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Towards action on social determinants for health equity in urban settings
Tord Kjellstrom and Susan Mercado Environment and Urbanization 2008 20: 551 DOI: 10.1177/0956247808096128 The online version of this article can be found at: http://eau.sagepub.com/content/20/2/551

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A C T I O N O N S O C I A L D E T E R M I N A N T S F O R H E A LT H E Q U I T Y

Towards action on social determinants for health equity in urban settings

TORD KJELLSTROM AND SUSAN MERCADO

Tord Kjellstrom (corresponding author) is an epidemiologist in the environmental and occupational health fields with 35 years experience in academia and international health agencies. He has worked as a researcher and teacher at the Karolinska Institute (Sweden), the University of Auckland (New Zealand), the Australian National University (Australia) and the National Institute of Public Health (Sweden). He was environmental epidemiologist and eventually Director of the Office of Global and Integrated Environmental Health at the World Health Organization (WHO) in Geneva for 12 years. During his time at WHO and later, he was involved in different aspects of Health Impact Assessment. Currently, he works part-time at the Australian National University and as a consultant in the environmental and health fields. Address: the National Institute of Public Health, Ostersund, Sweden; the Australian National University, Canberra, Australia; and the Health and Environment International Trust, Nelson, New Zealand; e-mail: kjellstromt@yahoo.com Susan Mercado is a medical doctor and public health practitioner with over 20 years experience in health

ABSTRACT More than half of the global population now live in urban settings. Urbanization can and should be beneficial for health. In general, nations with high life expectancies and low infant mortality rates are those where city governments address the key social determinants of health. Better housing and living conditions, access to safe water and good sanitation, efficient waste management systems, safer working environments and neighbourhoods, food security and access to services such as education, health, welfare, public transportation and child care are examples of social determinants of health that can be addressed through good urban governance. Failure of governance in today’s cities has resulted in the growth of informal settlements and slums that constitute unhealthy living and working environments for one billion people. A credible health agenda is one that benefits all people in cities, especially the urban poor who live in informal settlements. International agreements calling for urgent action to reduce poverty, such as the Millennium Development Goals, can only be met through national strategies that include both urban and rural commitments and involve local governments and the poor themselves. Health inequalities in urban areas need to be addressed in countries at all income levels. Urban development and town planning are key to creating supportive social and physical environments for health and health equity. Achieving healthy urbanization in all countries is a shared global responsibility. Eliminating deprived urban living conditions will require resources – aid, loans, private investments – from more affluent countries in the order of US$ 200 billion per year, no more than 20 per cent of the annual increase in GDP in high-income countries. Creating global political support for a sustained and well-funded effort for social, economic and health equity is one of the greatest challenges of this generation. KEYWORDS climate / disease control / economics / environment / equity / food / governance / health services / housing / slums / social determinants / urban health / urbanization

I. INTRODUCTION
The Knowledge Network on Urban Settings (KNUS) is one of nine networks established to provide evidence to the WHO Commission on Social Determinants of Health (CSDH). This paper is an abridged version of a KNUS report that was submitted to the CSDH and published by the WHO Centre for Health Development, Kobe, Japan.(1) The purpose of the report was to synthesize what is known about social determinants of health in urban settings and provide guidance and examples of interventions

Environment & Urbanization Copyright © 2008 International Institute for Environment and Development (IIED). Vol 20(2): 551–574. DOI: 10.1177/0956247808096128 Downloaded www.sagepublications.com from eau.sagepub.com by guest on August 30, 2012

