Urban Health Equity in All Policies: Toward a new science of the city

I just published a new opinion piece in the UK Guardian about the need to integrate Health in All Policies with urban equity.  The idea is to re-orient science-policy in fundamental ways to ensure social justice is that the center of new city, state and national policy making.

http://www.guardian.co.uk/sustainable-business/urban-health-equity-policies-city

Slum Surveys: Making the Invisible Visible

Our work with Slum/Shack Dwellers International and Muungano Support Trust in Kenya was recently featured in the Guardian Weekly.  The article focuses on the detailed enumeration and surveying work by slum dwellers around the world, organized by such organizations as our partner, SDI.

In the Mathare informal settlement in Nairobi, Kenya, UC Berkeley, the University of Nairobi the federation of slum savings groups called Muungano wa Wanavijiji and Muungano Support Trust, have worked for the past five years surveying and mapping residents and their living conditions. Importantly, these are not surveys to only document the unjust living condition, but more importantly help build local power by organizing residents and providing them with one important tool to negotiate for improvements with government.  What the community surveying work also reveals is that local people are experts that must be trusted to drive policy and investments, not merely act as researchers or respondents.  Our collaborative informal settlement upgrade plan for the entire Mathare valley in Nairobi, which emerged in-part out of local knowledge from slum surveys, is one example of the type of outputs slum dwellers are capable of producing from this work.  No longer capable of ignoring the urban poor, international organizations, donors, governments, academics and NGOs should take note: slum surveys build power for lasting change.

Slums, justice & health: From Neighbourhood to Nation

In Buenos Aires, Argentina, the government has established neighborhood "justice centers" where residents of the city's poorest areas can get legal assistance to gain access to government services, including health care, housing and other life-supporting programs. The model is similar to what the Asian Development Bank is supporting in Bangledesh, where a network of community health centres that provide comprehensive and integrated services, from legal and land rights to ambulatory care, for the urban poor. Improving unjust living conditions is at the heart of both these programs: “Poor living conditions leave the urban poor, especially women and children, more exposed to health problems than the general population,” said M. Teresa Kho, Country Director of the Bangladesh Resident Mission.
Brazil remains one of the world's leaders in linking neighborhood-based, integrated and comprehensive services to health equity for the urban poor.  Brazil's Family Health Program (PSF) and related clinics, staffed by clinicians, nurses, lay outreach workers, social workers and others, is increasingly seen as a one of the most significant reasons behind the health gains being experienced by the urban poor in Brazil, as discussed in this recent Lancet series. What is important to note about the factors of success in Brazil (and granted they still have much progress to make) is that public health officials are acknowledging that reductions in morbidity and mortality for the least well off are the result of an integrated set of economic, social, and place-based policies, along with national leadership but local (municipal and neighborhood-scale) priority setting and implementation.  As a government worker in the slums of Buenos Aires noted in the below referenced article, there is no one-size-fits-all or single intervention that will change entrenched inequalities that contribute to health inequities. Rather, what is needed are integrated strategies with the power of the national government but with the accountability of neighborhood organizations: “There are economic, social, cultural and geographic barriers standing in the way of everyone having access to the same rights. For that reason, rather than sporadic interventions, what we are seeking at the centre is to provide a stable state presence.”

Making Healthy City Planning Work

Here is a recent article on some of the work we are doing in Richmond, CA, promoting Healthy City Planning. Importantly, the article emphasizes that it takes leadership and action on multiple levels to make healthy city planning work -  not just in the planning or health departments.  The City Council and Mayor have made this part of their agenda, as has the City Manager and multiple city agencies. Contra Costa County Health Services, the public health department for the city of Richmond, is also playing a leading role.  While the article rightly notes that moving toward a healthier and more equitable Richmond is not about health care alone, improving access to and affordability of clinical services is important.  To support this, the County-run health clinics, including school-based services, as well as Kaiser - the largest health care provider in Richmond - are taking an active role in linking prevention programs with essential basic care.  Perhaps most important, community-based organizations are leading the way - - organizing residents, proposing and participating in projects and holding the government and industry (such as Chevron) accountable.  One sign of growing community accountability toward health, is the resubmission on May 23, 2011, by Chevron for a Conditional Use Permit to upgrade its Richmond refinery and a commitment to address the environmental issues the company ignored and Communities for a Better Environment and others successfully sued the company to address. 
Making healthy and equitable city planning work demands action and leadership on multiple fronts, and Richmond is increasingly moving in the right direction.  

