1. Urbanization as a Social Determinant of Health
Marilyn Rice, MA, MPH, CHES
Senior Advisor in Health Promotion
Coordinator, Urban Health & Health Determinants Team
Area for Sustainable Development and Environmental Health (SDE)

2. Social determinants of health (SDH): what and why?
What: a body of non-medical factors that affect individual health status
Examples: ethnicity, socioeconomic status, employment, food access, housing
Why: integrating SDH into health programs addresses root causes of health issues
Why treat someone only to return them to the situation that caused the illness in the first place
Diagram:
Downstream SDHs (black): temporally and spatially close to health effects, but influenced by upstream factors; examples—health-related knowledge, attitudes, beliefs, behaviors
Upstream SDHs (gray): fundamental causes that initiate causal pathways leading to health effects through downstream factors
Experts now realize that quality of and access to medical care is not the only determinate of good health. Common, everyday factors are just as significant.

3. Why urban health matters
Urban populations are increasing
Cities concentrate assets and solutions as well as risks and health hazards
Cities can promote well being or unhealthy lifestyles
Poverty is exacerbated in cities
Urban health matters for more and more people as the urban population continues to grow. Urbanization is not inherently bad for health. In general, urban populations are better off than their rural counterparts. They tend to have greater access to social and health services, higher literacy rates and longer life expectancy. When cities are planned, managed, and governed well, life flourishes for most residents and health outcomes surpass those seen in rural areas.
While cities concentrate opportunities, jobs, and services, they also concentrate risks and health hazards. Adverse effects are amplified due to large numbers of people living close together. Examples of this include water contamination, high levels of air and noise pollution, natural disasters, or a disease outbreak.
Cities also tend to promote unhealthy lifestyles, such as cheap and convenient diets that lack essential nutrients, sedentary behaviors, and the harmful use of alcohol, tobacco, and drugs  directly linked to obesity and the rise of chronic conditions like heart disease, stroke, cancer, and diabetes
These conditions are costly to treat, for households and communities, and they are increasingly concentrated in the urban poor.
The growth of cities is being accompanied by a shift in the burden of poverty. Poverty has become heavily concentrated in cities. Nearly every city everywhere has pockets of extreme deprivation together with extreme wealth. They have people who over-consume health care, and pay too much for it, together with people who forego the most basic and essential care for financial and other reasons.
The health consequences of poverty and deprived living conditions are contagious in a city setting. They are detrimental to city dwellers. Societies with big differences in opportunities, income levels, and health outcomes tend to have less social cohesion and more violent crime. Social unrest, violence, and outbreaks of disease can easily spread beyond a single neighborhood or district to endanger all citizens and taint a city’s reputation.

4. Urbanization is associated with many health challenges
Communicable diseases
Non-communicable chronic diseases and their risk factors
Violence
Harmful use of alcohol, tobacco and other drugs
Mental health, stress and social isolation
Road safety
Infant mortality

5. Key Challenges for Cities
WHO Kobe Centre “Our cities, our health, our future: acting on social determinants for health equity in urban settings” 2008, Kobe Japan 5

6. Some causes of challenges:
Different SDHs lead to individual inequalities in access to resources:
Social
Political
Economic
Cultural
Environmental
Perceived vs. real benefits of living in an urban setting
Crime in the last two weeks: a large proportion of crime occurs in a 5-6 block cluster in San Francisco.

7. Per 100,000 individuals

15. Poverty and health in the city

16. Why should local governments get involved in urban health?
Targeting SDH also addresses other endemic social issues
Health promotion is cost-effective
Local governments
Have the power to create and lead intersectoral partnerships at low costs and combine resources across sectors
Are able to influence policies, laws, and provision of human services
New York food improvement initiatives coordinated by mayor with private sector restaurants:
-water automatically served to all guests immediately at restaurants
-salt shakers withheld unless requested by customer
-food industry commitment to NO trans fats
-caloric information provided on restaurant menus
and for NY environment:
-smoke free parks and open spaces
-closing streets on weekend for more open spaces to exercise
In San Francisco County close to 200 people died annually from acts of violence. Community impact is costs which are often publicly born: average hospital charge for treating one firearm injury victim exceeded $29,000, and the total costs for treating 109 victims reached $3.2 million in San Francisco government began publically releasing data, implementing statistical analysis program for crimes, and having community meetings with citizens. Despite drastic cutbacks in police force and after years of high crime, crime decreased by 9% from 2009 to 2010, violent crime decreased 4% from 2009 to 2010.
Hidden Cities Report: Local authorities are often well-positioned to lead health promotion programs:
- have influence over land use, building standards, water and sanitation systems, roads and transportation, environmental protection, enactment or enforcement of tobacco use bans - oversight of occupational health and safety regulations
- play a significant role in the provision of a range of human services fundamental to health: education, social services, health services, libraries, parks and recreation services, and community development

