Can using the social determinants of health to develop climate change policy ‘build’ resilient cities? Current climate change policy focused on resilience, while effective, can acquire more depth with a health focus. How though, is the question? The social determinants of health can act as a guide for resilience-focused policy. The SDH with their focus on the causes of the causes may assist with the strengthening of policy aimed at mitigating the impacts of climate change. The paper emerges from the findings of a content analysis and a survey of 51 cities to identify policy areas with potential for growth based on a policy matrix developed using the social determinants of health.
Keywords: Climate Change, Health, Cities
JEL Classification: Q5, Q59, I18
Suggested citation: Dekker, Sabrina, Focusing Climate Change Policy on Health in Cities (September 4, 2014). Review of Environment, Energy and Economics (Re3), http://dx.doi.org/10.7711/feemre3.2014.09.001
Public health is an often forgotten principle of planning policy. [Note 1] Historically, urban planning had its roots in public health with the sanitation movement during the industrial revolution when the rapid spread of disease contributed to high death rates. [Note 2] When population health improved cities shifted their focus to growth and development. [Note 3] However, now with the increasing call for cities to respond to climate change, there is a renewed focus on health. [Note 4] This is supported by policy recommendations stemming from research on the health impacts of climate change. [Note 5] Specifically, public health professionals are calling for cities to take action, due to their ability to shape the built environment, which plays a role in human health and climate change. [Note 6]
This is not an unlikely policy path, especially within the context of the resilient cities movement through which cities are aiming to become resilient to climate change. [Note 7] Especially given that, one of the chief criticisms of the resilience movement is that it is too broad and complex. [Note 8] Critically, it lacks a distinct focus, as resilience policy tends to address system level vulnerability. [Note 9] Health can provide focus, by being a primary building block for resilience policy; as there are overlaps in the policy objectives of public health based on the social determinants of health and urban policy based on resilience. This potential is also demonstrated in policies implemented by cities; for example greenhouse gas emission policies have noted co benefits for health. The ‘gap’ for policy lies in identifying the potential for policy to go further and have greater breadth and impact. To discuss this potential the paper looks firstly at resilience and the social determinants of health. Secondly, it looks at what policy actions cities are implementing in the realm of climate change. Then concludes, by discussing the potential for utilizing health as a focus for building resilient cities via the social determinants of health as a guide for policy.
Resilience and the social determinants of health
Resilience has become the objective of cities in the process of mitigating the impacts of climate change. [Note 10] On the surface it appears to be a simple straightforward goal; prevent vulnerability to increase resilience to a threat. However, being resilient is dependent on the agreement a threat exists. In the context of cities and climate change, climate change is an agreed upon threat that creates numerous vulnerabilities in the urban environment. [Note 11] Therefore the complexity emerges in the process of addressing the threats. [Note 12]Specifically, what should be resilient and how? The options for what should be resilient in a city are numerous as are the options on how to be. In the context of climate change the ‘whats’ can be physical infrastructure, the economy, food systems and transportation systems. The ‘how’ for resilience policy can be achieved with targets specific to each system. The risk in using targets is that resilience is a process; targets create endpoints for policy and do not guarantee longevity. Resilience is a long-term (and life-long) process, it is not solely about short-term successes. [Note 13] As such cities need policy that has a focal point that speaks to their citizens in the short and long runs, namely health, which impacts the ability of individuals’ to live, work and play.
Health has been singled out as a unifying issue for all policy makers irrespective of their specialization. [Note 14] Moreover, it concerns all people regardless of their race, economic status and geographical location. It is something that all individuals care about; as such it provides a unifying point for cities aiming to be resilient to climate change. The argument for this stems from research in the health sector that not only links climate change to poor health outcomes, but highlights how the living environments of people determine their health status. [Note 15] Health professionals highlight that cities have the potential to set policy to mitigate these outcomes. [Note 16] The question is how?