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the Philippines. community-based organizations.(6) Unmasking health inequity in urban settings.com by guest on August 30. as defined by the WHO.E N V I R O N M E N T & U R B A N I Z AT I O N Vol 20 No 2 October 2008 policy and programme development at local. Her first job as a physician was to run an urban primary health care programme in the slums of Metro Manila. Prior to this. and as Acting Regional Adviser for Health Promotion at the WHO–WPRO (2002–2004). Health equity. 2012 . These people face health challenges similar to those faced by poor people in cities in past centuries. After the meeting.(3) Real-life stories. and has expertise in health promotion and health communication. examples to provide us with strong and compelling evidence of unfairly FIGURE 1 Percentage of urban population living in “slums” in different countries.pdf. The KNUS process started with a meeting in early 2006 and the generation of 14 thematic papers on different aspects of social determinants of health in urban settings. she served as Undersecretary and Chief of Staff at the Department of Health. 2001 SOURCE: Turkstra. however. Tanzania in November 2006. civil society. “Urban slum monitoring”. There are. vignettes and case reports or “voices from the urban settings”.esri.(5) More than half the urban residents in many low-income countries live in slums and informal settlements (Figure 1). UN–HABITAT paper accessible at http://gis. the thematic papers were revised and shorter versions published in the Journal of Urban Health. health advocates.sagepub. Data on health inequalities in urban settings are not routinely reported. Japan. that have been shown to be effective in achieving health equity. were presented at a second meeting of the KNUS “Synergy Circle” in Dar es Salaam. She is currently Regional Coordinator for the Tobacco-Free Initiative of WHO–Western Pacific Regional Office (WPRO). economically. Republic of the Philippines. The work of KNUS has a strategic focus on the most extreme end of the health inequity gradient: the billion people in low-income and informal settlements (“slums”) in urban areas.com/library/userconf/proc04/ docs/pap1667. Jan and Martin Raithelhuber (2004). researchers and WHO regional staff. where appropriate. 552 Downloaded from eau.(4) Focusing on slums and informal settlements in the urban setting.”(2) The report assembles evidence from all over the world. even though the knowledge and means to eliminate these unhealthy conditions are now available. This group included practitioners. She has worked previously as Team Leader. and Assistant Professor at the National Institute of Health. as hub leader of the Knowledge Network on Urban Settings of the WHO Commission on Social Determinants of Health (2005–2007). journalists and communities. demographically and geographically. national and international levels. using the guiding principles prepared by the Knowledge Network on measurement and evaluation and. is “…the absence of unfair and avoidable or remediable difference in health among population groups defined socially. Kobe. citing the work of other CSDH Knowledge Networks. commissioned through civil society groups. Urbanization and Health Equity of the WHO Centre for Health Development. policy makers.

or. who.(10) which have been a hallmark of most societies since urbanization began. 2012 .g. Urbanization can be beneficial to health. Sweden. Making our cities healthier. and has no commercial or other conflict of interest. and was undertaken for the Knowledge Network on Urban Settings (KNUS). The complete KNUS report (with the names of all KNUS members) has been published by the WHO Kobe Centre (www. Sweden and Japan Location Sweden Japan Kenya (rural and urban) Rural Urban (excluding Nairobi) Nairobi High-income area in Nairobi (estimate) Informal settlements in Nairobi (average) Kibera slum in Nairobi Embakasi slum in Nairobi Infant mortality rate (deaths per 1. In Nairobi. The extraordinary difference in health status within Nairobi and between Kenya. the Netherlands and Singapore are testimony to the potentially healthpromoting features of modern cities. social systems based on democracy and strong equity policies have flourished and achieved great social and health progress (e. Nairobi. infant and child mortality rates 15 to 20 times higher than Sweden and Japan.com by guest on August 30. Population and Health Dynamics in Nairobi’s Informal Settlements. while the average rates are lower than in Kenyan rural areas.jp). The views presented in this work/publication/report are those of the author(s) and do not necessarily represent the decisions. Urban areas can provide healthy living environments.int Acknowledgement: This work was made possible through funding provided by the World Health Organization (WHO Kobe Centre for Health Development) and the institutions where the writers were employed.000 children) 5 5 112 113 84 62 Likely to be less than 15 151 187 254 SOURCE: APHRC (2002). the rates are three to four times the Nairobi average and much higher than the Kenyan rural average. the Nordic countries and New Zealand). 2007.(9) Inequalities in health in urban settings reflect to a great extent inequities in economic. Kenya has.sagepub. on average. Health hazards remain and new health challenges have developed. policy or views of WHO or commissioners. they can improve health via their various material.000 newborn) 5 4 74 76 57 39 Likely to be less than 10 91 106 164 Under-five mortality rate (deaths per 1. This is an abridged version of the Report prepared by the Knowledge Network on Urban Settings (KNUS. service provision. psychosocial resources and political engagement is the powerlessness that underpins the vicious cycle of poverty and ill-health. distributed health opportunities. African Population and Health Research Centre. Sweden and Japan (Table 1) is a case in point. social and living conditions.who.(8) but creating healthy urban living conditions is possible if a supportive political structure exists and financial resources are applied appropriately.(7) Improvements over the last 50 years in mortality and morbidity rates in highly urbanized countries like Japan. Already during the early parts of the twentieth century. e-mail: mercados@wpro. 553 Downloaded from eau. Manila. of capability and of security. TA B L E 1 Infant and under-five mortality rates in Nairobi (Kenya). cultural and aesthetic attributes. the Philippines.(11) Health inequalities arise not only from poverty in economic terms but also from poverty of opportunity.(12) The net effect of deficits in material conditions. indeed. with 57 members) for the WHO Commission on Social Determinants of Health. The challenge in urban areas at any economic level is to improve the health situation for the poorest or most disadvantaged by “levelling up” their living conditions.A C T I O N O N S O C I A L D E T E R M I N A N T S F O R H E A LT H E Q U I T Y Address: WHO Regional Office for the Western Pacific. the city has a strong gradient from poor to rich: in the slums of Kibera and Embakasi.

