Reconceptualising health in cities: less disease care, more healthcare - Public lecture by Tolu Oni

“What good does it do to treat patients only to send them out to the conditions that made them sick in the first place?” asked Prof. Tolullah Oni. “Health is much more than the absence of disease, instead it encompasses a complete state of physical, mental and social wellbeing.” Oni is Associate Professor in the School of Public Health and Family Medicine at the University of Cape Town, where she leads the Research Initiative for Cities Health and Equity (RICHE) and is an Iso Lomso STIAS Fellow. She was presenting a public lecture on her current project at STIAS. The project will ask questions like: How are population patterns changing in South Africa? What role do our different environments play in contributing to our health? Are cities making us sick? Whose job is it to promote health and prevent disease? Who are the modern-day health professionals? “Africa is characterised by increasing urbanisation, increasing informality in living settlements and high rates of poverty and inequality,” she said. “62% of urban dwellers live in slum conditions in Africa.” “Informality is on the rise,” said Oni. “These living conditions are associated with high levels of health disparities and inequities, and the urban poor are often exposed to poor housing conditions associated with an increased risk of infectious and chronic respiratory conditions.” “However, as countries urbanise, we are also seeing a changing pattern of disease from predominantly acute and infectious to chronic and non-infectious,” said Oni. “Urban exposures driving these trends in rapidly growing cities in Africa and other low- and middle-income settings include a compromised food system, inadequate human settlements (including housing, access to safe transport, sport and recreation facilities), unsafe services (power, water, waste, sanitation), air and noise pollution, degraded work environments as well as individual lifestyle factors.” “This changing pattern of disease is being experienced in South Africa,” she continued, “with a rise in chronic disease and a rise in multi-morbidity – with co-existing chronic infectious and non-communicable diseases.” She pointed out that this puts even further strain on under-resourced health services because the public health system is largely geared towards acute episodic care rather than ongoing chronic care and co-existing diseases – for example, diabetes and HIV - interact in less-predictable ways. “We need to look beyond the causes of diseases to the causes of the causes,” she said. “Healthy people are important to the development of society,” she continued. “The need for health unifies all.” “Lack of equity equates to differential exposure and differential vulnerability,” she said. “And this goes from the cradle to the grave – low birthweight babies born to impoverished mothers face ongoing malnutrition leading to stunting and greater likelihood of infectious diseases – leading to adolescent health that may be characterised by obesity, diabetes, cardiovascular disease, injuries, violence and risky sexual behaviour – leading to adults with non-communicable diseases (NCDs) along with increased susceptibility to infectious diseases.” Oni encouraged the audience to consider their own vulnerability to the 8 Ss of urban exposure- Sugar and salt, Smoke and smoking, Sleep and stress, Sports and recreation, Sanitation and water, Safe housing and social cohesion, Sex and Substance and alcohol abuse – all of which are linked to the South African quadruple burden of disease: HIV/TB, maternal and child (largely infectious) diseases, NCDs and the risk of violence and injury. “For each of these, how do they relate to the burden of disease, differential exposure and vulnerability in different urban populations, and how are strategies to address the negative health effect of these exposures tackling inequity?” she asked. In exploring who is responsible for health in cities, Oni challenged the audience to think beyond doctors, nurses, and allied healthcare workers in clinics and hospitals as health professionals. Instead, this tag should be expanded to include all those who play a role in the 8 Ss of urban exposure, from the urban planner, architect, and transport engineer, to the politician, farmer and teacher. “We are all health professionals,” she said. “Next time you think of a city, think in terms of these eight exposures. Because therein lies the true soul of, and hope for, the city.” Promoting collective health “We have to look at how urban exposure can be harnessed to positively influence health,” she said. “We have to highlight the opportunities to re-think the concept of health, and how to equitably promote and protect our collective health in the context of urbanisation.” This highlights the need for policies and programme interventions to directly address equity in order to improve population health. “However, the health sector is only one player in health and human development, and a fully intersectoral approach is key to addressing these societal challenges. We need health in all policies,” said Oni. “In South Africa, efforts to upgrade the physical housing structure and community infrastructure are largely compartmentalised in the housing sector, and there is insufficient focus on health outcomes and the health-impact assessment of housing policies.” This was the reasoning behind the formation of RICHE which recognises that enhancements to health will come about principally through improvements in social, cultural and economic conditions coupled with behaviour change. “We assembled a merry band of health metastasisers and set about adventuring out into non-health spaces,” said Oni. “Applying a health lens to housing would include consideration of the four dimensions of housing (as described by the World Health Organization) – the physical housing structure, the psychosocial and cultural environment; the physical characteristics and socio-economic environment of the neighbourhood; and services within the community,” said Oni. “Currently there are very little data on these issues in informal settlements.” RICHE looks at the models of co-operation and collaboration across these sectors that can achieve mutual benefits and create efficiencies across agencies; at how to apply these co-creation models in African city settings; and, at understanding the true cost of housing and the cost-benefits of healthy affordable housing design. During her Fellowship, Prof. Oni will investigate and compare policies in Cape Town and New York which is also undergoing challenges around housing and health inequity. The aim is to build and strengthen North-South collaborations and networks with interdisciplinary urban health colleagues. She will also explore the knowledge and the barriers that prevent policy makers from incorporating health objectives into housing policies. “This is NOT to say that health objectives should supersede others,” said Oni, “but redefining a common health goal across sectors can facilitate identifying cost-effective and health-generating objectives and strategies.” Michelle Galloway, Part-time media officer at STIAS