Community-led water service: Kosovo village, Mathare slum, Nairobi

Our UC-Berkeley-University of Nairobi and Muungano Support Trust (MUST) collaboration in 2009 resulted in many positive outcomes for the residents of the Mathare Valley informal settlement.  In one village, called Kosovo, we helped plan and design for piped, 24-7, water access for each household. The Nairobi Water and Sewer Company eventually installed new water pipes and community members, through Muungano, are managing and maintaining the service by supporting residents to obtain meters and assist them in paying water bills.  While a comprehensive evaluation of this intervention is ongoing, here is an article by SDI describing some aspects of this community-level utility management .  Importantly, we are SCALING UP lessons from this project in our current Mathare Valley Zonal Plan, which aims to offer a comprehensive and integrated plan for improving infrastructure, economic livelihoods, housing, land rights and essential services, such as health care for all villages and over 150,000 residents of the Mathare Valley.

$300 slum house? Worthy but Worthless

The Economist published an article last month on the competition to build a $300 house intended to improve the lives of slum dwellers.  The article came from a blog post in the Harvard Business Review by Vijay Govindarajan, of Dartmouth College’s Tuck School of Business, and Christian Sarkar, a marketing consultant, who set out to explore the possibility of Govindarajan's idea of  'reverse innovation' - or an idea that starts in the Global South and makes its way to more wealthy nations (many of us know this already happens through stolen intellectual property, but that is a topic for another post).
What is the problem you ask?  Well, for starters, the response, Hands off Our Houses, in today's NY Times captures why this is fundamentally a bad idea for the urban poor - it doesn't include those intended to live in these houses in the design process.  This is a also a BAD idea because it fails to grapple with the complex relationships in informal settlements between housing, land rights, economic opportunities, gender rights, health and safety and a host of other issues.  With worthy intentions, this idea is likely to redirect resources toward a worthless outcome - a rational and nice looking house that will not improve the lives of slum dwellers.   
A fundamental error here is that design alone is NOT the solution - despite what green builders, architects, entrepreneurs and others continue to say.  The solution is an urban planning process where:
(a) slum dwellers drive the process;
(b) designs are not one-size-fits-all - but flexible to accommodate different uses, can expand and improve the existing social and cultural fabric of a community;
(c) donor & private sector resources support improvements to basic infrastructure (i.e., water, sanitation, roads, electricity, etc), schools, health care facilities AND housing, and;
(d) the process offers jobs, new skills, and builds community power.

Well, this isn't easy either, but it is being done.  Slum/Shack Dwellers International (SDI) has been doing just this in tens of countries around the world.  As I've mentioned in previous posts, our team at UC Berkeley has been working with one SDI-affiliated network, Muungano WA Wanavijiji, since 2008 to support community-led planning in the Mathare Valley informal settlement in Nairobi, Kenya.  Our process aims to act as an alternative to other planning and housing improvement schemes in Kenya, particularly the Government of Kenya's slum upgrading project in Kibera - -  where the government built housing for the urban poor, but local people prefer to rent out the housing rather than live in it! 

We must avoid the boutique design and technological quick-fixes promoted by business schools and the global elite in the donor and entrepreneurial community and invest in complex, messy, people-centered, locally-driven processes.  

Jason Corburn Keynote at International Conference of Urban Health

Jason Corburn at the ICUH 2010 from The New York Academy of Medicine on Vimeo.

Berkeley's Nairobi Slum Upgrading Project & UN-HABITAT

Professor Jason Corburn is delighted to report that he and partners from his collaborative slum upgrading project in Nairobi, focused on the Mathare Valley informal settlement, were invited to present at the 23rd Session of the Governing Council of UN-HABITAT, in April 2011.  Our partner organizations include the University of Nairobi, Slum/Shack Dwellers International, Muungano Support Trust (MUST) and Pamoja Trust.  Jason Corburn's project at UC Berkeley was also invited to join The Habitat Partner University Initiative, which aims to promote the cooperation between UN-HABITAT and institutions of higher education, to facilitate exchange and cooperation between and among universities in developing and developed countries, to link UN-HABITAT’s approach on sustainable urbanization with university curricula and to bridge the gap between theory and practice by strengthening knowledge management, training for practitioners, providing policy advise and by preparing students for the needs of cities.

