URBAN HEALTH:
IS THE CITY INFECTED?



Lecture at the Millennium Festival on Medicine and the Humanities Sponsored by St. Thomas' Guy's and King's School of Medicine and Southwick Cathedral

Medicine and Humanity. London: King's Fund, 2001.

May, 2000


Victor G. Rodwin*
Professor of Health Policy and Management
Wagner School of Public Service
New York University
Director, World Cities Project
International Longevity Center- USA

       The city is, at once, a center for disease and poor health and also a place for hope, cures and good health. From the earliest times, the city has attracted the poor and been the target of the plague, as well as war. Likewise, the health care industry has always been part of the economic base of cities - from Lourdes, in France, to Rochester, Minnesota, to megacities around the world. With its highly disproportionate share of health resources, e.g., hospitals, physicians, nurses and social services, the big city is a center of excellence in medicine. Yet, as Richard Horton, editor of The Lancet once noted, "Éfor all of its rational efficiency and benevolent intent, the city is likely to be the death of us."1 Are cities socially infected breeding grounds for disease? Or do they represent critical spatial entities for promotion of population health?

       I propose to begin with a global view of urban health and disease and the challenge this poses for public health today. Next, I examine some evidence for the hypothesis that population health in cities is relatively poor. Finally, I suggest that the more pertinent question is not whether the city is unhealthy or healthy but rather the extent to which we can alleviate the problems posed by inequalities of income and wealth - in the city as well as outside of it.

A Global View of Urban Health

       The United Nations projects that 61 percent of humanity will live in cities by 20252. There are now 19 megacities; in 2015, the UN estimates that there will be 233. The fastest growing megacities are located in developing nations. Such cities are like "huge human sponges, soaking up 61 million new people each yearÉ."4 Air travel and other routes of transportation have magnified their influence and vulnerability.

       In contrast to megacities in developing countries, New York, London, Paris and Tokyo -- the largest cities of wealthy nations belonging to OECD -- share a recent history of relative success in assuring their population's health and confront a range of common characteristics and problems. They are great centers for prestigious university hospitals, medical schools and medical research institutions. Despite these resources and the success of their public health reformers and urban planners in improving their quality of life, these world cities still confront onerous health risks -- albeit to different degrees -- for at least six problems: 1) the re-emergence of infectious diseases (e.g. tuberculosis, and the arrival of new ones, e.g. AIDS); 2) water and air pollution; 3) an increase in the homeless population; 4) barriers in access to medical services for ethnic minorities and/or the poor; 5) terrorism (e.g. the world trade center bombing in New York) and bio-terrorism (e.g. the release of toxic sarin gas in Tokyo's subway system); and 6) rising inequalities among social groups.

       These problems will challenge any big city to develop a solid public health infrastructure. With or without such investments, there is already widespread belief that urban health is not as good as that of the population as a whole. Those who disagree point to contrary evidence. Strangely enough, there is insufficient evidence to provide strong support for either view. (Hence, the "puzzles" to which Julian Le Grand has alluded).

       The reason for which we have so little solid evidence is that we have no routine information systems for monitoring the health of populations living in cities. While institutions responsible for disease surveillance and control - at the international, national, and local authority levels - collect vital statistics and epidemiological data by geographic location, national policy is made without systematic analysis of information for monitoring health status, public health infrastructure and the performance of health systems in cities. (Julian Le Grand is deceptively modest when he confesses to "knowing relatively little about health and the city." The fact is that all of us know relatively little because information on health status is reported routinely by national or regional units; the city is most often ignored as a unit of analysis in health policy.) I therefore propose to present a case for both sides of the urban health controversy - the city is sick and the city is healthy - summarizing highly selective evidence for each view.

The Sick City

       Since the city is, by definition, the place where human density is greatest, it is hardly surprising that the city is a vector for disease transmission, particularly for the spread of infectious disease. One has only to recall the vivid descriptions of the plague in Egypt or the cholera epidemics in London or New York or Paris to realize how cites can become epicenters for disease. But beyond such images of epidemics in the city, what kind of evidence do we actually have on population health in cities of OECD nations?

The Big Cities Health Inventory in the United States

       In 1997, an unusual and unpublished database was assembled, in the United States, by the Chicago Department of Health5. Data reported by Health Departments of 46 big cities in the US (between 1992-1994) indicated that the average incidence rates for the leading infectious diseases - tuberculosis, AIDS and syphilis - were much higher in these cities than for the U.S. as a whole. This is to be expected given the effects of population density on the transmission of infectious disease. More striking, however, were the mortality data (1994) reported by these cities for the leading causes of death from non-communicable diseases: heart disease and cancer. In stark contrast to the situation in England, the average age-adjusted mortality rate from heart disease across these cities was higher than the U.S. average (164 per 100,000 population vs. 145)6. For cancer, the average age-adjusted mortality rate across these cities was 153 per 100,000 population, in contrast to 132 for the U.S. as a whole.

