Intervention Strategies for Public Health in Urban planning and Landscapes

1. Intervention Strategies for Public Health in Urban planning and Landscapes Carlos Dora World Health Organization Geneva

2. This presentation • Public Health and the Urban Landscape • Reasons for PH to intervene • Key role of PH experts and Health Authorities • Tools for stewardship: HIA, monitoring and reporting, communication and partnerships • Opportunities: policies to respond to the economic crisis and to climate change

3. 1. Public Health in the Urban Landscape • Environmental and social determinants • Many depend on actions by other sectors • Public health gains of the 19th century – from water, sanitation and housing interventions • Similar in 21st century – transport and urban planning, housing, employment policies

4. Examples: • Transport • Housing

5. Many health impacts from transport: but dealt with separately NOISE INJURIES PHYSICAL INACTIVITY AIR POLLUTION PSYCHOSOCIAL EFFECTS

6. The importance of 'transport related' diseases Each year:Urban air pollution kills 800,000 Road traffic accidents kill 1.2 million and injure over 50 million Physical inactivity causes 1.9 million deaths, and loss of 19 million years of healthy lifeFor comparison:Malaria - 1.1 million HIV/AIDS - 2.9 million Tobacco-related - 4.9 million (WHO, World Health Report, 2002)

7. Narrow solutions: limited results. e.g. Continuing Traffic Growth Has Cancelled Out Pollution Savings from Cleaner and More Efficient Vehicles • Cars are becoming heavier and more powerful. • Trips are becoming increasingly long. • Total kilometers traveled by road continues to grow EC: Transport in Figures, 2000

8. 'Business as usual' health trends • Vast increase in car ownership and larger cars in emerging economies vs. better regulation, more efficient engines. • Road traffic accident deaths to double from 1990-2020. • Global Epidemic of Obesity. (WHO, 1996; WHO, 2004)

9. Different routes are possible Atlanta Bangkok Singapore Houston Zurich Hong Kong London Beijing Kenworthy, 2003

10. Great potential for improvement in physically active transport Percentage of people walking or cycling to work: Copenhagen 32 % Santiago 30 % Tokyo 22 % Brasilia 2 % Atlanta 0.3 % Percentage of urban trips by motorised private transport: USA 89 % Western Europe 50 % High Income Asia 42 % China 16 %

11. Traffic policies can have many benefits to health and environment • Traffic delays inside the charging zone average 30% lower than before • Pedal cycle movements have increased by about 20 % • Bus and coach movements have increased by over 20% • Van and lorry movements have reduced by about 10 % • Powered two-wheeler movements have increased by 10-15% • 8% reduction in personal injury accidents in the charging zone during charging hours compared to the same period last year. • 6% fewer pedestrians were involved in accidents, • (Based on the first 6 months of provisional data since charging began) London congestion charge Source: Congestion Charging: Update on scheme impacts and operations. February 2004 (www.tfl.gov.uk/tfl/downloads/pdf/congestion-charging/cc-12monthson.pdf) The congestion charge is a £5 daily charge for driving or parking a vehicle on public roads within the congestion charging zone between 07:00 and 18:30, Monday to Friday, excluding weekends and public holidays.

12. Bogota: urban space to public transport and pedestrians – reduction in traffic injuries and air pollution + political success before... ... after

13. There is a need for integrated policies that address all health impacts, environment and development: • Transport Demand Management via: • Economic measures • Changes in individual travel behaviours • Compact land use to reduce need to travel • Maintain high walking and cycling • Support public transport

14. Housing And Health INSIDE OUTSIDE Family and home Crowding, isolation, depression, infectious diseases, accessibility and ageing, etc. Neighbourhood Social problems, crime, fear, neighbourhood deprivation, lack of control, etc. PSYCHO-SOCIAL OUTSIDE Dwelling Mould / damp, allergens, pests, building emissions, ETS, VOC, PM, lead, radon, asbestos, EMF, accidents, thermal conditions, noise, sanitation, etc. Housing environment Noise, air pollution, lack of recreational areas, lack of physical activity, accidents, etc. PHYSICAL

15. Health hazards in construction • Risks of accidents – falls, cuts, electrocution • Chemical risks – silica, asbestos, glues, powders • Physical risks – noise, vibration, heat, cold, UV • Ergonomic risks – heavy weights, twisting, awkward positions • Social factors – migrant workers, long working hours, limited social support • Fatal and disabling injuries (42% of work-related deaths in Japan) • Occupational diseases – silicosis, mesothelioma, hearing loss, dermatitis, musculoskeletal disorders, alcoholism, depression

