With rapid urbanization has come a wide range of new health problems, particularly in low- and middle-income countries, and in low-income communities within the world's advanced economies. For policymakers, the challenge calls not just for more resources but for an entirely new approach to urban development.
CAMBRIDGE – In 1945, in the rural South African village of Polela, a community-based approach to improving health was implemented. In what became known as the Polela model, the prevailing health-care strategy was adapted to account for social, economic, and environmental data from community members. For example, monitoring of household crop failures and malnutrition in preschoolers allowed health authorities to anticipate vulnerabilities to health and well-being and intervene early to prevent ill-health.
For many years, the Polela model’s central ideas spread and were adopted by other communities around the world. But health care has since shifted back toward a narrower approach focused on biomedical interventions. We have recognized the importance of the environmental factors in health ever since the nineteenth century, when improvements in waste management and housing conditions helped to rein in cholera and tuberculosis in England, increasing life expectancy in the process. Yet with the rush of urbanization in recent decades, we have been neglecting these lessons, as well as our custodianship of the planet, with adverse consequences for public health.
Today’s cities have developed in ways that are ecologically disruptive and ultimately unsustainable. They are increasingly overcrowded, forcing the poor to live in low-quality housing with little access to health information, communication, and care. They are also chronically vulnerable to stresses on water, land, and food systems. And repeated shocks from natural disasters, climate change, and sociopolitical unrest – not to mention the legacies of colonialism and apartheid – will likely cause inequalities in health access and outcomes to widen further.
You may already know that in 2020, 1.8 million people (predominantly in cities) died from COVID-19. But did you know that another 1.8 million people are estimated to have died from tuberculosis in the same year? The world’s deadliest infectious disease is closely bound up with environmental factors. The United Kingdom’s “window tax,” enacted in 1696 and repealed in 1851, prompted many households to brick up their windows, contributing to an ongoing TB epidemic. Yet despite this earlier lesson, many cities and countries still have policies tantamount to “window taxes,” with low-income communities having poorer access to healthy green public spaces, clean air, and homes with adequate ventilation, water, and sanitation.
Another urban scourge is obesity, which kills 2.8 million people per year, and contributes to many common types of cancer. Urban food systems have gradually shifted toward supplying more energy-dense calories high in sugar, salt, and fats for populations that are already more sedentary. The result has been a steady increase in obesity rates, particularly in low- and middle-income countries and among low-income communities within high-income countries.
A Better Way
Reviving the Polela model requires that we make the invisible visible and think comprehensively about prevention, in addition to cures. Across the Global South, where urbanization is occurring most rapidly, a majority of people are being left behind, with over 50% of urban residents in Africa living in informal settlements. Similarly, in the Global North, the experiences of a growing minority have been ignored as the sources of poor health proliferate.
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Health is and always has been political. In Polela, the initial progress was lost under the racist, patriarchal apartheid regime installed in 1948. But while ideologies and special interests are often deeply entrenched, experiences from the COVID-19 response hint at the possibility for radical change.
Urban design holds one of the keys to better health – both for people and the planet. The best protection against health emergencies is a strategy to bring urban inequalities out from the shadows so that they can be addressed head on. Urban development must be seen not just as a process of construction and infrastructure expansion, but as an act of community building and health creation.
Cities should measure success by the availability of social infrastructure like public spaces, which are good for mental and physical health. They should focus on ensuring clean air, which will reduce the burden of childhood asthma and other diseases. By expanding access to healthy foods and placing restrictions on unhealthy foods, policymakers can reduce the economic costs of poor health while also improving well-being. And by ensuring the provision of ample high-quality housing, they can sharply reduce the transmission of infectious diseases.
In a city that puts public health first, assaults on these sources of well-being would be treated the same as oil spills and other environmental damage caused by negligence. Those who are responsible would be held accountable and made to pay for remediation.
With 68% of the world’s population projected to live in cities by 2050, the United Nations’ “Decade of Action” (2020-30) should prompt everyone to re-evaluate the purpose of cities. Particularly in the emerging metropolises of Africa and Asia, now is the time to create new health systems that integrate urban planning, transport, and housing.
Revisiting Old Thinking for a New Model
The challenges cities face call for a paradigm shift. We need to move from a narrative focused on individual behavior to one that accounts for the broader environment. Action against climate change and future health threats must be seen as two sides of the same coin. Health governance must be integrated more with other domains of public policy, because health is not and never will be a standalone issue.
Moreover, the idea of health security will need to be updated from a perspective focused solely on guarding against outside threats to one that recognizes the need for global solidarity in the face of shared problems. And policymakers will need to show some willingness to relinquish power to individual communities, furnishing them with the data and agency needed to hold urban systems and sectors accountable for health outcomes.
It is time to revisit the ideas behind the Polela model, so that we can develop a Polela 2.0 for the current age of urbanization and climate change. A twenty-first-century Polela system would use urban design to build climate resilience and safeguard the socioeconomic and environmental determinants of health. It would collect and collate intersectoral data to monitor for early signs of health and environmental vulnerabilities. It would facilitate interventions based on community expertise and experience. And these interventions would be administered by people who know the local context in which they are operating.
A Polela 2.0 system would also address the imbalances and inequities in how health is financed, by bringing local and foreign-donor representatives together to co-design solutions. No longer would the system treat the majority of urban inhabitants as invisible. In re-imagining urban health, we must learn from the past and be mindful of local communities’ experiences in the present. Failing that, we cannot possibly ensure a more sustainable, equitable, or healthier future.
