An urban health worthy of the post-2015 era

Abstract

This paper explores the intersections between the newly agreed urban and health Sustainable Development Goals (SDGs 3 and 11). It argues that while burgeoning studies theorizing cities of the global South have thus far largely failed to engage with the formative role of health in the experience of urban life and politics, concern with “global” health (health in the global South) has been slow to engage with the specific importance of urban issues. As these two interlinked domains skirt past each other, the potentially unifying field of urban health remains arguably marginal and under-theorized within both biomedicine and social science. The paper therefore asserts that a reinvigorated urban heath is crucial not only to realize the urban and health SDGs, but also to capitalize on new, emergent research and opportunities that may emerge as global health work shifts to better reflect the contours of the SDGs.

I. Introduction

As of 2016, the development landscape has shifted from the eight Millennium Development Goals (MDGs) and its 18 targets to a system of dramatically increased depth and complexity, operationalized through 17 Sustainable Development Goals (SDGs) and no fewer than 169 targets. Dubbed the “169 commandments” in a recent and highly reported piece in The Economist,⁽¹⁾ the SDGs’ substantial breadth has drawn both criticism and praise. Critics have tended to draw attention to:

• the vague nature of the goals and targets;

• the lack of thought regarding an implementation structure (including actors and incentives) and financing;

• the questionable cost-effectiveness of some of the targets;

• the challenges of global surveillance and progress reporting;

• an underplaying of the critical delivery role to be played by local government;

• a lack of cross-goal attention to the systemic barriers to sustainable development;

• the spatial and governance scales of target setting;

• the absence of interlinked targets that impact on the achievement of multiple goals; and

• perhaps most crucially, the absence of any overarching narrative of change that sets out the SDGs’ ultimate aspirations.⁽²⁾

On the other hand, advocates have praised the ambition and vision of the SDGs, the scale and inclusionary scope of the diplomatic process that has gone into their production, and their acknowledgement of the complexity of human–environmental systems and the logistical and political challenges of ensuring sustainable development funding in a “post-aid world” still scarred by the global financial crisis.⁽³⁾

Clearly, and despite the best efforts of the Open Working Group on Sustainable Development Goals, the SDGs can never be all things to all the people who played a part in the 26 thematic area open consultations, the 56 national consultations, the SDG e-Inventory, the Sustainable Development Solutions Network consultations, High-Level Panel meetings and, in 2015, six months of intergovernmental negotiations. Indeed, the array of amendment documents setting out proposed changes to the wording of the SDGs by “Major Groups” (e.g. the Women’s Major Group, the Business & Industry Major Group, etc.) and stakeholders’ interest groups (e.g. Save the Children, NCD Alliance, etc.) reveals the tensions and conflicts of interest inherent in any effort to address the interconnected causes and consequences of (un)sustainable development.⁽⁴⁾ In many respects, and as I will argue, SDG 3 (“Ensure healthy lives and promote well-being for all at all ages”) and SDG 11 (“Make cities and human settlements inclusive, safe, resilient and sustainable”) present some of the most obvious, yet most poorly elucidated, areas of overlap and synergy. It should also be noted that there are a raft of additional targets that are fundamental to health, for example:

• 1.3 (“Implement nationally appropriate social protection systems and measures for all”);

• 1.4 (“ensure that all men and women, in particular the poor and the vulnerable, have equal rights to economic resources, as well as access to basic services”);

• 6.1 (“universal and equitable access to safe and affordable drinking water”);

• 6.2 (“access to adequate and equitable sanitation and hygiene for all”); and

• 7.1 (“universal access to affordable, reliable and modern energy services”).

When taken together, the successful realization of these targets has profound significance for the future trajectory of the crucial, but under-theorized, discipline of urban health,⁽⁵⁾ in its concern with health as both a determinant and outcome of urban environments and vice versa.⁽⁶⁾ Just as the demands of MDGs shaped the development and character of the field of global health,⁽⁷⁾ it is likely that the “future of global heath [will be] urban health”.⁽⁸⁾ To unite two inherently interlinked domains, urban health arguably needs a greater sense of self, the need for which is the subject of this paper.

II. Mapping the Future of Urban Health

For a number of years, urban health scholars have been arguing that the urban setting is, itself, a determinant of health.⁽⁹⁾ However, the array of urban SDG targets also demonstrates the extent to which health is also a determinant of the sustainability of cities, in the sense of supporting vibrant economic and social sectors while ensuring that environmental policies are allied to health aspirations.⁽¹⁰⁾ Despite these dialectical dynamics and the remarkable success of both the health and urban SDG lobbyists in securing standalone goals, it is notable that health is thus far not listed as a thematic area or a subject for an issue paper or policy unit for the United Nations’ Habitat III event in 2016. If anything, this absence flags the still-tenuous connection between the urban and health agendas in a world where “global” health philanthropists are just starting to take the role of urban areas as seriously as technocratic solutions to infectious disease.⁽¹¹⁾ The Bill & Melinda Gates Foundation, for example, awarded US$ 27.2 million to a five-year city-level partnership programme to address urban poverty in Africa as part of its “Urban Health Initiative” special programme. Since then it has funded a number of smaller projects whose target populations have been the “urban poor”, ranging from sanitation interventions in informal settlements to tuberculosis treatment adherence. Bloomberg Philanthropies has funded significant obesity prevention advocacy efforts in Mexico, with urban concerns featuring in its funding of subway advertisements aiming to raise awareness of the causes and consequences of obesity in Mexico City. Yet, despite these tentative advances, the policy paper 2010 to 2015 Government Policy: Health in Developing Countries of the UK’s Department for International Development makes no mention of urban aspects.⁽¹²⁾ The US Global Health Programs Report to Congress for 2013 similarly makes no mention of urban matters, except for passing reference to the particular vulnerabilities of “urban slum” dwellers.⁽¹³⁾

