Innovating for Healthy Urbanization

Transcription

1 Innovating for Healthy Urbanization

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3 Roy Ahn Thomas F. Burke Anita M. McGahan Editors Innovating for Healthy Urbanization

4 Editors Roy Ahn Division of Global Health and Human Rights Department of Emergency Medicine Massachusetts General Hospital Boston, MA, USA Thomas F. Burke Division of Global Health and Human Rights Department of Emergency Medicine Massachusetts General Hospital Boston, MA, USA Anita M. McGahan Rotman School of Management University of Toronto Toronto, ON, Canada ISBN DOI / ISBN (ebook) Library of Congress Control Number: Springer New York Heidelberg Dordrecht London Springer New York 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer Science+Business Media LLC New York is part of Springer Science+Business Media (

5 Foreword Urbanization is essentially the physical growth of urban areas as a result of rural migration. The United Nations projected that half of the world s population would live in urban areas at the end of 2008 (International Herald Tribune, Associated Press, February 26, 2008). By 2050, it is predicted that 64.1 % and 85.9 % of the developing and developed world, respectively, will be urbanized ( Open air computers, The Economist, October 27, 2012). Urbanization has serious implications for health, and calls for innovations in global health professional education. Several health challenges needing urgent attention come to mind. The issue of human trafficking (and its implications for urban environments) is an emerging problem. With the decline in breastfeeding globally, a shift to fast foods, and the abandonment of traditional feeding practices, childhood malnutrition is bound to rise in urban areas. The need for innovations to address childhood malnutrition in urban environments, as well as newborn, childhood, and maternal health in urban resource-limited settings, cannot be overemphasized. Unscrupulous dealers and unfair trade practices have led to the proliferation of counterfeit drugs in low- and middle-income countries. This will have serious implications for the treatment of common conditions as well as drug resistance in urban environments. Therefore, there will be a need for more investments in diagnostic innovations in urban health settings. Due to poor planning and inadequate provision of basic services, an increasing number of urban populations in low- and middle- income countries are likely to be hard hit by climate change, noise pollution, and unintentional injury. The case for comprehensive, integrated, and standardized measures of health in cities cannot be overemphasized. Overall, this book will go a long way in highlighting innovations to address these urbanization-related health issues. School of Public Health University of Nairobi Nairobi, Kenya Dismas Ongore, M.B.Ch.B., M.P.H., Ph.D. v

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7 Contents Part I Innovations to Address Specific Populations and Health 1 Maternal Health Innovations and Urbanization... 3 Melody Eckardt, Hannah L. Harp, Roy Ahn, Genevieve Purcell, Emily de Redon, Rosemary Hines, and Thomas F. Burke 2 Innovations in Low- and Middle-Income Countries for Newborn and Child Health Brett D. Nelson, Lisa B. Collins, and Edward W.J. Pritchard 3 Addressing Micronutrient Malnutrition in Urban Settings Laura A. Rowe and David M. Dodson Part II Innovations to Address Specific Urbanization-Related Threats to Health 4 Innovations in Anti-Trafficking Efforts: Implications for Urbanization and Health Roy Ahn, Genevieve Purcell, Anita M. McGahan, Hanni Stoklosa, Thomas F. Burke, Kathryn Conn, Hannah L. Harp, Emily de Redon, Griffin Flannery, and Wendy Macias-Konstantopoulos 5 Securing Cities: Innovations for the Prevention of Civic Violence Horacio R. Trujillo, Elena Siegel, Malcolm Clayton, Gabe Shapiro, and David Elam 6 Disaster Preparedness and Response Innovations: Implications for Urbanization and Health Laura Janneck and Paul Biddinger 7 Innovations to Address Global Drug Counterfeiting: Implications for Urbanization and Health Kendra Amico, Emily Aaronson, and Howard Zucker vii

8 viii Contents 8 Community Noise, Urbanization, and Global Health: Problems and Solutions Charles M. Salter, Roy Ahn, Faiza Yasin, Rosemary Hines, Laurence Kornfield, Ethan C. Salter, and Thomas F. Burke 9 Modeling Vulnerable Urban Populations in the Global Context of a Changing Climate Vijay Lulla, Austin Stanforth, Natasha Prudent, Daniel Johnson, and George Luber 10 Urbanization and Unintentional Injury in Lowand Middle-Income Countries John D. Kraemer Part III Frameworks, Cases and Tools to Address Urbanization and Health Through Innovation 11 The Millennium Cities Initiative: An Experiment in Integrated Urban Development Susan M. Blaustein 12 Diagnostic Innovations in Developing Urban Settings Patrick Beattie, Matthew Stewart, and Charles Mace 13 Innovations in Global Health Professional Education: Implications for Urbanization Leana S. Wen 14 The Case for Comprehensive, Integrated, and Standardized Measures of Health in Cities Patricia L. McCarney and Anita M. McGahan Index