The social determinants of health have dominated the public health sector and health policy in the last decade shifting the focus of health policy from diagnosing a disease and treating the symptoms, to understanding the ‘causes of the causes’. [Note 17] The SDH are the factors that influence an individual’s health and well-being over the life course. [Note 18] They are divided into three categories: lifestyle factors, social and community networks, and general socioeconomic, cultural and environmental conditions. [Note 19] The categories and determinants are not exclusive of each other rather the factors that shape the determinants are fluid, interacting and influencing each other. [Note 20] Further, they also vary depending on where people live.
The SDH can also be considered on a spectrum of negative to positive outcomes, to illustrate considered income. Those who are poor are more likely to have negative health outcomes due to their inability to access health care or the factors that would ensure their health and well-being, such as nutritious food. The figure here shows how access to a determinant of health, income and employment, can force individuals to make choices that may affect their health outcomes and their family’s health.
Figure - Access to Income
Climate change can impact the ability of individuals to access an SDH. Critically, negative outcomes tend to be perpetuated by climate change. As an example related to income, consider access to food. Droughts stemming from climate change can threaten food supply causing prices to rise. For higher income groups the change may be negligible, but for lower income groups the consequence is graver and forces families to choose, and often the choice is cheaper foods, which can result in malnutrition. Depending on where, it could be obesity related to consumption of high fat nutritionally low foods in North America or protein energy malnutrition and vitamin deficiencies in developing countries. Malnutrition has numerous impacts beyond deterioration of physical health. Fortunately, policy can simultaneously address these issues.
Health policy based on the SDH bears resemblance to urban climate change policy based on achieving resilience. Both are concerned with the factors in systems that make them vulnerable to threats. The difference is that health policy based on the SDH are focused on health. Urban climate change policy based on resilience is arguably fuzzy in that as mentioned it has an unclear focus. However, climate change policy with the objective of resilience and health policy that stems from the SDH are similar in their objectives. Climate change policy is focused on the mitigation of adverse impacts on the environment through actions that increase the resilience of the environment. [Note 21] Embodied in the policy objectives are protection of the environment in its current state and its sustainable management for present and future needs. All the while recognizing the need for economic growth that will support the demands of a growing population. Health policy based on the social determinants of health is focused on the prevention of ill health. [Note 22] This is achieved through the identification, mitigation and prevention of causal factors that impact. Traditionally, health policy responds to immediate issues. However, the social determinants have added a sustainability dimension that acknowledges that health policy is more effective when the long run and the factors that contribute to ill health are considered. For example, a person may not be able to afford medication for an illness because their income goes directly towards food and housing. Finally, there is the objective of growth from the social perspective; namely the growth of populations. Considering the objectives it is evident that there is common ground between climate change policy and health policy based on the social determinants of health. It is now a matter of who is able to merge these two policy areas.
Local governments have the greatest potential for integrating and innovating policy that will see positive sustainable outcomes. Central to this is their ability to create an environment for collaboration on policy. Further, local governments have knowledge of the local context, specifically in relation to the SDH and climate change, they know the health status of the local population and the climate challenges they face.
Current policy actions in cities
Globally it has been recognized that cities possess the greatest capacity to address the impacts of climate change. [Note 23] This is largely due to their capacity to engage with people on a daily basis. Further, the impacts of climate change while researched at the global level, have local level impacts that cannot be addressed with global level policies. Policy needs to consider the unique characteristics of individual cities. Finally, cities themselves have recognized their innate capacity and have taken steps to mitigate climate change; and demonstrated success in reduced CO2 emissions. [Note 24]
However, climate change is not simply about C02 emissions. The science of climate change is complex and how its manifests itself ranges from super storms that cause mass devastation in a short span of time; to slow gradual increases or decreases in temperature that ‘sneak up’ and cause a chain reaction of multiple problems. Presently, the key impacts of climate change in cities are: extreme weather events, extreme temperatures, rising temperatures, air pollution and air quality, rising sea levels and flooding. These impacts have multiple impacts in cities from damage to physical infrastructure (buildings and roads), and the economy, to adverse health outcomes for citizens, the interest of this paper. There has been a considerable amount of research investigating the health impacts of climate change from the WHO and other research groups. [Note 25] The research shows that many diseases are impacted by climate change and that the occurrence of diseases, (specifically, vector borne illnesses), is correlated to climatic changes in specific geographical areas, for example rises in temperature and increased rainfall will see the re-emergence of malaria in formerly malaria free zones. Consequently not all cities will experience the same diseases. [Note 26] However, non-communicable and non-vector borne diseases, like cardiovascular and respiratory diseases whose prevalence is correlated to climate change, will be a challenge for all cities. Thus the concern for cities is the prevention of ill health and as such the creation and sustaining of an urban environment that supports good physical health.
