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.
Big Data and Urban Health
Mark Stevenson, Jason Thompson, and Thanh Ho
Digital Public Health: Quality, Interoperability and Capability Maturity
Digitalization was accelerated to address the access, safety and quality needs of health professionals and citizens during care provision in the presence of human, animal and environmental vectors of pandemic infections. Digital transformation will harness cloud computing, artificial intelligence (AI), data networks and personalized digital agents, sensors, and visualization tools to monitor and enhance the care of individuals, populations and communities. A sociotechnical, multidisciplinary, and enterprise-wide approach is essential to improve the quintuple aims of cost-effectiveness, provider and patient well-being, and equity. Digitally competent health professionals and digitally mature health organizations are necessary to produce and use high-quality interoperable digital data and technologies to improve decisions and practice. The maturity of five essential digital health foundations (infrastructure, tools/agents, readiness to share information, enablers of trust and adoption, and quality improvement) is assessed across the micro–meso–macro continuum. The Digital Health Profile and Maturity Assessment Toolkit Maturity Model illustrates a sociotechnical capability maturity approach to assess how organizations manage, govern, improve, and sustain the ethical and safe production, use and sharing of digital health tools and data in the real world. The linkage and convergence of real-word data (RWD) from public health, clinical and managerial practice highlights potential cost-efficiencies in integrated data collection, reporting, aggregation, analysis, and use. Challenges include access, quality, and interoperability of RWD and tools. AI-driven data analytics is increasingly being used, despite misgivings about trustworthiness, biases and fairness of software agents, algorithms, and training data sets. The sociotechnical approach emphasizes leadership, inclusive governance, mutual trust, and reciprocity within a cocreation paradigm; communities of learning and practice operating within regulatory frameworks that promote quality, safety, and equitable access to digital tools and data; quality improvement and professional development programs aimed to improve digital health maturity; and science and digital health diplomacy to harmonize the multiplicity of actors and technology in digital public health ecosystems and global supply chains. Learning organizations that “think small and big simultaneously” within a standards-based cocreation paradigm will create the digital assets and social capital necessary for the national and global digital public health enterprise.
Health Workforce: Situations and Challenges in Latin America, the Caribbean, and Brazil
Maria Helena Machado, Renato Penha de Oliveira Santos, Pedro Miguel dos Santos Neto, Vanessa Gabrielle Diniz Santana, and Francisco Eduardo de Campos
The greatest challenge in the development of universal health systems worldwide is to increase organization, training, and regulation of the health workforce (HWF). To accomplish this, the World Health Organization (WHO) has pointed out several strategies utilized since the beginning of the 2000s. One of the world regions with the greatest internal HWF disparities is the Americas, more specifically Latin America and the Caribbean. Brazil is another of the countries in this region that presents great inequities in its HWF distribution, although its Unified Health System (Sistema Único de Saúde, or SUS), created after 1988, is one of the largest universal health systems in the world. It is worth noting that Latin America, the Caribbean, and Brazil historically have high levels of social inequality and have recently become regions severely affected by the COVID-19 pandemic. Despite some advances in the formation and distribution of HWF in Latin America and the Caribbean in the last 10 years, structural problems persist in the health systems of several countries in this region, such as Brazil. The COVID-19 pandemic aggravated some problems such as the distribution of specialized health workers in intensive care units and the precarious working conditions in several public health services that were organized to face the pandemic.
How Primary Maternal-Child Healthcare Reduces Mortality among Mothers and Children throughout the World: A Historical and Personal Reflection on Progress and Missed Opportunities
In the first decades of the 21st century, despite major medical advances, women in the least developed parts of the world are dying in childbirth far more often than women in wealthier nations, and their children are far more likely to die before reaching age 5. The major reason for this is that healthcare in these areas lacks its foundation: basic primary maternal and child healthcare (MCH). Two early examples of primary MCH care showed that the high death rates for mothers and children could be reduced substantially at low cost: David Morley’s Under-Fives Clinic in Western Nigeria, which began in the 1960s, and the Aroles’ Jamkhed Project in Maharashtra State in India, which began in the early 1970s. The lessons learned from these two early projects were also highlighted as principles at the Alma Ata International Primary Care Conference in 1978. They included: 1. Integration of basic curative care with the various aspects of promotive/preventive care, the former building the trust required for full acceptance of the less-understood aspects of the latter, such as immunizations, family planning, and exclusive breastfeeding during the first six months of life. 2. Heavy reliance on well-supervised lower-level health workers (including community health workers) to reach entire target populations. 3. Reliable delivery of a limited formulary of common, low-cost medical supplies and medications. 4. Partnerships among government ministries of health, education, and finance with communities and with local, national and international non-governmental organizations, and, 5. Gradual buildup as the health system and the communities enhance their capacity to support the work, so that success builds on success. It is past time for building primary MCH and eventually total population-based care systems everywhere. The first and biggest benefit will be in least developed societies, where the present rate of preventable mother and child deaths is unconscionable.