9 Contributors Emily Aaronson, M.D. Harvard Affiliated Emergency Medicine Residency at Brigham and Women s Hospital/Massachusetts General Hospital, Boston, MA, USA Roy Ahn, M.P.H., Sc.D. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Kendra Amico, M.D., M.Phil. Harvard Affiliated Emergency Medicine Residency at Brigham and Women s Hospital/Massachusetts General Hospital, Boston, MA, USA Patrick Beattie, B.S.E. Diagnostics for All, Cambridge, MA, USA Paul Biddinger, M.D., F.A.C.E.P. Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Susan M. Blaustein, Ph.D. The Earth Institute, Columbia University, New York, NY, USA Thomas F. Burke, M.D., F.A.C.E.P., F.R.S.M. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Malcolm Clayton, B.A. Department of Diplomacy and World Affairs, Occidental College, Los Angeles, CA, USA Lisa B. Collins, M.A. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA ix

10 x Contributors Kathryn Conn, B.A. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Emily de Redon, B.A. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA David M. Dodson, M.B.A. Project Healthy Children, Cambridge, MA, USA Melody Eckardt, M.D., M.P.H., F.A.C.O.G. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA Boston University School of Medicine, Boston, MA, USA David Elam, M.I.A. Johns Hopkins School for Advanced International Studies, Washington, DC, USA Griffin Flannery, B.A. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Hannah L. Harp, B.A. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Boston University School of Medicine, Boston, MA, USA Rosemary Hines, B.A. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Laura Janneck, M.D., M.P.H. Cambridge Health Alliance, Cambridge, MA, USA Daniel Johnson, Ph.D. Indiana University Purdue University Indianapolis, Institute for Research on Social Issues, Indianapolis, IN, USA Laurence Kornfield City and County of San Francisco, San Francisco, CA, USA John D. Kraemer, J.D., M.P.H. Department of Health Systems Administration, Georgetown University School of Nursing & Health Studies and O Neill Institute for National & Global Health Law, Georgetown University Law Center, Washington, DC, USA George Luber, Ph.D. Centers for Disease Control and Prevention, Atlanta, GA, USA Vijay Lulla, Ph.D. Indiana University Purdue University Indianapolis, Institute for Research on Social Issues, Indianapolis, IN, USA Charles Mace, Ph.D. Diagnostics for All, Cambridge, MA, USA

11 Contributors xi Wendy Macias-Konstantopoulos, M.D., M.P.H. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Patricia L. McCarney, Ph.D. Department of Political Science, Global Cities Institute, John H. Daniels Faculty of Architecture, Landscaping, and Design, University of Toronto, Toronto, ON, Canada Anita M. McGahan, Ph.D. Rotman School of Management, University of Toronto, Toronto, ON, Canada Brett D. Nelson, M.D., M.P.H., D.T.M.&H. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Edward W.J. Pritchard, M.Phil. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Natasha Prudent, M.P.H. Centers for Disease Control and Prevention, Atlanta, GA, USA Genevieve Purcell, B.A. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Laura A. Rowe, M.S., M.P.H. Project Healthy Children, Cambridge, MA, USA Charles M. Salter, P.E. Charles M. Salter Associates, Inc., San Francisco, CA, USA Ethan C. Salter, P.E. Charles M. Salter Associates, Inc., San Francisco, CA, USA Gabe Shapiro, M.P.D. University of Southern California, Los Angeles, CA, USA Elena Siegel, B.A. Department of Diplomacy and World Affairs, Occidental College, Los Angeles, CA, USA Austin Stanforth, M.S. Indiana University Purdue University Indianapolis, Institute for Research on Social Issues, Indianapolis, IN, USA Matthew Stewart, Ph.D. Diagnostics for All, Cambridge, MA, USA Hanni Stoklosa, M.D. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA

12 xii Contributors Horacio R. Trujillo, M.Phil., M.B.A., Ph.D. Departments of Politics and of Diplomacy and World Affairs, Occidental College, Los Angeles, CA, USA Leana S. Wen, M.D. M.Sc., F.A.A.E.M. Baltimore City Health Department, Baltimore, MD, USA Faiza Yasin, M.P.H. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Howard Zucker, M.D., J.D. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, USA

