-level decisions that society faces for transition toward a smart, sustainable, and healthy urban future (Ramaswami et al., 2016).

Crypto-capital and block chain, for example, are brand-new forms of economic and security infrastructure for the smart cities but also for financialization of the global market; they are still puzzling facets of these new human relationships that reconfigure the urban space of coexistence (Sabrina & Jang-Jaccard, 2021). Certainly, we are increasing the phenomenon of trans-humanity with the acceleration of technological devices that are increasingly incomprehensible to the scale of human information processing, comprehension, and sense of coherence (Chapman, 2010). This accentuates inequalities of generation, race, gender, and socioeconomic and health conditions. The new generations may be more adapted, but how many of the older generations are able to reframe these new worlds?

Cities and Health

Cities have been considered the main engine of innovation and wealth creation in society, producing healthier generations, although they are also an important source of pathogenic determinants. Living in cities should always mean a privilege—not by chance; accordingly, it is pursued by many who seek better living conditions, fleeing from the adversities of life in the countryside or in the hinterlands (Nieuwenhuijsen, 2016).

However, frequently, this demographic transition also implies further epidemiological, nutritional, and technological transitions that do not benefit most migrants. In large- and medium-sized cities around the world, mostly in the Global South, prevail inadequate living conditions, social exclusion, economic inequities, low coverage, or lack of access to public policies and quality services, among other problems. Thus, the city that could potentially be the setting for cultural, social, and intersubjective production becomes a deadly trap of misery, diseases, violence, and premature death, displaying intraurban differentials and distinct interurban gradients (Ferreira et al., 2010; Minuci & Almeida, 2009; Moyses et al., 2006). There is a need to reflect on the right to the city and its relationship with health in all policies (Lange, 2021).

Public health and urban planning should always be umbilically linked, given the intersectoral nature of both, especially in a new era (also geological) in which there are massive impacts of human action on the planet—the hallmark of the Anthropocene (Moyses & Soares, 2019). There is a well-evidenced forecast of emerging risks, challenges, and possibilities for the health of the world population in this new era, based on the urban structure that consumes nonrenewable energy and brings threatening climate impacts. Human activities have increasing impacts on the environment and a fundamental shift in the relationship between humans and earth systems, in many ways that exert both intentional and unintended influences on natural and social processes. The current paradigm of unlimited economic growth and exploitation of limited natural resources is unfair and unsustainable, leading to geopopulation and temporal inequities among generations, including the problem of the inverse care law, whereby people who need it most receive less and poorer-quality health care (Haines & Floss, 2021; Moyses et al., 2006; Tong et al., 2021).

This has been a constant concern of areas of teaching, research, and structuring agendas called “planetary health,” “global health,” or “one health” (Buse et al., 2018). Unfortunately, this premise is not met globally, except for programmatic interventions in sanitation policies in some places. The growing pace of urbanization committed to market interests, focused on the central objective of generating profits for building companies and real estate developers, and closely related to environmental damage, adds to increasing impacts on individual and collective health inequities.

It is no longer possible to romanticize rhetoric and “bet” on converting the interest of the global market; it is necessary to invest in strong mechanisms to confront such interests, such as the Sustainable Development Goals—SDGs (Labonte, 2016; Raphael, 2017; van de Pas, 2017). The United Nations’ 17 SDGs are important guides for development processes, notably in developing countries. For example, the role of globalization, democracy, and gross domestic product per capita was investigated in life expectancy in 16 low-income countries over the period from 1970 to 2017. All these indicators were positively associated with higher levels of life expectancy, with the inference that, to achieve a healthier society, it is necessary to advance in economic, social, and political integration between governments and societies (Guzel et al., 2021).

The current COVID-19 pandemic is a historic event that emphasizes the close association between health and the urban environment, but it is likely just a herald of other pandemics on the horizon (David et al., 2021). Public measures for the preparation of postpandemic scenarios should recursively make use of new evidence produced in the field of health in the cities, fostering decision-making centers on urban life and urban planning and public health reconnected in planning and decision-making decisions that affect us all (Gouveia & Kanai, 2020).

Research on health inequities has grown exponentially since 1960. In the meantime, the Dahlgren and Whitehead model of the leading determinants of health has received worldwide acclaim. However, it is important to understand what he does not do and what he never intended to do, as the conceptual debate is sometimes sidetracked by wrong assumptions (Dahlgren & Whitehead, 2021). What effects did they generate, and how were they translated to solve serious and everyday problems in the reality of peoples? Why is this field defined by siloed research groupings?