       There are two convenient ways to summarize this information: The first is to calculate an overall mortality rate for all causes of death; the second is to calculate years of potential life lost (YLL). For all of the criticisms one might make of the YLL measure, it is nonetheless an important indicator of the health of a population. Simply defined, it is the number of years of life lost by people who died before the age of 65. The overall mortality rate for the 46 cities was 654 per 100,000; for the US as a whole it was 507. The average years of potential life lost for the 46 cities was 75 per 1000 population; for the U. S. as a whole, it was 54.

Urban Social Health in the United States (1995)

       In 1995, the National Association of Public Hospitals in the U.S. published a compendium of data on the 100 largest cities7. Among a range of indicators, this report notes that, in 1993, the gonorrhea rate in the 25 largest cities was 434 per 100,000; for the US as a whole, it was 172 per 100,000. Shifting to more generalized health indicators, the average infant mortality rate for the 100 cities was 12.2 per 1000, in 1988; for the U.S. as a whole it was 9.8. In a subsequent study more specifically on "inner city health," Dennis Andrulis, the former Director of Research for the National Association of Public Hospitals, characterizes the greater prevalence of a large number of health problems in cities than in suburbs and rural areas as the "urban health penalty."8

       In support of these findings on the urban health penalty and in contrast to evidence from the É.Survey in England (See J. Le Grand paper), a study of low birth weight and children's height in England's Northumberland County concludes that "there is substantial disadvantage to living in urban areas compared with rural areas." This finding is particularly noteworthy because it adjusts for levels of "deprivation" across urban and rural areas9. Yet another study in Wales using a different indicator of "health" - premature mortality from all causes-also supports the sick city hypothesis after controlling for differences in "deprivation" measures across urban and rural areas10. What then should one conclude from this assorted evidence on health in cities? People don't just "feel worse" in cities (as indicated by the Survey cited by Le Grand) -- they are doing worse. Cities are therefore unhealthy places - at least in the U.S., England and Wales. What about in the rest of the EC?

Project Megapoles: Health in Europe's Capitals

       Project Megapoles, a study of Europe's capital cities, has generated some fascinating comparative data. Funded by the EEC, this project seeks to improve health in these cities, especially for three target groups: 1) Youth and young families; 2) the socially disadvantaged; and 3) older persons. In its main report, Project Megapoles compares age-specific mortality for each European capital to national rates11. Once again, we have, for the most part, evidence in support of the "sick city hypothesis." On average, mortality rates for infants (0-4 years) were 7 percent higher in the cities than in their respective nations (31% higher in Copenhagen; 44% higher in Vienna; only 6% higher in London and Stockholm). In contrast, these rates were lower in 5 cities: Helsinki (-18%), Lisbon (-9%), Lazio (-12%), Madrid (-20%), and Lyon (-25%).

The World Cities Project

       The Megapoles project was as source of inspiration in designing our own World Cities Project, a collaborative enterprise between the Wagner School of Public Service, New York University, and the International Longevity Center (ILC-USA). Among the megacities of the world today, New York, Paris, London and Tokyo often serve as a model for their counterparts in developing nations due to their relative wealth and dominance, their ties to the global economy, and their concentration of business, cultural and scientific activities. Along with our partners at ILC-UK, ILC-France and ILC-Japan, we have embarked on a project to study public health infrastructure as well as health outcomes and health services for older persons and children in these cities12.

       The evidence we have examined so far lends some qualified support for the hypothesis that population health in cities is worse than at the national level. I emphasize the term "qualified" because the evidence is mixed (Table 1). In NYC, the evidence is incontrovertible: life expectancy at birth (LEB) is lower than in the U.S. as a whole, particularly for males (67.8 years); infant mortality (IM) is higher; and rates of "feeling worse" (self-reported total mobility limitations among persons 65 years and older (18.1%) are higher than for New York State overall (16%). In Tokyo, however, there are no significant differences, along these measures, in comparison to Japan. In Paris, although there are no differences in LEB when compared to France as a whole, infant mortality is lower in Paris than in France (4.0 vs. 4.6). And in London, although there are no significant differences in IM, or in LEB for men, women have a longer LEB (79.3) than in the UK as a whole (78.8).

       This "qualified support" is fractured, however, when one examines life expectancy at 65 years, particularly for women (Table 2). In New York City and London, there are no differences between city and the nation. In Tokyo, however, women live longer at 65 than in Japan (21.2 years vs. 20.9 years). And in Paris, women live much longer than in France, as a whole (26.5 vs. 20.6).

       Such findings -- however intriguing -- do not refute the hypothesis that cities are unhealthy for the strongest case has yet to be made. It is that these wealthy world cities, along with all other megacities, are places where flagrant inequalities exist among subpopulation groups. All of the averages we have considered mask enormous pockets of poverty with disadvantaged groups that suffer disproportionately in terms of their health status.