More optimistically, the New York Academy of Medicine has recently pledged its support for “advancing the discourse of global urban health” through the work and remit of the International Society for Urban Health (ISUH). This work has culminated in the Dhaka Statement on Urban Health in Sustainable Development, agreed at the International Conference on Urban Health in May 2015. The statement calls for urban health to be a priority in the post-2015 sustainable development field and for this to recognize that cities – especially in low- and middle-income countries – can be drivers of both sustainable and unsustainable forms of development. To ensure that the former eclipses the latter, the statement calls for strong and clear governance across a variety of spatial scales: national, regional, metropolitan and local. More specifically and with regard to the SDGs, the statement calls for the mainstreaming of an urban lens across all the SDGs. And it cautions that efforts to meet the targets of the health SDG should not compromise the achievement of the urban targets and efforts to address inequities, and vice versa (e.g. that efforts to provide “sustainable transport systems” also enhance opportunities for “active travel”, rather than imposing new barriers).

This call reinforces that of this paper. In all the recent flurry of writings “from the South” on cities of the South,⁽¹⁴⁾ especially those texts calling for the strengthening of urban planning as a route to more sustainable forms of urbanization with quality of life at its core,⁽¹⁵⁾ rarely is health an explicit object of study.⁽¹⁶⁾ Vice versa, in the manifold public health engagements with health in the global South, rarely is the urban setting a cause for novel theorizing.⁽¹⁷⁾ Moreover, even in some of the most celebrated recent anthropological explorations of the everyday experiences and contradictions of global health ambitions, the urban location remains a passive (or absent) backdrop to the drama of the quotidian minutiae of everyday lives.⁽¹⁸⁾ Urban health is a recognized field of study, with its own dedicated journal. But rarely (with the exception of a few dedicated research centres such as the University of California, Berkeley’s Center for Global Healthy Cities) does this field move beyond the “shadow of medicine”⁽¹⁹⁾ to directly engage with the insights offered by shifts in urban theory drawn across an array of social sciences as well as its recent turn to complexity science.⁽²⁰⁾

As a consequence, and if the urban and health SDGs are to achieve their ultimate goals of enhanced quality of life and well-being and reduced inequities across all city spaces, then we need to go beyond using health purely as a proxy for economic concerns, the functioning of services or infrastructure. Health and cities are inextricable, especially in relation to the intersections between efforts to address communicable and non-communicable diseases and mental health with those to upgrade housing, enhance employment opportunities, transport, environmental quality and governance, and mitigate climate change and disasters. While the intersections are obvious, it will fall to an enhanced and inherently multi-disciplinary, ecologically minded urban health field to explore and explain the causal relationships between them and how they vary within and between cities.⁽²¹⁾ The complex dynamics of causality and (un)intended consequences in urban health have largely been beyond the remit of public health and epidemiology,⁽²²⁾ but have provoked substantial attention from urban theorists, even if not within the realm of health. Understanding why is crucial to developing a sustainable politics of implementation for the SDGs, as well as to grasping why and how some efforts to meet targets may fail even as others succeed. For this, a revitalized urban health field is essential.

III. Conclusions

I have explored how the aspiration of bringing forth the “supremely ambitious and transformational vision” of the SDGs for a world “free of poverty, hunger, disease and want, where all life can thrive [and] … where physical, mental and social well-being are assured”⁽²³⁾ will require more than the current field of urban health has, thus far, offered. The achievement of standalone urban and health SDGs is a testament to powerful lobbying efforts; it is hoped that the combination of the two – alongside a host of related SDGs – will profoundly reshape the future of global health priorities, diplomacy and funding streams. More than this, however, if taken forward in positive ways, the goals and their related targets hold the potential to draw attention to the social, economic and environmental flaws of current modes of urbanization. They also provide a basis by which governments can be held accountable for creating cities that have quality of life and sustainability at the core of their governance agendas, rather than the unidimensional pursuit of economic growth. Aspirations of this scale demand conceptual tools that are equally ambitious. The days of compartmentalizing public health, biomedicine, epidemiology, social, economic and political sciences, and the humanities cannot continue in a fit-for-purpose urban health domain. A new field that is bold and experimental, open to both challenging and being challenged, and attuned to the complex and volatile dynamics of urbanism is needed. Now is the time for an urban health field that better reflects the shifting demands of a post-2015 era and can shape ambitious research agendas capable of making cities healthy in the most holistic of senses.