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also see reference 36. No 1. dung and agricultural residues) and coal to meet their most basic energy needs: cooking. “The trend in international health inequality”. landslides or fire – for economic and political reasons. Journal of Asian Studies Vol 61.(70) describe how housing and shelter quality impact on health (Table 3). Earthscan. Cecile. Studies in Comparative International Development Vol 27. pages 131–146.(73) The Bhopal disaster is one of the more infamous examples. asbestos and radon. No 1. The Canadian Institute for Health Information(71) has reported strong causal relationships between ill-health and exposure to some of the following agents: lead. Environment and Urbanization Vol 18. 2000 Number and proportion of urban dwellers without adequate provision Region Africa Asia Latin America and the Caribbean Water 100–150 million (~35–50%) 500–700 million (~35–50%) 80–120 million (~20–30%) Sanitation 150–180 million (~50–60%) 600–800 million (~45–60%) 100–150 million (~25–40%) SOURCE: UN–HABITAT (2003b). especially by women and girls. including higher risks of HIV–AIDS. UNAIDS (2007).cdc. often at disastrous levels. In addition. htm. more efficient convenient fuels are gradually replacing traditional biomass fuels. With increasing prosperity in some regions. accessed 2 May 2007 at http://www. Poor quality housing is a key challenge in high. gov/ncidod/eid/vol1no1/morse. also Mabala. Morse. coal and other less efficient and more polluting energy sources. Geneva. “Factors in the emergence of infectious diseases”. Boston. Sheuya et al. “Strangers in the city: reconfigurations of space. London. Stephen (2007).A C T I O N O N S O C I A L D E T E R M I N A N T S F O R H E A LT H E Q U I T Y (1996). The poor settle in marginal lands – often subject to flooding. 38.000 people died and more 559 Downloaded from eau. The Global Burden of Disease. Goldestein. M E (1995). British Medical Journal Vol 311. pages 1364–1366. 43. power and social networks within China’s floating population”. A and S Guo (1992). tuberculosis and other infections. often resulting in exposure to extremes of noise and temperature as well as to harmful chemical and biological agents.org/en/HIV_data/ 2006GlobalReport/default. See Guang. “2006 report on the global AIDS epidemic”. Richard (2006).(72) The frequent co-location of industry and poor residential areas is another problem. “Infectious diseases: an ecological perspective”. unaids. house dust mites and cockroaches. Mirjam (2006). The inefficient burning of solid fuels on an open fire or traditional stove indoors creates a dangerous cocktail of hundreds of pollutants that causes respiratory diseases. will not attend to their sanitary needs during daylight hours if they lack household toilets. 42. 46. 41.com by guest on August 30. Water and Sanitation in the World’s Cities: Local Action for Global Goals. No 4. Poor quality of housing and shelter. Wilson. for reasons of culture and modesty. HIV. The housing of low-income families may be characterized by insubstantial and fire-prone materials. boiling water and heating. These families are faced with a terrible dilemma: cook with solid fuels or pass up a cooked meal. lack of convenient access to drinking water means that many hours each day may be wasted on carrying water from distant sources. women and girls are vulnerable as many of them. temperature and lack of ventilation. 45. 40.asp. “From HIV TA B L E 2 Estimates of the proportion of people without adequate provision for water and sanitation in urban areas. 2012 . Goesling. Stockholm. pages 39–56. The poor often end up living in unsafe locations. Harvard School of Public Health. “Temporary migration in Shanghai and Beijing”. depend on solid fuels including biomass (wood. See reference 36. Ambert. “‘Positive’ urban futures in sub-Saharan Africa: HIV/AIDS and the need for ABC (A Broader Conceptualization)”. cleaner. Guang reports that the “floating population” of China now numbers 140 million and they suffer from a wide range of disparities. Aids and Urban Development Issues in sub-Saharan Africa.as well as low-income countries. L (2002). 44. particularly in young children and women who spend the longest times close to cooking fires. April. poor foundations and hazardous locations. The WHO report Fuel for Life(69) points out that more than 3 billion people. No 2. Sida.sagepub. Population and Development Review Vol 30.(68) Again.(74) where 2. For instance. Proper sanitation is just as important for keeping infectious diseases at bay. Indoor air pollution. Brian and Glenn Firebaugh (2004). Katja Jassey and Liz Thomas (2006). UNAIDS. 39. Van Donk. pages 155–175. pages 1681–1684. accessed 2 April 2007 at http://www. living in both rural and urban areas.