16. Asbestos in housing • 95% of asbestos is used in construction materials, e.g. roofing • 125 million people exposed to asbestos at the workplace • More than 90,000 people die annually from asbestos related diseases • Safer alternatives are available • Preventing exposure is very difficult • WHO considers that the most effective way to eliminate asbestos-related diseases is to stop the use of all types of asbestos Tsunami reconstruction Nam Khem Village, Thailand 2005

17. Thermal comfort and excess winter deaths in the UK Mortality (all causes) in relation to the lowest point in summer => BLUE LINE: for coldest dwellings => RED LINE: for hottest dwellings Wilkinson et al. (2001)

18. Housing insulation and thermal comfort WHO (2008)

19. 2003 European Summer Heatwave Deaths During Summer Heatwave. Paris Funeral Services (2003)

20. Mortality housing risk factors during French heatwave in 2003 Source: Vandentorren et al. 2006

21. Unintentional Injuries (EU-15*) • 130.000 fatalities (54% home & leisure) • 390.000 disabled (68% home & leisure) • 5.000.000 hospitalised (66% home & leisure) • 39.000.000 injured (67% home & leisure) • Killer No. 1 in age group 1-45 years • More then 10% of all health costs France, UK and Germany have more home accidents than road traffic accidents!!! DG SANCO (2004) *15 EU member states only

22. Radon in homes and smoking Darby et al, 2005

23. RADON MITIGATION SYSTEM A – Gas-permeable layer B - Plastic sheeting C - Sealing and caulking D - Vent pipe E - Junction box It is recommended that homes be tested for radon on the lowest lived-in level – basement or ground floor www.epa.gov/iaq/radon/construc.html

24. Electrical wiring Electrical appliances Concerns on Housing and Health Electromagnetic Fields

25. Housing and Health Electromagnetic Fields • Radiofrequency fields (e.g. wireless technologies)

26. European Disability Forum 2002:% of population being limited in their daily activities due to handicaps (based on Eurostat) Strongly limited – 4% Partially limited – 9% Not limited – 87% Accessible housing ...and for the popula-tion above 65 years: European Disability Forum 2002 / Eurostat 2002

27. Reducing GHG emissions, promoting health Buildings Indoor air pollution Heat and cold protection Transport Air pollution Traffic injuries Physical inactivity Greenhouse Gas Emissions Industry Occupational risks, mining and transport Energy supply & conversion Occupational risks; Construction and transport Agriculture Nutrition, Water / vector-borne disease Waste Occupational, chemical

28. 2. Why governments should act? To make optimal decisions in view of competing points of view Car and Road lobby: “Benefits outweigh the Costs, the health burden is a price societies pay for mobility and convenience they enjoy.” Health & Environment: “Healthy transport can improve public health, safeguard the environment, enhance access and the economic vitality of cities”

29. 1st: To ensure sound economic decisions (utilitarian view) The Market for transport fails to deliver socially optimal patterns as Transport Costs are not all paid for the user, and the costs borne by others (external costs) are substantial. The overall use of transport, particularly more polluting modes, is then higher than socially optimal The right investments and prices (for pollution, accidents etc.) would correct these distortions The end result is cost to all society that are not seen by the individual: • absenteeism to work and costs to businesses, • increasingly high health care costs of chronic diseases,

30. 2nd. To ensure policy making draws on existing knowledge and best practice • Difficulty in accessing information on the health impacts of transport interventions • Myths about what is good practice are repeated and reinforced • Scientific evidence is often not translated regarding its implications for policy • A trusted and balanced in formation broker is needed

31. 3rd. To give a voice and protect vulnerable groups • Children are vulnerable to injuries, air pollution and noise, their cognitive and physical development require exploration of the neighbourhood and outdoor activity. • Children and other vulnerable groups are exposed to risks from traffic but enjoy few benefits from it. • These groups often do not have a voice to influence decisions. Governments need to be that voice.

32. 4th. To promote health equity Exposure to health risks depends on mode of transport used Need to ensure safety of people using all modes Pedestrians and cyclists do not cause pollution, contribute to reducing traffic congestion, will use health services less and be more assiduous to work, but are exposed to health risks caused by motor vehicle users (injuries, pollution)

33. Key role of PH experts and Health Authorities:To influence other sectors to incorporate health objectives into their policies (stewardship) • Health standards and norms • Gather relevant knowledge about health implications of decisions • Inform and engage stakeholders about health issues in other sector policies • Provide feedback about expected and actual health consequences of policies in other sectors, including health equity aspects • Monitoring system (accountability) • Communicate Positive feedback • Establish partnerships with actors in other sectors and stakeholders