Thus, if cities are to be responsible for mitigating climate change’s impact on health and the ways in which health are impacted vary immensely, how can cities create coherent and feasible policies? One option would be to start from scratch and centre all policy with the aim of preventing ill health. A more viable option is to consider current policy actions by cities and identify areas for expansion and growth, using the social determinants of health as a guide.
In order to see what cities are currently doing in the area of climate change and health a content analysis of 51 official city plans were reviewed for policy actions pertaining to climate change. In addition to this a web-based survey was sent to the 51 cities to: 1. Verify the information in the plans and 2. Identify if new actions are currently being undertaken and 3. Determine if cities believe they have the capacity to address the health impacts of climate change.
The results of the content analysis and survey highlighted common policy actions by cities such as: focusing on integrated transportation networks, bike sharing schemes, green building guidelines (LEED, BREEAM or self-developed), green infrastructure (greenways, parks, ecosystem services) and integrated water resource management. Where health outcomes are concerned policy is focused on the built environment; namely mitigating heat islands through green infrastructure, and tree planting to reduce air pollutants that cause respiratory diseases. Some cities have embarked on innovative endeavors that address climate change and health simultaneously. For example, New York City has the New York City Environmental Public Health Tracking System that consists of indicators used to monitor changes in the health status of the population by neighborhood. In addition to this NYC has collaborated with a range of stakeholders to develop a comprehensive strategy to address its heat island issues. Elsewhere, the city of Portland incorporates physical and mental well-being into a year round outdoor conservation school that teaches children about the environment and how to protect it, whilst getting them outside and active. The City of Glasgow has taken the step of using the social determinants of health as the basis for their new climate change strategy and city plan.
However, not all cities have taken steps to address the health impacts of climate change. From the survey, it was clear that many cities felt their role is to provide a living environment that is characterized by a robust economy and a strong community. In regards to climate change, the majority of cities stated it is their role to be leaders and drive action on climate change. However, when it came to health, cities placed the responsibility on health authorities and higher levels of government. Some did acknowledge that they have a role in providing space and services that will enable citizens to be physically active and infrastructure that will allow medical professionals to respond to health needs.
The questions within the survey also sought to identify the barriers for cities in addressing climate change and health. These were the challenges that were the most prevalent for cities: 1. Their capacity and role in addressing climate change and health. (who is responsible for what?) 2. Incorporation and interpretation of a range of opinions from stakeholders. 3. How to focus policy such that it succeeds, economically, socially and scientifically.
Thus the question is how can cities overcome these perceived challenges and broaden the effectiveness of policies and become resilient to climate? This is where the social determinants of health have potential to guide policy.
Conclusion: SDH based resilience policy
As discussed, resilience based climate change policy can acquire greater focus through health, and the SDH can provide a guide for policy. However, the success of policy will require urban policy makers to be creative and at the forefront of issues facing their cities. In developing climate change policy based on the SDH cities should consider [Note 27] :
A potential tool for policy makers are two matrixes relating SDH and climate change; One that considers the interactions between the SDH and climate change impacts and a second that can be used to identify policy gaps, which is presented here. At the moment within the matrix are policies currently used by cities, not included are the innovative actions by individual cities. It is evident that there are gaps and significant room for growth in terms of policy, for example education. There is potential for adult education coupled with the use of information technology to promote life long learning and to create environmental education in novel spaces, ultimately contributing to the long-term success of policy. Another innovative idea is to build on urban agriculture by incorporating courses on nutrition and understanding the impacts of growing locally versus transporting food. The options beyond this are numerous and have multiple benefits for long-term resilience and protecting human health.