Criticisms include allegations that the field has failed to gain public and political clout. Researchers partially attribute these challenges to the fragmentation resulting from disciplinary and methodological differences. Apparently, no single factor clearly describes the observed fragmentation; health equity scholars exhibit a diverse disciplinary background, and geographic, institutional, and historical factors seem to intersect to explain patterns of isolation and loss of political power (Collyer & Smith, 2020).

There is a heated debate, under the Foucaultian concept of “governmentality,” that medicine and public health are being co-opted into a political population control program to protect power in some (ultra)neoliberal states (Horton, 2020). But then, if scientists want to make a difference, they should leave science for a moment and dare to do politics (Bambra et al., 2005; Horton, 2009; Lange, 2021; Mangione & Tykocinski, 2021). Public health evidence is never enough; more is needed to influence stakeholders and make them change. Science can identify solutions to pressing public health problems, but only policy can make most of these solutions a reality. Politics, more than analysis, determines policies (Chiolero, 2021).

To this end, urban agendas were developed to deal with the ambiguity of the modern city. Are healthy cities, sustainable cities, smart cities, and educating cities beneficial realities in the daily lives of millions of humans, or are they mere sympathetic rhetoric pervading part of the academic world—well intentioned and supported by research evidence, but not powerful enough to make positive contributions for the most vulnerable groups?

Advocates of these agendas strive to generate momentum, calling for social participation, intersectoriality, and “sense of belonging” to the territory as central to facing exclusion and inequities. Even so, such fundamentals need to be critically understood (Andrade & Franceschini, 2017). Little evidence is available, but it appears that practitioners of the health-in-all-policies approach introduce equity selectively and strategically (Hall & Jacobson, 2018). Looking forward in a long-term process, the path of social-environmental determinants of health is a new frontier in public health that offers ample opportunities for research, collaboration, and collective health benefits (Hahn, 2019).

Dilemmas of Intersectoriality

The singular noun “intersectoriality,” derived from the adjective “intersectoral,” is ordinarily conceived as a coordinated intervention of representative institutions of more than one social sector, in actions addressed, totally or partially, to face problems related to health, well-being, and quality of life (Cunill-Grau, 2014). Put into practice, intersectoral coordination is expressed in actions aimed at the gradual involvement of different actors in the decision-making process, aiming at the effective solution of problems, for which it is necessary to generate adequate spaces to share leadership, resources, strategic lines, opportunities, and joint planning (Oliveira & Guizardi, 2020; Panader-Torres et al., 2014).

The diverse character of the term “intersectoriality,” used in the plural form, has been stressed (Akerman et al., 2014). Inspired by the polysemy of the word, the authors highlight the need to build a research agenda that favors a theoretical framework for intersectoral action, not only as a public management experience but as a praxis of political action. There are no consensual theories and methods for its daily application; therefore, the context for intersectoral debate is opened.

Actions on the social determinants of health (SDHs) through the formulation of intersectoral policies have been recommended to promote health and health equity. However, the intersectoral policy-making process influences how SDHs are interpreted and implemented in municipal policymaking. The intention of intersectorality, by itself, already has the potential to integrate health into other sectors to ensure productive collaboration.

The intersectoral policy process, however, tends to favor smaller-scale interventions aimed at introducing healthier practices in various environments, for example, creating healthy school environments to increase physical activity or healthy eating. Contrariwise, more comprehensive interventions on the health impacts of broader welfare policies (e.g., education policy) tend to be neglected. Interventions do not address the most fundamental social determinants of health because they do not sufficiently consider the importance of understanding the role of civil society, community leaders, and territorial specificities, including health assets and community resources. Nor do they consider the potential that exists if they favor synergistic processes between networks within cities that contribute to health from environments, such as networks of schools, universities, and healthy organizations. Thus, cross-sectoral policymaking to address SDHs may translate into a limited approach to action on so-called intermediate determinants of health and as such may end up corrupting the broader SDHs, impeding overall success and long-term sustainability of intersectoral efforts (Holt et al., 2017).

Some examples from different countries help to illustrate how those responsible for the Health in All Policies strategy, as recommended by the World Health Organization and other international institutions, have been implemented and what results are obtained.