Cities & Environmental Health Regulations

Moving toward more healthy cities will require better enforcement of exiting environmental laws and new environmental health regulations tailored to protect a city's most vulnerable populations.  A recent decision by the US Supreme Court refusing to hear New York City's case for why they want to regulate fuel emissions from taxis sets a dangerous precedent that may limit local governments' ability to set health-protective rules.  The Court refused to hear the City's case for why local jurisdictions should be able to regulate automobile emissions by stating, in-part, that the setting of ambient air pollution and vehicle emissions standards is the responsibility of the Environmental Protection Agency under the  Clean Air Act (CAA).  Yet, since the 1970 Clean Air Act, local governments, particularly California, have been allowed to set their own, more strict air pollution regulations because of their "compelling and extraordinary" circumstances related to unhealthy air.  The Obama Administration recently reiterated their support for California's more-strict air pollution rules in an executive order.  California has also been allowed to move forward, ahead of the EPA and Congress, with climate change related regulation.  In short, the Supreme Court's refusal to hear New York City's case for clean vehicle taxis is a major step backwards for allowing local governments to innovate and set health-protective regulations and comes, not surprisingly, as republicans unfairly attack the EPA.  To help show the importance of the CAA, EPA and local air regulations, the EPA released a new study  highlighting that the benefits far exceed the costs of clean air regulations (see example in table below).  Now is not the time to scale back or limit government regulations that can improve urban health and benefit the economy.

Toward the Equitable & Heathy City - Santa Ana, California

I recently gave a talk at UC Irvine on my book, Toward the Healthy City, and we had close to 200 people turn out, including many community members from the City of Santa Ana.  Santa Ana is one of the sites for the Building Healthy Communities (BHC) initiative sponsored by The California Endowment.  I also participate in a half-day workshop organized by Professor Michael Montoya, students and community organizations working in both the Santa Ana and Long Beach BHC sites.  The folks organizing for health equity in Santa Ana are doing amazing work, particularly America Bracho of Latino Health Access.  America is one of the most dynamic and inspirational community organizers and public health leaders in the United States.  We talked about the importance of and difficulty to sustain long-term community-university partnerships and the critical role of local knowledge for addressing health inequities, something I wrote about in my first book Street Science.  In particular, Latino Health Access has trained community leaders through their Promotores model, and these folks (mostly women) are some of the most important experts on what it will take to build a more equitable and healthy community.   I learned a lot from America and enjoyed our conversations about how to truly work for a more healthy and socially just city that address the specific needs of Latinos, people of color and everyone. I truly look forward to working closer with her team to help build a more equitable and healthy Santa Ana.   

Kenyan Informal Settlements Improvement Programme (KISIP)

The Kenyan government recently launched the Kenyan Informal Settlement Improvement Programme (KISIP) with the soupport of the World Bank and the Swedish International Development Agency (SIDA).  Our partnership in Kenya that includes the Muungano Support Trust (MUST), Slum Dwellers International (SDI) and the University of Nairobi, Department of Urban and Regional Planning, and my team at UC Berkeley, have been actively involved in trying to shape this program to ensure civil society groups are at the table and shaping project investments.  Our work in the Mathare Valley informal settlement in Nairobi aims to act as a model for how urban upgrading can meaningfully involve community residents, NGOs, the academic community and local service providers including government agencies.  We are also working to ensure that KISIP and other Kenyan Government supported initiatives aimed at improving the well-being of slum dwellers, such as the Kenyan Slum Upgrade Program (KENSUP) supported by UN-HABITAT, learn from the expertise of residents, the enumeration and planning work that has already happened and continues in communities like Mathare, including the plan our team helped draft for the Kosovo community in Mathare.  I am also leading a studio class during this semester that will run simultaneously at Berkeley and the University of Nairobi, involve all our community partners, and will draft an upgrading plan for the entire Mathare Valley in Nairobi.  More on that soon.

Healthy Planning in California

In spite of the economic downturn, incorporating public health into the planning process is increasing in California. From Sacramento to San Diego, planners are slowly realizing that land use and other urban planning decisions are health policy decisions. Whether these actions, which include Health Elements in General Plans and using Health Impact Assessment to review development and other decisions, will focus only on relatively apolitical built environment issues (like walking and community gardens) or include more important political and social determinants of urban health equity -- such as poverty, residential segregation, tax policies, and building community power  - - is yet to be seen.  As I've noted in other blog entries and in my book, Toward the Healthy City, the impetus for this reconnection of planning and public health is coming from community-based organizations, with resources from foundations, not planning departments.  County health departments, especially those in San Francisco and Alameda, have been key leaders and will need to increase their efforts to bring along complacent planning agencies. An article in the The Sacramento Bee reviewed some of the efforts across the state, many of which are funded by The California Endowment's Healthy Communities Program:
http://www.sacbee.com/2010/11/14/3181550/urban-hip-and-healthycan-wellness.html

