Dr Stephen Monaghan Why Cardiff? A Tale of Two Cities Public Health Director, Cardiff LHB Consultant in Public Health Medicine, NPHS Why Cardiff? A Tale of Two Cities

A Tale of Two Cities Whilst Cardiff is a thriving, affluent city, It is really a tale of (at least) two cities in terms of health outcomes and deprivation indices, the reality is that there are still over 50,000 people living in the top decile of of disadvantage according to the Welsh Index of Multiple Deprivation. More people in the top decile of deprivation than than in RCT or in Merthyr Tydfil and Blaenau Gwent combined 10 year life expectancy difference between the Lisvane and Butetown 2 LSOAs “southern arc” – south of the railway line – “wrong side of the tracks”

Demography and population sub-groups

Current Population 2006 Population Estimates give Cardiff a population of: 317,523 as derived from the ONS or 352,954 as derived from NHSAR

Cardiff Population Age Structure in 2006 [317,500 persons - ONS data]

Population Trends The average annual increase in Cardiff’s population was 2,400 persons (2001-2005) natural population growth net migration Migration accounted for 43.7% of the total estimated population change.

Ethnic Minority Populations 25,735 persons (2001 Census) Cardiff has the highest population proportion of ethnic minority in Wales Half of the ethnic minority population in Wales live in Cardiff Often live in the poorest inner city areas Many rank amongst the most impoverished of the city’s inhabitants

Ethnic Minority Populations

Asylum Seeker Population

Student Population 25,000 students (and rising) in Cardiff Population is concentrated in specific areas: Cathays, Plasnewydd, Penylan (Central Locality) Gabalfa (North Locality)

Determinants of Health

Welsh Index of Multiple Deprivation by LSOAs (2001)

Lifestyle <29% of Wales’ residents reported meeting the physical activity guidelines (30 mins moderate exercise 5 days / week) Cardiff had a lower proportion of adults who met the guidelines than the Welsh average 64.1% of Welsh adults are overweight or obese. The proportion in Cardiff is slightly lower than this Welsh average Welsh Health Survey 2003/5)

Lifestyle 27.1% of Welsh adults reported being smokers with the proportion in Cardiff just above this Welsh average Almost 40% of Cardiff (and Wales’) adults report their average weekly alcohol consumption is above recommended limits Cardiff residents report higher rates of binge drinking than the Welsh average Welsh Health Survey 2003/5)

Lifestyle Sexually transmitted infection rates continue to increase Cardiff has the highest prevalence of HIV in Wales

Health Outcomes

EASMRs for All Cause Mortality by MSOA (2002-2004)

EASMRs for all circulatory diseases (persons, all ages) by MSOA (2000-2004)

EASMRs for respiratory disease (persons, all ages) by MSOA (2000-2004)

Female Morbidity from All Malignancies (excl NMSC) WASR Per 100,000 Population

Female Mortality from All Malignancies (excl NMSC) WASR per 100,000 Population

Key Points A Tale of Two Cities

A Tale of Two Cities Whilst Cardiff is a thriving, affluent city, It is really a tale of (at least) two cities in terms of health outcomes and deprivation indices, the reality is that there are still over 50,000 people living in the top decile of disadvantage according to the Welsh Index of Multiple Deprivation. More people in the top decile of deprivation than in RCT or in Merthyr Tydfil and Blaenau Gwent combined 10 year life expectancy difference between the Lisvane and Butetown 2 LSOAs “southern arc” – south of the railway line – “wrong side of the tracks”

Most modern health problems and diseases are: All major diseases except cancer – a genetic disease Problems of maladaptation between human biology and the modern environment 24

If we truly want to tackle our modern health problems: we have to consider changing the environment Economic, social, physical not just treating human biology consequences not just educating/informing people re: choices