Cities, ultimately, in reaching their goal of being resilient to climate change, stand to benefit immensely by considering the interactions between the SDH, which guide daily life and can be adversely impacted by climate change. Policy informed from these considerations have the capacity to be dynamic and respond to the evolving needs of citizens and the uncertainty of climate change’s impacts on the urban environment. Finally, it enables policy to reach the entire population of city by engaging citizens in an area that matters to them, their health.
Table - Matrix Climate Change Policies and SDH
[Note 1] Botkin and Beveridge, 1997; Friedmann, 2010; Fleischman and Barondess 2004;
[Note 2] Friedman, 2010; Kenzer, 1999;
[Note 3] Friedman, 2010; Botkin and Beveridge, 1997;
[Note 4] Barton, 2009; Few 2006; Campbell-Lendrum and Corvalan, 2007; Ford et al, 2006; Rydin, 2012; Kovats and Akthar, 2008; WHO 2010; Barton et al, 2003
[Note 5] Barton, 2009; Few 2006; Campbell-Lendrum and Corvalan, 2007; Hajats et al, 2010; Corburn, 2009;
[Note 6] Corburn, 2009; Rydin, 2012; Kovats and Akthar, 2008;
[Note 7] Younger et al, 2008; Harpham, 2008; Ilbanez, 2011; Petersen, 1996; WHO 2010
[Note 8] Norris et al, 2008; Gotham and Campanella, 2010; Carver, 1998
[Note 9] Norris et al, 2008; Cutter et al, 2008;
[Note 10] Norris et al, 2008; Gotham and Campanella, 2010; Cutter et al, 2008; Carver, 1998
[Note 11] Norris et al, 2008; Gotham and Campanella, 2010; Cutter et al, 2008; Miller et al, 2010
[Note 12] Norris et al, 2008; Gotham and Campanella, 2010; Cutter et al, 2008; Miller et al, 2010; Sandler, 2001; Carver, 1998
[Note 13] Carver, 1998; Miller, et al, 2010; Cutter et al, 2008; Pendall et al, 2009
[Note 14] WHO, 2010: Rydin, et al 2012; Galvao et al, 2009
[Note 15] Galvao, et al, 2009; Rydin et al, 2012; Kenzer, 2009; Schulz and Northride, 2004
[Note 16] ibid
[Note 17] Marmot, 2005; Blas, et al, 2008;
[Note 18] ibid
[Note 19] ibid
[Note 20] ibid
[Note 21] Blas et al 2008; Grady and Goldblatt, 2012; Ritsatakis
[Note 22] Forde and Raine, 2008;
[Note 23] Rydin, et al, 2012;
[Note 24] ibid
[Note 25] WHO 2010; Campbell-Lendrum and Corvalan, 2008
[Note 26] WHO 2010; Campbell-Lendrum and Corvalan, 2008
[Note 27] Armstrong, et al 2012; Galvao et al, 2009;WHO, 2010; WHO 2000
Armstrong, B., et al. (2012). “Climate Change: How Can Epidemiology Best Inform Policy?” Epidemiology 23(6):780-784.
Barton, H. (2009). “Land use planning and health and well-being”. Land Use Policy 265: S115-S123.
Barton, H., Mitcham, C., and Tsourou, C., eds (2003). “Healthy urban Planning in practice: experience of European cities” Report of the WHO city Action Group on healthy Urban Planning. WHO
Berger, A.M., ed (2013). “Report: Health and Urban Planning” MIT.
Blas, E., et al. (2008). “Addressing social determinant of health inequities: what can the state and civil society do?” The Lancet 372:1684-1689.
Botkin, D.B., and Beveridge, C.E., (1997). “Cities as environments”. Urban Ecosystems 1 pp 3-19.