34. Tools for stewardship: Health Imapct Assessment (HIA) " Health impact assessment is a combination of procedures, methods and tools that systematically judges the potential, and sometimes unintended, effects of a policy, plan, programme or project on the health of a population, and the distribution of those effects within the population. HIA identifies appropriate actions to manage those effects." - IAIA definition based on the WHO "Gothenburg Consensus Statement" (2006)‏

35. What is ‘health impact assessment’? • Prediction – what are expected impacts ? • Systematic process & procedures • Public/stakeholder involvement – what are perspectives of those affected? • Link to Policy /Project decision making • Mitigation of adverse effects

36. What is HIA trying to achieve? • Inform/influence decision-making during project development • Enhance the positive health impacts of the project • Reduce (or mitigate) the negative health impacts of the project • Contributing to reduction in health inequalities

37. Quickly establishes "health relevance" of the policy or project. Is HIA required? Screening Policy, programme , or project development phase for prospective assessments. Identifies key health issues & public concerns, establishes ToR, sets boundaries. Scoping Rapid or in-depth assessment of health impacts using available evidence – who will be affected, baseline, prediction, significance, mitigation. Appraisal Conclusions and recommendations to remove/mitigate negative impacts on health or to enhance positive. Policy or project implementation phase Reporting Action, where appropriate, to monitor actual impacts on health to enhance existing evidence base. Monitoring HIA procedure

38. Screening Policy analysis Profiling of communities Scoping Qualitative and quantitative data collection Conduct assessment Impact analysis Report on health impacts and policy options Establish priority impacts Monitoring Recommendations developed Impact and outcome evaluation Process evaluation A Generic Health Impact Assessment methodology Abrahams et al (2004)‏

39. ‘Tight’ bio-medical model of health measurement-based non- participatory approaches ‘Broad’ versus ‘Tight’ HIA methodologies • ‘Broad’ • socio-environmental model of health • key informants/ stakeholders • participatory-focus

40. Desk-based Rapid In-depth/ Comprehensive Broad overview ---- Existing accessible data ---- Days More detailed ---- Existing data and some new qualitative ---- Weeks Comprehensive assessment ---- Multiple methods and sources ---- Months HIA ‘depth’

41. Assessment of health risks: Causal Pathways • Causal pathways or logic diagrams can be used to map and examine the relationships between proposed activities and health outcomes. • How does the proposed project and/or related activities affect the determinants of health? • Which determinants? • How strongly? • How are these determinants of health likely to affect the health outcome in the given population?

42. Sample Causal Pathway Model Source: EPHIA, 2004

43. Main Populations Affected Majority of health impacts likely to affect: • Construction workforce and associated camp followers (4,000 workers and between 8,000-16,000 followers)‏ • Resettlement of 6,000 individuals Photo: Nam Theun 2 Power Company • Additional impacts could be felt by 100,000 individuals living in surrounding area, e.g. Xe Bang Fai river communities

44. Construction camps: workerspotential risk profiles Source: Nam Theun 2 HIA report (2004)‏

45. Main mitigation and enhancement opportunities identified for construction camps • Measure that improve the underlying disease burden via improvements in basic sectors • housing, • water/sanitation, • transportation (e.g. dust control and road safety)‏ • communications Photo: Nam Theun 2 Power Company

46. Health action plan • Evaluating the proposed measures to mitigate and/or prevent adverse health impacts and promote positive health outcomes • Crucial activities • Role and responsibilities • Verification methods • Mechanisms to monitor changes in health status • Performance indicators

47. Health indicators Such as infant and child mortality, incidence and prevalence of communicable diseases, changes in nutritional status Environmental indicators Such as disease vector densities, concentration of chemical pollutants, and coverage for adequate sanitation Socioeconomic Indicators Such as changes in income levels, inflation, unemployment Monitoring & Surveillance * Indicators used to measure and report performance * Verification measures used to ensure compliance with stated HAP

48. Determinants of health influenced by transport activities (Watkiss et al, 2003)

49. Policy context of HIA • WHO influence • European Union • Article 152, Treaty of Amsterdam, 1999 • EC Strategic Environmental Assessment Directive, 2001 • EC Public Health Strategy, 2002-2007 • Europe – Protocol for Strategic Environment Assessment – 2004.

50. Growing Consensus on Inter-sectoral Action for Health Amsterdam Treaty "A high level of health protection shall be insured in definition and implementation of all community policies and activities" 1997 Reporting on the Right to Health to the UN Commission on Human Rights • Special rapporteur identified HIA as a means to judge if governments ensure the right to health when pursuing economic development.