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CAMBRIDGE – In 1945, in the rural South African village of Polela, a community-based approach to improving health was implemented. In what became known as the Polela model, the prevailing health-care strategy was adapted to account for social, economic, and environmental data from community members. For example, monitoring of household crop failures and malnutrition in preschoolers allowed health authorities to anticipate vulnerabilities to health and well-being and intervene early to prevent ill-health.
For many years, the Polela model’s central ideas spread and were adopted by other communities around the world. But health care has since shifted back toward a narrower approach focused on biomedical interventions. We have recognized the importance of the environmental factors in health ever since the nineteenth century, when improvements in waste management and housing conditions helped to rein in cholera and tuberculosis in England, increasing life expectancy in the process. Yet with the rush of urbanization in recent decades, we have been neglecting these lessons, as well as our custodianship of the planet, with adverse consequences for public health.
Today’s cities have developed in ways that are ecologically disruptive and ultimately unsustainable. They are increasingly overcrowded, forcing the poor to live in low-quality housing with little access to health information, communication, and care. They are also chronically vulnerable to stresses on water, land, and food systems. And repeated shocks from natural disasters, climate change, and sociopolitical unrest – not to mention the legacies of colonialism and apartheid – will likely cause inequalities in health access and outcomes to widen further.
You may already know that in 2020, 1.8 million people (predominantly in cities) died from COVID-19. But did you know that another 1.8 million people are estimated to have died from tuberculosis in the same year? The world’s deadliest infectious disease is closely bound up with environmental factors. The United Kingdom’s “window tax,” enacted in 1696 and repealed in 1851, prompted many households to brick up their windows, contributing to an ongoing TB epidemic. Yet despite this earlier lesson, many cities and countries still have policies tantamount to “window taxes,” with low-income communities having poorer access to healthy green public spaces, clean air, and homes with adequate ventilation, water, and sanitation.
Another urban scourge is obesity, which kills 2.8 million people per year, and contributes to many common types of cancer. Urban food systems have gradually shifted toward supplying more energy-dense calories high in sugar, salt, and fats for populations that are already more sedentary. The result has been a steady increase in obesity rates, particularly in low- and middle-income countries and among low-income communities within high-income countries.
A Better Way
Reviving the Polela model requires that we make the invisible visible and think comprehensively about prevention, in addition to cures. Across the Global South, where urbanization is occurring most rapidly, a majority of people are being left behind, with over 50% of urban residents in Africa living in informal settlements. Similarly, in the Global North, the experiences of a growing minority have been ignored as the sources of poor health proliferate.
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At a time when democracy is under threat, there is an urgent need for incisive, informed analysis of the issues and questions driving the news – just what PS has always provided. Subscribe now and save $50 on a new subscription.
Subscribe Now
Health is and always has been political. In Polela, the initial progress was lost under the racist, patriarchal apartheid regime installed in 1948. But while ideologies and special interests are often deeply entrenched, experiences from the COVID-19 response hint at the possibility for radical change.
Urban design holds one of the keys to better health – both for people and the planet. The best protection against health emergencies is a strategy to bring urban inequalities out from the shadows so that they can be addressed head on. Urban development must be seen not just as a process of construction and infrastructure expansion, but as an act of community building and health creation.
Cities should measure success by the availability of social infrastructure like public spaces, which are good for mental and physical health. They should focus on ensuring clean air, which will reduce the burden of childhood asthma and other diseases. By expanding access to healthy foods and placing restrictions on unhealthy foods, policymakers can reduce the economic costs of poor health while also improving well-being. And by ensuring the provision of ample high-quality housing, they can sharply reduce the transmission of infectious diseases.
In a city that puts public health first, assaults on these sources of well-being would be treated the same as oil spills and other environmental damage caused by negligence. Those who are responsible would be held accountable and made to pay for remediation.
With 68% of the world’s population projected to live in cities by 2050, the United Nations’ “Decade of Action” (2020-30) should prompt everyone to re-evaluate the purpose of cities. Particularly in the emerging metropolises of Africa and Asia, now is the time to create new health systems that integrate urban planning, transport, and housing.
Revisiting Old Thinking for a New Model
The challenges cities face call for a paradigm shift. We need to move from a narrative focused on individual behavior to one that accounts for the broader environment. Action against climate change and future health threats must be seen as two sides of the same coin. Health governance must be integrated more with other domains of public policy, because health is not and never will be a standalone issue.
Moreover, the idea of health security will need to be updated from a perspective focused solely on guarding against outside threats to one that recognizes the need for global solidarity in the face of shared problems. And policymakers will need to show some willingness to relinquish power to individual communities, furnishing them with the data and agency needed to hold urban systems and sectors accountable for health outcomes.
It is time to revisit the ideas behind the Polela model, so that we can develop a Polela 2.0 for the current age of urbanization and climate change. A twenty-first-century Polela system would use urban design to build climate resilience and safeguard the socioeconomic and environmental determinants of health. It would collect and collate intersectoral data to monitor for early signs of health and environmental vulnerabilities. It would facilitate interventions based on community expertise and experience. And these interventions would be administered by people who know the local context in which they are operating.
A Polela 2.0 system would also address the imbalances and inequities in how health is financed, by bringing local and foreign-donor representatives together to co-design solutions. No longer would the system treat the majority of urban inhabitants as invisible. In re-imagining urban health, we must learn from the past and be mindful of local communities’ experiences in the present. Failing that, we cannot possibly ensure a more sustainable, equitable, or healthier future.