Intervention Approaches for Osteoarthritis
Susan Hughes, Cheryl Der Ananian, and Andrew DeMott
Osteoarthritis (OA) currently affects 32.5 million people in the United States at a cost of $136.8 billion. The available literature on the epidemiology of OA shows that the number of people affected will increase exponentially by the year 2040, affecting 78.4 million people. There is an abundance of evidence that self-management and physical activity (PA) approaches improve multiple outcomes for individuals with arthritis. However, these programs are not widely accessible to the population that can benefit from them across the United States. Two national organizations—the arthritis program of the Centers for Disease Control and Prevention (CDC) and the Administration on Community Living (ACL)—have established similar, but distinct, criteria for the review of evidence-based programs and seek to promote their dissemination. The CDC arthritis program has reviewed the evidence bases of arthritis-appropriate, evidence-based intervention programs and classified them as self-management or PA approaches. These “recognized” programs are recommended for national dissemination by the CDC. The ACL has also recognized several of the same programs by using its own criteria and classified them as Self-Management or Falls Prevention approaches. The different review criteria used by these two national public organizations present significant challenges for investigators who design interventions. The situation is further compounded by an investment in funding that hugely supports the discovery of interventions as opposed to the dissemination of interventions that have demonstrated efficacy. The National Public Health Agenda for Osteoarthritis: 2020 Update presents a blueprint that includes nine strategies for improving public health outcomes among persons with OA. These recommendations should be considered by interventionists in the future when developing programs. Other areas that can substantially benefit from further research include weight management and weight loss, injury prevention, technology-based interventions, addressing comorbid conditions, and understanding program mechanisms of action. Finally, underscoring all of these approaches and common to them is the need to enroll underserved populations to improve health equity. Underserved populations disproportionately include African Americans, Hispanics, persons with low socioeconomic status, and persons who live in rural areas of the United States. Policy recommendations to render future approaches to improving health outcomes for persons with OA are (a) to increase funding for the dissemination of programs that demonstrated efficacy and effectiveness, (b) to increase the transparency of the review and funding processes across public agencies, and (c) to nurture, broker, and provide sustainable funding streams to maintain evidence-based programming for all persons with OA across the United States.
Occupational Health Challenges for Immigrant Workers
Emily Q. Ahonen
Occupational health and safety concerns classically encompass conditions and hazards in workplaces which, with sufficient exposure, can lead to injury, distress, illness, or death. The ways in which work is organized and the arrangements under which people are employed have also been linked to worker health. Migrants are people who cross borders away from their usual place of residence, and about one in seven people worldwide is a migrant. Terms like “immigrant” and “emigrant” refer to the direction of that movement relative to the stance of the speaker. Any person who might be classified as a migrant and who works or seeks to work is an immigrant worker and may face challenges to safety, health, and well-being related to the work he or she does. The economic, legal, and social circumstances of migrant workers can place them into employment and working conditions that endanger their safety, health, or well-being. While action in support of migrant worker health must be based on systematic understanding of these individuals’ needs, full understanding the possible dangers to migrant worker health is limited by conceptual and practical challenges to public health surveillance and research about migrant workers. Furthermore, intervention in support of migrant worker health must balance tensions between high-risk and population-based approaches and need to address the broader, structural circumstances that pattern the health-related experiences of migrant workers. Considering the relationships between work and health that include but go beyond workplace hazards and occupational injury, and engaging with the ways in which structural influences act on health through work, are complex endeavors. Without more critically engaging with these issues, however, there is a risk of undermining the effectiveness of efforts to improve the lot of migrant workers by “othering” the workers or by failing to focus on what is causing the occupational safety and health concern in the first place—the characteristics of the work people do. Action in support of migrant workers should therefore aim to ameliorate structural factors that place migrants into disadvantageous conditions while working to improve conditions for all workers.
Priming Healthcare for Health Equity Management
Ebbin D. Dotson, Kimson E. Johnson, and Jada Irving
Health equity management (HEM) is defined as an actionable framework that supports the development of an industry-defining position for healthcare organizations and senior leaders to guide their business practices for investments in and financial gains from health equity. As healthcare leaders confront the disparate racial and ethnic burdens caused by the nation’s racialized societal history, making investments that increase health equity can help eliminate health disparities. To achieve health equity, leaders must cultivate a sense of interdependence among stakeholders and community members to effectively communicate the importance of collaboration, which is a shared understanding of the necessary actions that engage stakeholders around a central purpose. Achieving health equity forces healthcare systems to consider the notion that creating an equitable environment, where the costs of health inequity and barriers to achieving community and population health are shared with stakeholders and community members, might be addressed by the modification of certain management practices. HEM encompasses an applied management model to help healthcare organizations maximize their efforts to increase health equity for vulnerable populations. It provides a stepwise approach to help frame the social, economic, and educational changes necessary for leaders to invest in health equity initiatives. The HEM involves the following actions: (a) redefining health equity, (b) identifying upstream inequalities, (c) realigning fiscal investments, and (d) leveraging community partnerships. Establishing and sustaining health equity initiatives through HEM ensures that both economic and social criteria are systematically considered, and financial investments are prioritized for sustained impact. Without addressing all four, the efforts of healthcare organizations will fall short of what it will take to effect lasting change. Redefining health equity requires incorporating upstream and downstream inequities to offer a lens to align mission, assess capacity, and leverage profitable partnerships. The systematic approach to HEM goals and principles can be integrated at various organizational levels as a tool to successfully address health inequalities and social determinants of health.