17. What can be done to make cities healthier?
Attend to the needs of the vulnerable population and include them to reduce inequality
Participate in urban planning that promotes safe, clean spaces and healthy environments
Creating laws and municipal politics that reduce violence, the degradation of the environment, and that promote healthy living
Investing in improving urban living conditions that attend the needs of living, social protection, and conditions of employment
Building adaptable, accessible, and comprehensive cities for the elderly
Cultivate networks to create and sustain social capital
Mobilize existing community capacities & resources
Permit the intervention of the civil society in making decisions by governing urban participation
Construct buildings and infrastructures that are safe and can support disasters and emergencies
Adopting equal health as a fundamental objective shared among the different sectors: government, NGOs, private sector and citizens
Integrate health actions with income generating activities
Make available ongoing training for professionals on new topics
Move forward an urban health research agenda
Public politics can do a lot to improve the urban environment. A good urban plan, for example, includes dispositions to have clean public spaces, basic services of water and clean-up, public transportation and optimized traffic management, as well as roads and paths for walking and cycling, and safe meeting places. All this helps to create healthy spaces and to promote healthy behaviors.
The laws and municipal politics can also help to reduce the violence and to promote healthy ways of life by reduction of tobacco consumption, alcohol and other drugs, and promoting physical activity. Also, politics that reduce air pollution, including the emission of greenhouse gases and chemicals, are important.
It is very important to reduce inequities and to increase the participation of the different sectors and civil society, undertaking the needs of the most vulnerable, including inhabitants of shanty towns, elderly, people with disability, street children, and homeless adults. The investment in improving the urban living conditions will have large benefits. One of the better examples is the configuration of "healthy spaces", according to which the municipalities, communities, schools and places of work take measures to improve their own environment and to promote health among their residents or associates. It will be fundamental to be centered in attending and to include all the inhabitants.
In recent months, we have seen also --under the most tragic human point of view in JAPAN -- the vital importance of the planning and construction that assures that buildings and the urban infrastructure are safe in case of an earthquake or another disaster.

18. How can PAHO help? Tools and instruments:
HMC Network – linking members and experiences
Economic impact of health promotion efforts
Mayor’s Guide to MDGs
Mayor’s Guide to HMC
Urban HEART and HIA/HEIA
Participatory evaluation of HMC
PAHO Documentation Template

19. URBAN HEART Assessment an indicator guide
Response a guide to plan action
Urban HEART is a user friendly tool for city officials to identify inequities in health and health determinants, and develop appropriate responses to them. The tool was piloted in in cities from 10 countries across the world, and with inputs from an expert international advisory group.
There are two main components of the tool: (1) assessment which is an indicator guide consisting of both health outcomes and health determinants indicators, and (2) response a guide to develop a plan of action based on the assessment with references to best practices on key topics. The tool is accompanied by a User Manual which identifies a six step process to implement the tool in a city. 19

20. How can we work together?
Contribute to PAHO’s documentation template
Join PAHO’s SDE listserv:
Participate in Urban HEART and Health Impact Assessment workshop in Bogotá (9-13 May 2011)
Organize events during Wellness Week on NCDs (12-17 September 2011)

21. Thank you! Marilyn Rice, MA, MPH, CHES ricemari@paho.org
Area for Sustainable Development and Environmental Health (SDE)
Pan American Health Organization
SDE site:
Can you give us some examples of successes in preventive programs?
New York City
In photo: 78th Street, between Northern Boulevard and 34th Avenue, is closed to traffic on Sundays in Summer to allow for games, free play, performances, markets, and other activities to take place in the car-free street.  78th Street is right next to Travers Park, which is very crowded on weekends, and often there is not enough space for everyone to enjoy the park. The Play Street makes it possible for the park to spill into the street, allowing people to stroll, play, attend events and relax in the space, while reducing crowding in the park. We need more park space, and the Play Street is a small practical step in our search to expand and improve neighborhood parks. The Play Street is also a space for the Greenmarket to expand, adding more vendors, and making it more comfortable for shoppers. 
A coalition of neighborhood groups initiated and developed this project with the support of NYC Department of Transportation. These groups are: JH Green, Friends of Travers Park and The Western Jackson Heights Alliance.
2. San Francisco crime mapping—a collaboration between the local government (police department) and citizens (through regular community meetings with police): the police department began publically releasing all crime reports; the data is analyzed by government’s CompStats project and released online; citizen feedback through community meetings has altered the way policing occurs—a success despite drastic cutbacks in police force and resources: after years of high crime, crime decreased by 9% from 2009 to 2010, violent crime decreased 4% from 2009 to 2010
Play Street (78th St), NYC: car-free on weekends for physical activities, performance, markets; collaborative work of neighborhood groups and Dept. of Transportation