13 Introduction Roy Ahn*, Thomas F. Burke*, and Anita M. McGahan Innovating for Healthy Urbanization The United Nations projects that the world s population will grow from 7 billion today to nearly 11 billion by the year At the same time, cities will grow disproportionately, accounting for 80 % of humankind by 2100 (up from about 50 % today). The growth of cities presents unprecedented challenges, but also important opportunities. The concentration of human populations in increasingly dense urban areas raises the prospect of intensification of communicable diseases, while aging populations suggest a greater incidence of noncommunicable diseases in the future. On the other hand, cities can facilitate prevention, early diagnosis, and comprehensive treatment of health conditions through increased access to quality health services. When we commissioned the chapters for this book, we envisioned that the contributing authors would advance understanding of the ways in which urbanization and health co-evolved. We had in mind that the book would point to the importance of early childhood education, sanitation systems, stable food supplies, personal security, and secure housing as important prerequisites and complements to classic health infrastructure. The chapters in this book certainly have delivered on this expectation. * Roy Ahn and Thomas F. Burke serve as co-lead editors of this book. 1 United Nations, Department of Economic and Social Affairs, Population Division (2013). World Population Prospects : The 2012 Revision, Highlights and Advance Tables. Working Paper No. ESA/P/WP.228. R. Ahn, M.P.H., Sc.D. (*) T.F. Burke, M.D., F.A.C.E.P., F.R.S.M. Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place Suite 104, Boston, MA 02114, USA RAHN@mgh.harvard.edu A.M. McGahan, Ph.D. Rotman School of Management, University of Toronto, Toronto, ON, Canada xiii

14 xiv Introduction What we did not fully anticipate were the ways in which the chapters would illuminate an entirely new way of thinking about the nature of health itself. Many chapters emphasize a conceptualization of health as resilience, and of cities as platforms for personal and community growth. This approach goes much further than evoking social determinants of health, by considering the complex interplay among environmental, economic, political, social, and health systems. Numerous themes cut across the chapters: 1. Migrations indicate health challenges in both source and target communities. Several chapters in this book point to migrations as indicators of health challenges in source communities and as complicit in the emergence of new problems in targeted urban settings. For example, Rowe and Dodson report that migrants may escape chronic hunger but continue to face nutritional deficits in cities. Trujillo and colleagues allude to the frequent incidence of migration in escape from tribal conflict but focus primarily on the tragedy of urban violence, especially in cities where rapid population growth strains housing and other security systems. Ahn and colleagues describe the hazards of migration to the cities and the negative consequences of human trafficking. Beattie, Stewart, and Mace find that inadequate housing and sanitation systems mean that rapidly growing cities must contend with persistent infectious disease as well as a larger burden of non-communicable illness. Kraemer considers the significantly higher risk of unintentional injury as a major health challenge in urban settings as compared to rural communities. The implication? Urbanization does not guarantee improved health. Health systems must be constructed to address the specific problems that arise first from migration itself and subsequently with population density in cities. These problems arise in basic systems: food, water, housing, and security. And the chapters posit innovations to address many of these challenges in resourceful ways. 2. The chronic shortage of health professionals is worsening and compels a new vision for primary care in urban areas of developing countries. The shortage of health workers including physicians, nurses, administrators, and specialists in almost every other domain of delivery is well-described in the academic literature. The authors in this book focus on the consequences of the shortage for health in cities. Wen envisions innovations in global health education that involve not only extensive task shifting but also the training of a generation of providers specialized in the needs of the urban poor. Kraemer suggests the utility of a system adapted to the urban needs of low- and middle- income countries, where first responders are trained to provide sufficient care and reduce the risk of preventable death and disability, particularly from traffic accidents. Eckardt and colleagues, plus Nelson and colleagues, describe the need for training frontline health workers to bring about improvements in maternal, newborn, and child health in resource-limited settings. Some chapters address opportunities for improved governance in the delivery of care. Blaustein describes the necessity for coordination among nongovernmental agencies (NGOs) and for addressing gaps in the provision of primary