In Catalonia, the plan was drawn up by the Interdepartmental Health Commission (CIS, in its Catalan acronym) and is a collaboration between all the Departments of the Generalitat. The plan also receives contributions from 42 local, social, and scientific entities. It proposes 30 initiatives, defined by collaboration between public sectors, targeting the determinants of health and paying special attention to combating inequities and measuring impacts on health. Although it is only in its first year of implementation, many of its initiatives are already working and involving many health professionals in Catalonia (Mateu i Serra, 2015).

Until October 2021, the Brazilian Bolsa Família Program has been one of the largest conditional cash transfer programs in the world, providing cash transfers and intersectoral actions. In one of the experiences analyzed, families entitled to the Bolsa Família Program had worse living conditions in general and acquired greater access to health services, such as medical assistance, community health agents, and home visits. Whether or not they were entitled to the program affected the variability of the pattern of access to services by 31%. There was a proper focus on the program; the greater access to health services was related to the fulfillment of conditionalities to be entitled to the benefits of the program. However, it is warned that low access to intersectoral actions and social control with public governance can restrict the interruption of the intergenerational transmission cycle of poverty (Neves et al., 2021).

The dilemma of intersectoriality in public policies in Brazil and other countries reflects the curious situation of a discursive consensus but a practical dissent. The paradox crosses the need to choose between two contradictory and equally unsatisfactory solutions that permeate politics, in the relationship between health and society. Of course, modern conservative opponents of income redistribution have failed to claim that the poor are inferior beings. However, they spread the belief that redistribution of wealth (income) is totally unnecessary due to the market’s ability to allocate income fairly and efficiently among members of society. Furthermore, they argue that state-based redistributive policy is bad for society as well as low-income people who become dependent on welfare (Chernomas & Hudson, 2010; Medvedyuk et al., 2021).

In the medical professional sphere, for instance, what unfolds is, on the one hand, the contradictory project of preventive medicine (neofunctionalist, technical, scientific) and social medicine (neo-Marxist, at least reformist, and of confronting the health market). The Brazilian Health Reform movement created another alternative, which opened to a left-wing Marxist analysis of health, in which the concept of health/disease and the work process is rediscussed, instead of just dealing with the doctor/patient relationship. The social determination of the disease is discussed, and the notion of system structure is introduced.

Therefore, the construction of intersectoriality has also been a challenge. For example, in occupational health, although intersectorality is addressed, few clear propositions about the effectiveness of this practice between managers and workers underlying the field are observed (Lancman et al., 2020). It is also emphasized the lack of interest shown in how intersectoriality favors transformations, not only in the situation being addressed, but also in each public official and person or group of the community active in each sector that has the opportunity to incorporate the learning and broaden perspectives and the way they relate to each other.

To face these challenges, it is important to analyze the context from the political, organizational, and institutional point of view, to assess the implications and possible achievements of implementing intersectoriality; the characteristics of institutions and organizations must be considered as key actors in the intersectoral collaboration process. Managing intersectoriality necessarily implies planning and a political decision to achieve integration, as well as the identification of its different levels of execution according to the contexts and characteristics of the sectors to be integrated.

Intersectoriality is an input and a product of systemic networking. It is a form of management with multiple integrative, propelling, and resulting elements. Box 1 shows other strategies of healthy municipalities and cities that have been developed in Latin America as an example of intersectoral action to face problems related to health, well-being, and quality of life.

Environmental, Social, and [Corporate] Governance (ESG): Rhetoric or Reality

Intersectoriality has been presented as a rhetorical premise for the political definition of most accountable practices, based on social transparency and public governance. However, there is a gap between the intention to practice intersectoriality, witnessed by political decisions, and effective intersectoral action in everyday life.

The effect of environmental, social, and governance (ESG) scores on a company’s performance and financial value (or even the image value of a state-owned company) is already known, since a relational nexus with sustainable growth and socioenvironmental risk that an enterprise generates has been established. A negative relationship is particularly established for companies in environmentally sensitive sectors (Teng et al., 2021). Along these lines, it is important to reflect on how to strengthen intersectoral work capacities that lead to creating conditions for social well-being. Equity, for example, is reinforced through labor participation and the opening of opportunities for joint and continuous training to different identity groups, giving voice and respecting “places of speech” and “places of representation” to those who are politically invisible and socially vulnerable (low-ranking workers). For this, it is important to consider organizations and grassroots sectors in the possibility of working together in medium- and long-term processes to transform conditions in favor of equity, health, and life of current and future generations.

