The City as an Instrument of Public Health
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Cities are the future; the near future. According to WHO projections, by 2050 over two-thirds of the world’s population will live in a city.
What does this mean for public health? It could be nothing short of catastrophic, placing an increasing burden on health systems worldwide as unhealthy lifestyles associated with urban areas become commonplace. Food is fast and unhealthy, pollution is rampant, transport is often motorized, making physical exercise unnecessary, and excessive alcohol and tobacco consumption are a part of a common lifestyle: a deadly combination for the development of non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, and cancer.
The concept of urban health is becoming an increasing concern as awareness of the true extent of the issue spreads. Particularly for health services in low and middle-income countries (LMICs), which are already struggling to cope with the burden of infectious diseases, the added pressure of NCDs poses a serious threat.
And yet, this does not need to be the case. There is positive work that can make an enormous difference to the health of city-dwellers. We need to close the gap between awareness and action, recognizing cities’ potential enabling features to address public health issues.
Compared to rural areas, cities can be relatively well resourced with healthcare workers, and supported by more developed facilities and infrastructure. The concentration of people and skills make cities a good site for public health initiatives that aim to operate at scale to improve outcomes for as many people as possible as quickly as possible.
Better Hearts, Better Cities
The untapped potential of cities was a key consideration for the Novartis Foundation’s new urban health initiative, Better Hearts Better Cities. Our program seeks to improve the control of hypertension – or high blood pressure – as a key modifiable risk factor for cardiovascular disease.
Despite evidence on how to prevent, treat and manage hypertension, control rates in many LMICs are extremely low. This places a disproportionate burden on health systems, where resources to deal with chronic conditions are scarce. For example, the control rate of hypertension is just 8% in Senegal,[i] compared to 66% in Canada and 53% in the USA.[ii]
A Multisector Approach
The challenges surrounding hypertension require action on several fronts, including:
- Strengthening health systems and innovating care provision
- Encouraging physical exercise through smart city design and urban planning
- Creating a healthy food environment for the city populations
- Establishing policies to encourage smoking cessation and reduce alcohol consumption
- Improving air quality and addressing other environmental factors
These challenges are systemic and require a multisector approach if we are to tackle hypertension in an integrated and sustainable way.
Better Hearts Better Cities is convening sectors beyond healthcare – including local governments, digital and telecommunication organizations, food suppliers, employers, insurance funds, social enterprises and civil societies – bringing together complementary expertise and resources to co-design and implement interventions that can be effective at scale. Made up of both public and private organizations, the network will operate globally and at the local level.
Active participation and buy-in from local government is vital to achieve longer-term impact and sustainability in strengthening the health system.
Technology makes cities more inclusive, connected, healthy and vibrant and, as cities become home to an ever-increasing proportion of the world’s population, new challenges and opportunities will arise for digital health to improve population health outcomes.
From raising disease awareness to screening, diagnosing and monitoring hypertension, digital health technology can support healthcare providers and empower patients to better manage their disease. It also provides better data reporting, enables real-time, data-informed decision-making and can reduce costs while increasing patient engagement and improving overall quality of care.
Through partnerships with companies such as Intel Corporation, Better Hearts Better Cities brings together complementary expertise to co-design and implement interventions beyond healthcare.
The implementation of Better Hearts Better Cities is underway in Ulaanbaatar, the capital city of Mongolia and home to half of the country’s population.
Ulaanbaatar is one of the world’s most polluted cities, clouded with dense smog caused by ever-increasing traffic and indoor heating from coal, log, or earth fires in the Ger districts, which are informal settlements on the outskirts of the city.
There is a very high prevalence of smoking (21.7%) and excessive drinking (23.5%), and the population consumes a diet high in salt and low in fruit and vegetables. All of this contributes to a growing health burden, with cardiovascular disease accounting for over 40% of deaths every year, and more than 25% of the population suffering from hypertension.
In Ulaanbaatar, the first wave of Better Hearts Better Cities will focus on strengthening primary care, improving awareness and screening opportunities, addressing barriers in access and quality of care through digital health tools, and working with government and other local partners to improve affordability of care.
In addition, Intel recently conducted an ICT assessment in order to accelerate implementation of a digital platform to assure a coordinated care pathway for hypertension and its CV complications across the different levels of healthcare.
- An audit of the status of hardware, network and data exchange capabilities
- Data application standards
- Dialogue with future users to ensure barriers to the uptake of new tools would be considered
Every city has its own unique environment, culture and combination of lifestyle factors which contribute to the growing burden of hypertension and make it such a complex disease to tackle.
But cities are also united by one common feature: the opportunity presented by the concentration of people, sectors and disciplines in a single area. Better Hearts Better Cities will initially demonstrate the feasibility of a multisector approach to address hypertension in three cities. The ultimate goal being to identify an approach that can be applied to tackling other NCDs in cities around the world. After all, cities are only as healthy as their citizens.
This is an ambitious project. But big problems need big solutions. If those who design, plan, build and govern cities recognize the power of the city and its citizens and agree on sustainable plans, there is huge potential to improve people’s quality of life and reduce the burden of NCDs worldwide. That is surely something to aim for.
Visit the Novartis Foundation website for more information on Better Hearts Better Cities and follow us on Twitter at @NovartisFDN for regular updates on our initiative.
[i] WHO STEPS survey, Senegal 2015. Available at: http://www.who.int/chp/steps/Senegal_2015_STEPS_FS.pdf?ua=1
[ii] Joffres M, Falaschetti E, Gillespie C, et al. Hypertension prevalence, awareness, treatment and control in national surveys from England, the USA and Canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study. BMJ Open 2013;3:e003423. doi: 10.1136/bmjopen-2013-003423
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“Every city has its own unique environment, culture and combination of lifestyle factors which contribute to the growing burden of hypertension and make it such a complex disease to tackle. But cities are also united by one common feature: the opportunity presented by the concentration of people, sectors and disciplines in a single area.”
If this trend continues, do you expect tele-health to decline? I mean, doctors tend to be more accessible in urban areas (as compared to rural ones). Plus there is currently a proximity limit on tele-health devices for providers receiving government funding.