Brown, K.J., et. al. (2012). “Governing for a Healthy Population: Towards and Understanding of How decision-making will Determine Our Global Health in a Changing Climate”. International Journal Environmental Research and Public Health. 9 pp 55-72
Campbell-Lendrum, D., and Corvalan, C., (2007). “Climate Change and Developing-Country Cities: Implications For Environmental Health and Equity.” Journal of Urban Health: Bulletin of the New York Academy of Medicine 84(1):i109-i117
Carter, J.G., (2011). “Climate Change in European Cities”. Current Opinion in Environmental Sustainability. 3: 193-198
Corburn, J. (2009). “Cities, Climate Change and Urban Heat Island Mitigation: Localising Global Environmental Science”. Urban Studies 46(2):413-427
Fleischman, A.R., and Barondess, J.A. (2004). “Urban Health: A Look Out Our Windows”. Academic Medicine 79(12):1130-1132
Folke, C., (2006). “Resilience: the emergence of a perspective for social–ecological systems analyses”. Global Environmental Change 16(3):253–267.
Ford, J., Pearce, T., Smit, B., Wandel, J., Allurut, M., Shappa, K, Ittusujurat, H., and Qrunnut, K., (2006). “Reducing Vulnerability to Climate Change in the Arctic: The Case of Nunavut, Canada”. Arctic 60(2):150-166
Friedmann, J. (2010). “Place and Place-Making in Cities: A Global Perspective”. Planning Theory and Practice 11(2):149-165.
Galvao, L.A.C., et al. (2009). “climate change and social determinants of health: two interlinked agendas”. Global Health Promotion. Supp 16:81-84.
Grady, M., and Goldblatt, P. eds (2012). “Addressing the social determinants of health: the urban dimension and the role of local government”. WHO.
Hajat, S., O’Connor, M., and Kosatsky, T. (2010). “Health effects of hot weather: from awareness of risk factors to effective health protection”. The Lancet 375: 856-863
Hall, P. (1996). Cities of Tomorrow. Blackwell Publishers Massachusetts, USA.
Harlan, S.L., and Ruddell D.M., (2011). “Climate change and health in cities: impacts of heat and air pollution and potential co-benefits from mitigation and adaptation”. Current Opinion in Environmental Sustainability 3 pp. 1260134.
Harpham, T. (2008). “Urban health in developing countries: what do we know and where do we go?” Health and Place 15:107-116
I Ibanez, E.L. (2011). “Municipality, space and the social determinants of health”. Environment and Urbanization 23:113-117.
Kenzer, M. (1999). “Healthy cities: a guide to the literature”. Environment and Urbanization 11(1): 201-220.
Kovats, S., and Akthar, R. (2008). “Climate, climate change and human health in Asian cities”. Environment and Urbanization 20:165-175.
Marmot, M. (2005). "Social determinants of health inequalities". The Lancet 365:1099-1104
Marmot, M. et al. (2008). “Closing the gap in a generation: Health equity through action on the social determinants of health”. The Lancet. 372: 1661-1669
Ritsatakis, A. (2012) “Healthy cities tackle the social determinants of inequities in health: a framework for action”. WHO. regional office for Europe.
Rydin, Y. (2012). “ Healthy cities and planning”. The Planning Review 83(4): xiii:xviii
Rydin, Y., et al (2012). “Shaping cities for health: complexity and the planning of urban environments in the 21st century”. The Lancet 379:2079-2108.
Schulz, A., and Northride, M.E., (2004) “Social Determinants of Health: Implications for Environmental Health Promotion”. Health Education and Behavior 31:455-471
WHO (2000). Regional Guidelines for Developing a Healthy Cities Project. WHO Regional Office for the Western Pacific.
WHO (2010), Why Urban Health Matters
WHO (2013). Our cities, our health, our future: Report to the WHO Commission on Social Determinants of Health from the Knowledge Network on Urban Settings Acting on social determinants for health equity in urban settings.
Younger, M., Morrow-Almeida, H.R., Vindigni, S.M., and Dannenber, A.L., (2008). “The Built Environment, Climate change, and Health: Opportunities for Co-Benefits”. American Journal of Preventive Medicine 35(5): 517-526