Then again, do foreign investors consider the voluntary disclosure of corporate information, such as carbon emissions? In an extremely complex financialized world, naive approaches to such relationships that drive global economic dynamics no longer serve. It is necessary to know and influence environmental, social, and governance activities in the relationship with foreign investors, especially those minimally committed to global agendas such as discussed at COP26, in Glasgow (Atwoli et al., 2021).

Foreign investors motivate companies to improve the environment to prepare for future environmental risks, with widespread impacts on health. The world faces multiple health financing challenges as the global burden of disease advances. Furthermore, countries have defined an ambitious health policy agenda for the next decades, prioritizing universal health coverage in line with the SDGs. The scale of investment required for equitable access to health services means that global health is one of the main economic opportunities for decades to come. Opportunities for global investment in health should be debated, exploring the intersections of financial and health sector interests, as well as the role that investment in health can play in economic development. One cannot ignore, for ideological pureness, the growing demand for impact investing, with responsible financing and the expansion of the global movement for sustainable capital markets. Adding an explicit health component (H) to the ESG investment criteria, creating the ESG + H initiative, could serve as a critical and pragmatic catalyst for the inclusion of health criteria in business practices and objectives of investment of the main financial actors. Health considerations directly impact business longevity and planetary and social resilience; therefore, they must be incorporated into the economic analysis of health. A positive assessment of the impact on health, on a broad social or environmental level, as well as on the employees of a company, can become a competitive advantage that increases the financial value and image of companies. To prevent the planet from suffering catastrophic global warming, it is necessary to reduce greenhouse gas emissions to net zero. Divestment of fossil fuels should be a strategic interest for health insurers (Kim et al., 2021; Krech et al., 2018; Teng et al., 2021).

For example, a survey on ESG strategies was sent to German private health insurers. It assessed investment strategies and boundaries for sector exclusion and business practices, as well as company strategies for sustainable business development. German private health insurers manage assets worth more than €350 billion. According to quantitative data, €66 billion in assets are managed according to some ESG criteria; this equates to an average of 76% of each company’s titles. The findings contrast with the expected intrinsic economic interest of insurers in halting global warming and improving public health. Most assets are managed in a highly problematic manner. Lack of transparency is a major issue that limits citizens in choosing the insurer that has the most advanced ESG criteria (Schneider et al., 2020).

From the socioenvironmental perspective of health promotion, a Brazilian survey investigated experiences considered successful by municipal managers, interviewing coordinators, professionals, and observations of participants in the practices. It is concluded that there is potential for intersectoral interventions on social and environmental determinants in favor of health promotion, but the lack of consistency between what happens in practice and political aspects reveals a challenge to be overcome (Silva et al., 2014).

To face such contradictions, some public governance structures have been created to accompany different policies and programs, covering different groups defined by gender, race, generation, or social status. They are governance structures to enhance the guarantee of rights through articulation between government and civil society sectors. It has been possible to detect the importance of these spaces that enable the influence and control of institutionalized civil society over the state, for example, in actions and services for the elderly. However, difficulties in forwarding actions, obstacles in the relationship between social actors, and insufficient involvement of some government agencies were observed. In the context of accelerated demographic changes, social inequalities, and the vulnerability of the elderly population, this governance strategy alone has not been enough to guarantee the realization of the desired rights (Souza & Machado, 2018).

Social Inequities, Political Polarization

Inequities seem to be one of the most ubiquitous social problems, whether advanced capitalism or not, in societies undergoing industrial and technological revolutions. Even in societies with a long tradition of studying, denouncing and (supposedly) confronting the issue, the challenges continue to plant their flags in the foreseeable future (Birch, 1999).

Likewise, splitting up and social hatred is not a recent issue but a dated subject. It seems to have come to stay from the medieval era (Browning, 1894), as portrayed by the conflicts between Guelphs and Ghibellines. Celebrations on the Universal Declaration of Human Rights have over time called on medical professionals to pay attention to the growing gap between rich and poor. The rights outlined in the Universal Declaration of Human Rights include an adequate standard of living for the health and well-being, including food, clothing, housing, medical care, and necessary social services. Socioeconomic status is directly related to health status, with inequities in wealth distribution affecting morbidity and mortality. The global polarization of politics and the growing concentration of wealth renew the challenges for societies to face such disparities (Kasper & Meyers, 1998).