WHO Healthy Cities This is what led us to Healthy Cities A world-wide movement of city-based public health initiatives “In one sense the Healthy Cities Project was a new initiative, in another it was the Health of Towns Association of Exeter 1844 reborn…the challenge to us is to pick up where Chadwick’s thinking left off 100 years ago” (John Ashton 1992) Origins of public health in the Victorian era: Context of new type of industrial town in Northern England (cotton, wool factories) – owners built cheap back-to-back housing with little or no sanitation, with overcrowding, where workers & their families were vulnerable to epidemic infectious disease Argued that it was possible for the government to improve people’s lives by bringing about reform – response was seen to lie in housing standards & hygiene regulations, paved streets & publicly funded water & sewage systems

Phase V themes (2009 – 2013) Caring and supportive environments Healthy Living Healthy urban environment and design (Healthy Urban Planning) Overarching theme Health and health equity in all local policies

Cardiff: WHO Healthy City Obesity proposed as an initial unifying theme - incorporating healthy urban planning as a major element (alongside physical activity, food, work place health and weight management) Political: Support from CMO, Tony Jewell Rodney Berman, Leader of Cardiff Council & WLGA spokesperson for health improvement has agreed in principal to taking this approach forward in Cardiff, supported by CC Corporate Directors and Proud Capital Vision Forum; will go to CC Executive Business Group on 8th Nov 07 WLGA has identified funding to advise the 4 cities in Wales in developing this approach – Cardiff, Swansea, Wrexham, Newport Infrastructure: Need to identify a focal point & someone to co-ordinate the approach Needs to be developed through a partnership arrangement (exploring how this might be done through the Proud Capital Vision Forum Politician responsible for the project Admin & office support Dedicated resources Products & outcomes: City health profile (needs assessment) Activities – programme to deliver the goals of Healthy Cities; systematic monitoring & review process Annual report must be produced using standard ‘annual reporting template’ Networking: Attend annual business meetings of the WHO European Healthy Cities network (will be held in Zagreb, Croatia in 2008) Can also join European ‘sub networks’ for different themes, e.g. Healthy Urban Planning UK currently has informal networking arrangements at the national level Require an identity, including an e-mail address & web site

Obesity – initial exemplar / unifier Partners have agreed to use the issue of obesity as an exemplar and unifier, as a framework for the Cardiff Healthy City Programme. The causes of obesity and overweight are complex, resulting in the need to implement a range of approaches and complimentary strategies to address individual, social, and environmental determinants.

Obesity Trends Health consequences Mortality Financial costs Issues are well known and will not be covered here

Obesity: What is the explanation? What in particular has changed in recent years to potentially explain the rise?

Can a city make you fat? How can a city change its environment to help prevent its people not to be obese?

Foresight Report 2007

Foresight Report 2007

Causes of obesity Causes of obesity are complex and the Foresight Report summarises: Technology The built environment Opportunities for physical activity Food and drink availability The price of food and drink Food marketing Purchasing capacity and impact on eating patterns Impact of working practices

Obesity: An Initial Exemplar and Unifier leaves people with chronic health problems like diabetes, cancer, osteoarthritis, as well as increasing mortality from heart disease and strokes. Our answer can't be to just treat people in the NHS and send them home again, Rather to design our city, educate people and provide opportunities that stop people developing these problems in the first place.

Obesity: An Initial Exemplar and Unifier Reducing obesity levels is a major challenge and involves far more than consideration of what we eat and whether we go to the gym. We need to consider: healthy urban planning, the food environment, transport, housing regeneration Introducing changes that may not be easy for us, but are critical to our long term health.

Work so far / future action Much work already focuses on tackling obesity in Cardiff To ensure co-ordination and synergy, a draft Cardiff-wide Healthy Weight Strategy and Action Plan has been developed. WHO European Healthy Cities Network will support and strengthen the delivery of this multi-agency strategy, build on current work, identify gaps in activity and address the broader issues.

Work so far / future action The momentum from WHO Healthy City should enable Cardiff to drive forward the public health agenda with regards to lifestyle choices, the impact of the built and natural environment on health and the provision of supportive services. Although the initial focus will be on obesity, the action will impact right across the determinants of health. Community involvement and engagement will be key.

Next Steps Today is both a celebratory event and a planning workshop to discuss the way forward and to develop plans for implementing the Healthy Cities Programme Health is everybody’s business The workshops will be your opportunity to: highlight issues, voice your ideas and the contributions you can make to this important work.