Why We Need Urban Health Equity Indicators: Integrating Science, Policy, and Community

Policy Forum Why We Need Urban Health Equity Indicators: Integrating Science, Policy, and Community Jason Corburn 1 *, Alison K. Cohen 2 1 University of California Berkeley, Department of City and Regional Planning & School of Public Health, Berkeley, California, United States of America, 2 University of California Berkeley, School of Public Health, Division of Epidemiology, Berkeley, California, United States of America Toward Healthier and More Equitable Cities As the world urbanizes, global health challenges are increasingly concentrated in cities. Currently, over 80% of the popula- tion in Latin America already lives in cities. The African urban population is projected to double in the next decade and China has urbanized in thirty years at a rate it took Europe and North America a century [1]. Rapidly growing new cities and increasing- ly segregated older cities in the global north and south are contributing to health inequities. Urban planning and policies can influence population health by sup- porting or stymieing opportunities for employment, housing security, political participation, education, protection from environmental risks, access to primary health care, and a host of other social and physical determinants of well-being [2]. As the World Health Organization (WHO) and UN-HABITAT acknowledged in the 2010 report entitled ‘‘Hidden Cities: Un- masking and Overcoming Health Inequi- ties in Urban Settings’’, where in a city you live and how that city is governed can determine whether or not one benefits from city living [3]. Measuring the forces that contribute to urban health is one challenge for promot- ing more healthy and equitable cities. Burden of disease estimates have tended to focus on the whole world or specific geographic regions [4,5]. These data can mask intra-city differences and global data may not be relevant to inform national or municipal policy making. Public health has developed metrics for single patho- genic exposures or risk factors, but these measures often ignore both community assets that promote health equity and the cumulative impacts on health from expo- sure to multiple urban environmental, economic, and social stressors [6,7]. Rec- ognizing these population health challeng- es, the United Nations (UN) Commission on Social Determinants of Health (2008) called for ‘‘health equity to become a marker of good government performance’’ ([8], p. 11) and for the UN to ‘‘adopt health equity as a core global development goal and use a social determinants of health indicators framework to monitor progress’’ ([8], p. 19). More recently, the 2011 World Social Determinants of Health Conference and the Pan-American Health Organization’s Urban Health Strategy called for the development of new urban health equity indicators that track the drivers of health inequities across place and time, particularly within a city neighborhood [9] (Box S1). In this paper, we briefly outline an approach for pro- moting greater urban health equity through the drafting and monitoring of indicators. We draw examples from the cities of Richmond, California, and Nair- obi, Kenya. More specifically, we argue that participatory indicator processes hold the potential to shape new healthy and equitable urban governance by: integrating science with democratic decision making; tracking policy decisions that shape the distribution of health outcomes; and including protocols for ongoing mon- itoring and adjusting of measures over time. Indicators for Health Promoting Policy Change Ongoing measurement and evaluation is one critical aspect of moving toward more healthy and equitable cities because what we measure often matters for whether and how we act. Yet, the danger of indicator efforts is that they portray a too simplified picture of a complex reality and policy solutions may suffer the same defects. For example, indicators of single chemical exposures cannot produce policy-relevant knowledge about the environmental health consequences of multiple exposures. In a similar way, cross-sectional measures of single built and social environmental fea- tures of urban neighborhoods tend to ignore the cascading and relational effects of inequalities in urban areas. For example, in our own work in the slums of Nairobi, we have found that typical indicators that only measure population access to a toilet can misconstrue whether an ablution block is hygienic or safe. In Nairobi’s slums, accessing a toilet may be controlled by a local cartel that might extort a high price for users, disproportionately impacting family income, while at the same time acting as a location for rape and sexual violence against women, particularly at night, when the toilet has no lighting or security, which in-turn might contribute to the spread of sexually transmitted diseases. Capturing the relationships between a physical or economic measure, the political decisions that shape the distribution of community resources, and how urban Citation: Corburn J, Cohen AK (2012) Why We Need Urban Health Equity Indicators: Integrating Science, Policy, and Community. PLoS Med 9(8): e1001285. doi:10.1371/journal.pmed.1001285 Published August 14, 2012 Copyright: s 2012 Corburn, Cohen. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was provided for writing this article. The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: MuST, Muungano Support Trust; UN, United Nations; WHO, World Health Organization. * E-mail: jcorburn@berkeley.edu Provenance: Not commissioned; externally peer reviewed. PLOS Medicine | www.plosmedicine.org August 2012 | Volume 9 | Issue 8 | e1001285