15 Introduction xv care by these NGOs. McCarney and McGahan focus on the importance of the measurement of population health, and indicate that the measurement itself involves governance, simply through the act of data monitoring. The general vision of primary care suggested by these analyses thus involves the construction of basic social systems in the interests of health. This act of construction depends primarily on effective governance through sound management and creative leadership in the deployment of human resources in low- and middle-income countries urban settings. 3. Urbanization can simplify geographic access to care and can enable innovation that lowers the cost and improves the quality of diagnostic care. Beattie, Stewart, and Mace argue that diagnostic innovations and especially digitally-enabled diagnostics create a basis for fundamental change in access to high-quality care. Their argument emphasizes the unique opportunities available in cities for implementing protocols that can be administered by trained health workers and monitored by specialists. Rowe and Dodson indicate that opportunities to improve nutrition in urban settings are legion, and Eckardt and colleagues pose a similar argument for maternal health in such settings. Kraemer and Trujillo and colleagues all suggest that innovative approaches that account for the density of the poor in urban settings and that combat unsafe practices can lead to better quality of urban life and lower costs in health delivery. Lulla and colleagues focus squarely and primarily on the opportunities associated with innovation in the delivery of care in urban settings. They identify the particular stressors on health tied to urban living, including pollution of all types. Salter and colleagues hone in on the innovations present and future that could mitigate a decidedly urban public health hazard: noise pollution. Taken together, these chapters suggest that the opportunities for improving urban health arising from novel diagnostics include the implementation of effective protocols for administering familiar monitoring tests (such as on heart rate and glucose level), and the development of new devices and protocols that account specifically for health problems in urban slums. The latter may include, for example, diagnostics on asthma, toxic metals, and nutritional deficiencies, as well as on the psychological and social stresses that may accompany geographic dislocation. 4. Climate change has reshaped and will continue to reshape primary care, acute care, and disaster management. Climate change influences urban health in myriad ways. Three are highlighted in the essays in this volume: food insecurity, air pollution, and weather disasters. Each has a direct impact on urban health and thus carries important consequences for health systems. Food insecurity is the primary subject of Rowe and Dobson s study on micronutrients. These authors show how the chronic absence of sufficient nutrition among the urban poor creates significant challenges for primary and acute care. Lulla and colleagues describe the relationship between climate change and air quality in urban locales. Janneck and Biddinger discuss the consequences of weather disasters for emergency and disaster management.

16 xvi Introduction The requirements for innovation implied by these analyses are extensive. Building the capacity to deal with weather disasters requires unprecedented coordination at all levels of health systems. Addressing food insecurity requires integration between health and other essential systems in both the public and private sectors. Pollution is perhaps even more challenging, as its mitigation requires implementing controls as well as incentives in individual, private- sector, and public-sector institutions. Many of the chapters offer solutions to mitigate disasters of all types through the lens of innovation (e.g., Janneck and Biddinger s analysis of innovations in disaster management). 5. Increasing urban inequality, coupled with rising prices on basic goods such as food, raises the stakes on the design of inclusive systems. Many of the chapters specifically address the adverse consequences of inequity. Lulla and colleagues point to inequality, not only in the administration of health resources but also in vulnerability to health problems as a central facet of urban life. Trujillo and colleagues chronicle these vulnerabilities among the poor, particularly with regard to injury and personal violence. Wen describes inequality in the accountability of health providers with systematically greater tolerance for poor health delivery when patients are vulnerable. What suggestions arise for addressing these challenges? McCarney and McGahan suggest that measurement of inequity itself is a step toward its mitigation because of the implicit importance attached to the conditions as a consequence of measurement. Kraemer highlights the need to address environmental hazards such as substandard housing and workplace safety. Blaustein similarly points to the importance of inclusive systems. 6. Effective governance of health resources requires better data, accountability on health metrics, and innovation in health-system administration. Almost every chapter in this book asks for more accurate, timely, and relevant information on urban health challenges. Lulla and colleagues highlight the value of mapping and of comprehensive assessments as essential to the design of effective warning systems. Amico, Aaronson, and Zucker describe novel information technologies used to track pharmaceuticals through the supply chain in order to curb incidents of global drug counterfeiting. McCarney and McGahan focus on the promise of comparative measures that can allow city leaders to assess their performance relative to other jurisdictions with similar problems. Kraemer points to the importance of information on effective mechanisms for coordinating emergency response. Blaustein shows how better information would enable more effective and affordable solutions in the effective administration of resources in urban environments. Better information is only the first step in larger processes that each of these authors advocates. Overall, their vision is for more effective and creative governance of health systems. This vision requires persistence and determination in the allocation of decision rights, property rights, and financial claims on the provision of essential health services.

17 Introduction xvii Summary Human health in the twenty-first century begins and ends in cities. The purpose of this book is to explore the implications of massive urbanization for the health of humankind and to unearth innovations to address the problems associated with urbanization and health. As a whole, the chapters point to the potential for healthy cities that are rich in resources that matter for resilience: access to opportunity, better governance, equity, innovativeness, and actualization. In that vein, innovations are broadly construed as solutions that may include cutting-edge technology but often times may involve a lower-tech analog that is simple, elegant, and wholly impactful. The implications for urban health systems are extensive: a new vision for the provision of primary care; urgency in addressing urban pollution and climate change; and improving accountability of health providers and especially of publicand private-sector leaders with the capacity to allocate resources to improve health systems. On the whole, the chapter authors point to a future dominated by climate change, megacities, and resource scarcity. They call for creativity and innovation in the face of the challenges and simultaneously warn us against taking for granted that existing systems will work. Our current emphasis on access will give way to a broader agenda on equitability and fairness. Effective governance in the creation, stewardship, and allocation of scarce resources will be central to the resilience of cities and to the people who live within them.