MDGs - Focus on equity, not just poverty

The summit on the Millennium Development Goals last week at the UN highlighted that the indicators are mixed bag of failure and success...even with 5 years to go.  Failure because they tend, among other things, to measure national progress which can mask within country inequalities and few countries in the global south have systems in place to report on the measures.  Yet, the mere existence of the MDGs provides a space for discourse about development and ways to make the world more equal...even if the measures alone, if reached, won't get us there.  A new blog on the Guardian's web site is one of the best I've seen on these issues. Madeleine Bunting, a contributor to the Guardian, has an especially interesting post on why equality, not just measures of development "progress," are not a major priority of the UN, but should be.   

Boston Health Commission: Where you live matters for health equity

Following the work of other local health departments, such as Alameda County in the San Francisco Bay Area, the Boston Public Health Commission has launched a program to address health disparities in the city's neighborhoods.  A fancy web site, http://whatsyourhealthcode.com/, emphasizes that PLACE MATTERS for health. Unfortunately, only $150,000 is dedicated to this campaign and most of the "Take Action" suggestions do not give the reader any clues about how local, state and federal policies are largely to blame for health inequities and that new policies are needed to reverse these inequities.  The Boston Public Health Commission's Center for Health Equity and Social Justice does have some more direct information and action items, including some excellent presentations on the relationships between structural racism and health.  Planners and others can build all the community gardens, parks, sidewalks and bike lanes they want, but until we start getting serious about reversing the connections between racism, place and health, those built-environment strategies alone are not going to move society toward more healthy and equitable cities.

Making Environmental Justice a priority...again

The Obama administration finally got around to convening the Interagency Working Group on Environmental Justice. This group, established in 1994, had not met for almost a decade.  A Federal Advisory Committee, this group was a very important forum for EJ activists and others to gain the attention of federal decision makers.  I remember attending one meeting of the IWGEJ where residents from Mossville, Louisiana, made their case about dioxins and other chemicals in the air and water and related health issues facing their community and the adjacent chemical plants.  The EPA and other federal agencies were forced to respond and are continuing to address EJ concerns in Mossville.   This forum was also supposed to hold EPA and all agencies accountable to their mandate to develop policies and strategies for incorporating EJ analysis into agency decision-making.  Hopefully this meeting will show some real leadership to follow-through on the EPA's own Inspector General report from 2006, that revealed few if any EPA senior managers were directing their staff to conduct EJ reviews of federal policies, programs or projects.  Implementing this step alone could have a significant and lasting positive impact on urban health inequities in communities across the country.

Sustainable development from Obama?

As I've noted in this blog before, the Obama Administration has a number of iniatives that are aiming to promote sustainable development.  The most visible program is called Sustainable Communities and is a partnership between 3 federal agencies: EPA, HUD and DOT - or environment, housing and transportation. The program is off to a commendable start: re-introducing regional planning into the lexicon of the federal government, re-connecting land use, housing and transportation decisions and, at seeming to place equity as a key priority.  They iniative is up against years of federal, state and local actions that have contributed to unsustainable and most importantly for environmental health, inequitable development.  Razing urban neighborhoods to build the interstate highway system, promoting white-flight to suburbs through mortgage insurance policies, concentrating poverty and racial residential segregation through federal housing programs, and siting multiple hazardous facilities, such as sewage treatment plants and power plants, in low-income, communities of color - - are just some examples of federal policies that this initiative must confront.  An article from The American Prospect, The Reverse Commute,  reviews this program and the myriad of challenges it faces - - particularly its tendency to over-rely on New Urbanist design principles to move the nation toward sustainable development.   Written by a planner and someone with experience of social justice issues in cities, this is one of the better articles on the program but fails to engage enough with the issues of bureaucratic fragmentation and issue segmentation, home-rule, and structural racism that continue to plague our planning institutions.  

 

Here is a recent press release detailing the federal funds behind this program and their attention to livability and human health.