) Insect vector diseases Rodent vector diseases Excreta-related diseases Zoonoses Diseases due to microbial toxins Airborne excreta-related diseases Enhanced infectious respiratory disease risk Chronic lung disease Heart disease Cancer Neurological/reproductive diseases Injuries *In addition to these examples. Environment and Urbanization Vol 18. 47. No 2. prevention to HIV protection: addressing the vulnerability of girls and young women in urban areas”.E N V I R O N M E N T & U R B A N I Z AT I O N Vol 20 No 2 October 2008 TA B L E 3 Indicators of unhealthy housing and shelter Principal risk factor Defects in buildings Communicable diseases Insect vector diseases Rodent vector diseases Geohelminthiases Diseases due to animal faeces Diseases due to animal bites Overcrowding-related diseases Non-communicable diseases* and injuries Dust and damp and mould-induced diseases Injuries Burns Defective water supplies Heart disease Faecal-oral (waterborne and waterwashed) disease Cancer Non-faecal-oral water-washed diseases Water-related insect vector diseases Faecal-oral diseases Geohelminthiases Taeniases Water-based helminthiases Insect vector diseases Rodent vector diseases Acute respiratory infections Stomach cancer Defective sanitation Poor fuel/defective ventilation Peri-natal defects Heart disease Chronic lung disease Lung cancer Fires/burns Poisoning Injuries Burns Cancer Defective refuse storage and collection Defective food storage and preparation Poor location (near traffic. abridged version: “The design of housing and shelter programmes: the social and environmental determinants of inequalities”.com by guest on August 30. including stress-related conditions.(75) These workplaces. WHO/World Bank (2004). Journal of Urban Health Vol 84.000 were poisoned. and drug and alcohol abuse. Health and Environment in Sustainable Development. industry. violence. “World report on road traffic injury prevention”.8. etc. Supplement 1. informal settlements are home to the thriving informal economies that dominate urban employment. and see reference 45. “The design of housing and shelter programmes” (thematic paper for KNUS second meeting). October. Continuous community exposure to workplace hazards in informal settlements. pages i98–i108. waste sites. The risks caused by industrial activity in proximity to the urban poor are often compounded by weak regulatory measures and lax enforcement at national and municipal levels. In many countries. World Health Organization. poorly designed and located housing and shelter can lead to various mental health problems. SOURCE: WHO (1997). especially those in close proximity to living quarters. S Patel and P Howden-Chapman (2007).sagepub. Document WHO/EHG/97. delinquency and vandalism. World Health Organization. than 200. Geneva. pages 407–432. Geneva. the 560 Downloaded from eau. 2012 . also Sheuya S. often present health hazards through the use of toxic products.

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(96) Providing this key infrastructure is fundamental in reducing health inequalities. D et al. also UN–HABITAT (2003b). “Does urban agriculture help prevent malnutrition? Evidence from Kampala”. 70. all are compatible with high levels of prosperity but have very different implications for air pollution. Journal of Urban Health Vol 84. and make the fuel affordable and convenient to access. Canadian Institute for Health Information. Supplement 1. WHO (2005). 68. S Patel and P Howden-Chapman (2007). 71.3 per cent in Atlanta.(93) An analysis of the case studies presented in the KNUS papers confirms this.(102) Investment in improved public transport (three to five times more energy efficient than private transport) can create great improvements in air pollution exposure. Studies of the benefits and monetary costs of major air pollution control efforts in high-income countries(101) have concluded that the benefits in terms of cleaner and healthier neighbourhood air far outweigh the costs. 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