Economic inequalities are playing a large role in determining health in cities. Photo credits: Jon Tyson via Unsplash
The UK chief medical officer (CMO) advises the government on public health and represents the UK in the World Health Organisation. Every year, the CMO publishes a report on a particular aspect of health in the UK to advise the government in detail on pressing issues. Previous reports have covered topics like ageing, air pollution, and antimicrobial resistance; this year’s report is on health in cities. This is particularly important as around 85% of the UK population lives in urban areas—London alone is home to over 1 in 10 Brits. They are the engines of Britain economically, socially and culturally. Getting health in cities right is vital for UK public health.
Major cities have many unique traits that affect public health in positive and negative ways. For example, people in cities are, on average, younger than in rural areas, giving urban areas a better old-age support ratio, making it easier to provide social care for the elderly. Also, cities often have large teaching hospitals that conduct lots of research, which typically results in more advanced treatments. However, urban populations are much more mobile than rural ones, making it more difficult to have consistently high regular immunisation rates and to have a stable relationship with a trusted GP. Air pollution is also concentrated in cities, and quality green spaces can be harder to access, both of which have health impacts that will be elaborated on later. Finally, and arguably most importantly, cities can have stark economic inequality, leading to significantly different health outcomes between communities living in geographical proximity. These examples of the unique health contexts in urban areas highlight that a biomedical perspective alone is insufficient to understand health in cities.
…cities can have stark economic inequality, leading to significantly different health outcomes between communities living in geographical proximity.
Examples
The report outlines the role that urban design plays in health. In theory, the highway code contains a hierarchy of road users that prioritises pedestrians and cyclists over cars and vans; however, in practice, this is not consistently applied to urban design. This discourages active travel (getting around by walking, wheeling or cycling), resulting in more driving. Active travel, or rather regular exercise, brings a variety of health benefits such as improving cardiovascular and mental health and reducing the onset of cancer. However, air pollution (of which vehicle traffic is the largest contributor) can accelerate the development of strokes, lung cancer, and respiratory infections and worsen asthma. In contrast, research from the University of York has found that access to quality green and blue spaces (areas taken up by plants or water) reduces all-cause mortality and improves mental wellbeing; simply viewing green or blue spaces out your window improves your perception of your general health by 10%. Therefore, designing cities in a way that makes it harder and less pleasant to walk and cycle results in fewer benefits from active travel and greater exposure to the harmful effects of air pollution.
…there is a correlation between economic deprivation and age-standardised mortality rate.
The report also highlights the role that social deprivation plays in public health. Deprivation is not unique to cities, but it is particularly concentrated in them—major cities contain over a quarter of Britain’s 10% most economically deprived. This matters since economic deprivation limits people’s access to good housing and education. Healthy, organic food is more expensive than unhealthy, ultra-processed food, contributing to those with lower income typically having poorer-quality diets. It is not surprising, therefore, that there is a correlation between economic deprivation and age-standardised mortality rate. This takes the relative age makeup of the population into account, meaning that higher mortality rates are not simply the result of a group being older, suggesting that the correlation is likely linked to economic deprivation. This demonstrates that economics and demography, like geography, are highly relevant to field of public health.
Discussion
Overall, cities are worse at preventing ill health than they are at treating it: it is harder to stay healthy in cities than in the country, but easier to access healthcare once things go wrong. For example, urban design choices make it harder to achieve the NHS-recommended minimum of 150 minutes of moderate exercise per week in cities, but it is much easier to access a variety of hospitals once the consequences of physical inactivity, such as cardiovascular disease, emerge. This illuminates the biggest pitfall of current public health management in cities: preventing disease is both cheaper for the government and better for the patient than curing diseases once symptoms appear. This does not mean that health in cities is worse than health in the countryside, since accessing healthcare can be challenging in remote places; it means that geography and other social factors play a large role in determining what specific health challenges people face.
…the biggest pitfall of current public health management in cities: preventing disease is both cheaper for the government and better for the patient than curing diseases once symptoms appear.
What the CMO’s report highlights is that there is far more to health than just medicine. The role that economic deprivation alone plays demonstrates clearly that social factors play a huge role in public health. These people live in the same country, with some of the world’s most advanced medical technology, yet experience wildly different health outcomes. The major threats to health in cities are not problems solely rooted in physiology, genetics or pathology, but instead phenomena that are greatly influenced by urban planning, sociology and public policy—ultimately, the solutions to health problems lie in both the medical and the social. Prevention is better than cure, which is why interdisciplinary research extending beyond the medical sciences is essential to improve health in cities.
**some ideas expressed in this article are opinion, and may not represent the opinion of The Oxford Scientist as a whole**