HUDNo.10-131/U.S. Department of Housing and Urban Development (HUD

 

Planning, sexual violence & HIV/AIDS

A new report from Amensty International confirms what we have seen and heard in our own work in Nairobi's slums: a lack of planning contributes to sexual violence against women, including rape, and the spread of HIV/AIDS.  The Amnesty report, called Insecurity and indignity: Women's experiences in the slums of Nairobi, Kenya, documents the experiences of women living in four of Nairobi's slums, Kibera, Mathare, Mukuru Kwa Njenga and Korogocho. Of course, planning is not solely to blame, but lack of adequate toilets, places to bathe, lighting, housing, and other place-based issues make life insecure for many girls and women living in slums.  Violence against women also happens inside the home, at the workplace and is unacceptable anywhere, anytime.   Compounding the problem is that violence against women, from rape to domestic abuse, often goes unreported and unspoken about, adding to the trauma.  Police presence is rare in Nairobi's slums and in Mathare and Makuru, where we are working, social control is more often by youth gangs than any government authorities.  Another horrific outcome of violence against women is the spread of STDs, especially HIV/AIDS, and the burden this places on women, families and entire communities. 
For more media coverage of this important issue: Fears of rape in Kenya's slums 'trap women'

Sustainable Urban Development Act 2010

New legislation sponsored by John Kerry, called the Sustainable Urban Development Act of 2010 (S. 3229), directs the United States Agency for International Development (USAID) to focus on urban planning and governance issues because this is a priority of US foreign policy.

The legislation calls for USAID to address common issues in cities of the global south, including growing informal settlements, increasing levels of pollution, overburdened transport systems, and lack of affordable housing, land tenure, gender equality, and basic water and sanitary infrastructure. The legislation calls for updating the Making Cities Work Strategy, and focusing on supporting urban planning and governance strategies, with an emphasis on community participation in decision-making. establishing a senior adviser for urban sustainable development at the agency and launching a 'pilot urban strategies initiative' implemented in select cities in the global south.
Some more commentary on this important legislation from the Cities Alliance and IRIN news.

Read more about the Making Cities Work Strategy here.

Health care legislation, disparities & healthier places

Lost in the media coverage of March 2010's Health Care legislation (namely the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010) were some important provisions to address health inequities experienced by both populations and places. Here are some of the important sections I've found. Please send me yours.

SEC. 2303. COMMUNITY HEALTH CENTERS = $9 Billion allocation!
SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE SERVICES = with a focus on health disparities.
SEC. 3151. COMMUNITY PREVENTION AND WELLNESS SERVICES GRANTS for
HEALTH EMPOWERMENT ZONES = community-based projects that address multiple causes of health disparities.
SEC. 399Z-1. SCHOOL-BASED HEALTH CLINICS = Communities with high percentages of children and adolescents who are uninsured, underinsured, or eligible for medical assistance under Federal or State health benefits programs.
SEC. 339. GREEN SCHOOLS = improving the physical quality of the school environment.

OK, not enough, and we should already have a government run health system for all, but these additions to the legislation should contribute to addressing health inequities.  Better sumthin' over nothin'.

Racism & wealth in the US

In 1903, W.E.B. DuBois said in The Souls of Black Folks: "To be a poor man is hard, but to be a poor race in a land of dollars is the very bottom of hardship."
One of the most important, but ignored in most US media, stories of the last week highlights this hardship in a striking way.  A study,  published by the Institute on Assets and Social Policy at Brandeis University (one of my alma maters) found that the wealth gap between blacks and whites quadrupled between 1984 to 2007; from $20,000 in 1984 to $95,000 in 2003! This gap persisted for African Americans and white families in the same income range. Wealth is defined by what you own minus what you owe, so this is a much more robust and important measure than income or poverty status. What we need to remember is that income quality doesn’t lead to racial wealth equality and this helps explain the persistence of racial and ethnic health inequities!


These data are disturbing for blacks and Latinos, and especially for single women of color:

One reason for this is racism in our policies - such as tax cuts for investment income (the tax rate on capital gains income is only 15%  while ordinary paycheck income is taxed at 35%) and inheritance taxes - both of which benefit the already (mostly white) and wealthy.  Persistent discrimination in housing, credit (think predatory/subprime lending, credit-card debt and pay day loans/check cashing stores), and labor-markets also perpetuate these wealth inequities.

The solutions? TARGETED PUBLIC POLICIES, with the federal government leading the way! Federal policies must close tax loopholes exploited by businesses and redistribute the wealth of the rich - whose wealth often relies on federal government built highways and tax codes.  New wealth building opportunities must be targeted to families and communities of color whose lives and health are made even more precarious by not having enough assets to stay healthy when an economic challenge arises.