Besides, current models of understanding global health frame problems and solutions in ways that obscure the role that the private sector, in particular large corporations, plays in shaping a transnational ethos influencing individual consumption behaviors and therefore the health outcome of the population.

Globalization and commerce, corporate structures and regulatory systems, articulation of social and economic power, and neoliberal and capitalist ideologies all are elements that still add other corporate activities such as marketing, political activities such as lobbying with the capture of lawmakers, the existence or not of extensive social and environmental corporate governance, supply chains, harmful products and production, and accessibility issues. This significantly contributes to worsening overall health outcomes (Diderichsen et al., 2021; Kickbusch et al., 2016; Rochford et al., 2019; Wood et al., 2021). In the successive recent global crises, with emphasis on the period 2008 and now in the trans-pandemic period of 2020–2022, the impact of commercial determinants in general on governance, quality of life, and health of populations is undeniable—in particular, for example, the food crisis and how the inflated trade in agricultural commodities affects the health of the most vulnerable populations, in the great apartheid among hemispheres, continents, and countries. Intersectoral regulatory and grassroots action would favor global food security interventions, counteracting the power of food industries that put profit above hunger and naturalize the burden of nutritionally based disease and early death, then proactively bringing to the fore of global agendas the importance of joint efforts to ensure food sovereignty. Allied to that, great attention should be given to programs that are self-sustainable or economically braced by societies and national states, such as investment in agroecology; smallholder family farmers; indigenous, peasant women’s movements, and “quilombola” communities. “Quilombo” is the denomination for communities of black slaves that resisted the slave regime that prevailed in Brazil for over 300 years and was abolished in 1888. “Quilombola” communities were formed from a wide variety of processes that include the escape of slaves to free and generally geographically isolated settlements.

While it is broadly understood that dealing with inequities is best addressed with an understanding of upstream socioenvironmental, political, and commercial determinants, most attempts to address them have been and continue to focus on downstream determinants and particularly on individual behavioral determinants, under the umbrella of lifestyle models. This means that health inequities among social groups, although they have been the focus of much work for some decades now, have not been substantially reduced and, in many cases, have increased. The continuum of social determinants of health inequities shows where policy approaches are most likely to intervene and what their success or failure effects would be, whether they are likely to address the salient issues in health, disease, and care; reduce vulnerability and exposure to detrimental health factors; or palliatively mitigate the effects of ill-health (Mantoura & Morrison, 2016).

Inequities in the conditions in which people are born, live, work, and age are, however, motivated by inequalities in power, money, and resources. Political, economic, and resource allocation decisions taken outside the health sector need to consider health as an outcome across social distribution, as opposed to focusing solely on increasing production. Measuring SDH progress globally will be key to the future development of successful policy and implementation plans, enabling the identification and sharing of best practices (Donkin et al., 2018; Marmot, 2005, 2017).

Furthermore, an economic or deterministic approach, although correct in assuming the influence on the health of the socioeconomic systems created by humans, is no longer sufficient as a single explanatory rationale. There is an imperative need to adopt an ecosocial approach to promoting population health, recognizing the interactions between ecological determinants (all planetary systems, natural and otherwise) and human health dispositions (Hancock, 2015).

Final Considerations

Here it comes, the 21st century—so what? Among the various global challenges, education has been presented as an urgent priority. The issue is present in several countries and is often emphatically situated within a secular chronology that we possess a 19th-century school, 20th-century teachers, and 21st-century students.

In seeking a secular evolution analogy for the theme of intersectoriality, we would dare to say that, for the social production of health, the problems we have are from the 21st century, the tools to face them are from the 20th century, and the bureaucratic organization of nation-states is still from the 19th century. On November 20, 2019, during the 12th European Congress of Public Health, professionals from various countries met in Marseille with the following call: “Intersectoriality: next generation, a real way to tackle inequalities?”¹

Implicit in the title of the event is the need to overcome a certain past and an explicit intention to seek this new generational aspiration to intersectoral action. In other words, we must overcome the intersectoriality of the 20th century, so that this is not just a technocratic policy resource articulation but a true device to serve social justice. The lecturers at the event in Marseille analyzed different intersectoral practices in New Caledonia, Canada, Brazil, and Denmark. These interventions were followed by a round table to identify facilitators and obstacles to intersectoriality, gaps between theory and practice, and priorities to move toward the “true” intersectoriality.

Some necessary conditions were identified to consider putting in practice what would be a “new generation of intersectoriality”:

This is a debate that needs to be carried on.