The Healthy City

       Since the city has been a symbol of civilization and human accomplishment over the past 2000 years and earlier, it has been the place for visions of human betterment, including population health13. In 1875, Sir Benjamin Ward Richardson, a disciple of Edwin Chadwick, gave a lecture to the Social Science Association meeting in Brighton, England on "Hygeia: A City of Health." His vision of an ideally healthy city inspired Ebenezer Howard and the garden city movement of the 1890s, as well as WHO's Healthy Cities movement that began in the late 1980s14

       Moving from the vision to the concept, the case for the healthy city is typically grounded in economic arguments or celebrations of its vitality and innovation in such diverse realms as architecture, urban design, culture, technology, and more. A recent American example may be found in President Clinton's State of the Union message in 1998 in which he refers to American cities as the "vibrant hubs of great metropolitan regions." In this respect, the Report of the U.S. Conference of Mayors and the National Association of Counties notes that, between 1982-1998, metropolitan areas in the United States generated 85 percent of all jobs and 86 percent of the nation's total economic growth15. This economic power is concentrated among some regional giants that dwarf not only their own states but most of the world's nations. Metropolitan New York's economic output, for example, is greater than that of 45 of the 50 states.16

       Claims for the enduring power of cities, including big cities, most often come out of the literature on urban planning and do not typically invoke evidence about population health. But there is a body of evidence in support of the hypothesis that urban health compares favorably to that of the nation, as a whole.

The National Health Interview Survey

       The National Health Interview Survey (NHIS) is one of the most reliable indicators of functional health (how people feel) in the United States. In 1988, the results of this national survey were reported for major metropolitan regions in the U.S. Comparison of health indicators for these regions - an aggregation of the urban population - with the national average provides a unique opportunity to shed light on another dimension of urban health (Table 3). In contrast to the Big Cities Health Inventory which relies on outcome measures of health, NHIS suggests that most indicators of self-assessed health status are better in major metropolitan areas than for the country as a whole.

       For example, the percent of population with activity limitations is lower in metropolitan areas than in the country as whole (12.4 in MSAs vs. 13.7). Likewise, the percent of population reporting fair or poor health in the metropolitan areas is lower than in the country as a whole (8.7 vs. 9.4). Also, the number of restricted activity days per 100 persons is lower in metropolitan areas than in the rest of the country (1390 days vs. 1470 days). Self-reported data on selected chronic conditions support these more general indicators of functional health in the NHIS (Table 3). There are only two conditions for which reported rates appear to be higher in major metropolitan areas than in the U.S., as a whole: asthma and deformities or orthopedic impairments.

Focused Studies on Urban-Rural Differences

       In Virginia, a study of low birth weight infants in rural vs. urban areas found that rural areas had a higher incidence of low-birth weight infants.17 This study probably reflects the fact that the infants' parents in rural areas were more apt to be single, less educated, African American and have lower income than their counterparts in the urban areas.

       In Kentucky, a comparison of health status between rural and urban adults found few differences when measured by a sophisticated set of criteria used in the "medical outcomes study" (physical functioning, role functioning, social functioning, general mental health, and general health perceptions.) With respect to rural vs. urban elderly adults, however, Mainous and Kohrs found a situation of "rural inferiority" - rural elderly had significantly worse health status than their urban counterparts.18

       In Georgia, with respect to cancer, a study found that residents of a rural area were twice as likely to have unstaged cancers as their urban counterparts. This probably reflects less effective diagnosis and assessment of the tumors' growth. Among patients with a known and documented tumor "stage" at diagnosis, rural patients tended to have more advanced disease than urban patients, which probably reflects better access to medical treatment in urban areas19. Thus, for cancer care there may be an urban "advantage" as least in terms of treatment.

       Additional and more recent evidence from the NHIS (beyond Table 3) suggests that the central city is healthier with respect to self-reported incidence of diabetes and hypertension. Also, as in England, the U.S. National Household Survey of Drug Abuse reports higher rates of binge drinking and consumption of alcohol in rural areas than in urban areas. But in contrast to England, the US has higher tobacco use in rural areas than in cities. In summary, a review of selective evidence can support the hypothesis that cities are actually healthy in comparison to rural areas.

Concluding Observations

       There is evidence of an "urban penalty" in terms of doing worse and feeling worse in the United States. But there is also evidence of an "urban advantage" in terms of self-assessed health status, health habits and with respect to quality cancer screening services. The reason for which the evidence reviewed here is mixed and possibly confusing is two-fold: 1) There are many ways to define and measure health. As we have seen, measures range from disease prevalence, LEB, age-specific mortality rates, and indicators of self-assessed health; 2) There are many ways to define and measure cities. As we have seen, spatial definitions range from inner cities to large metropolitan areas. Therefore, an apt conclusion may be that the a priori is as dangerous in health policy as it is in philosophy! More concretely, this suggests that in thinking about rural versus urban health, it is prudent to avoid assumptions about the validity of urban versus rural factors as determinants of health and to include well known risk factors for bad health as they affect both rural and urban spatial units. These factors are: poverty, inequality and low levels of social capital/social cohesion.

Acknowledgements:

I wish to thank Irena Dushi, Susan Ghanbarpour and Meron Makonnen for their assistance with my review of the literature and preparation of tables for this paper.



APPENDIX

Table 1. Life expectancy, infant mortality and total mobility limitation, national and city data

  LEB
(Male)
LEB
(Female)
IM
1995)
Total Mobility Limitation
New York City
(1990)
US
67.8

71.8
77.7

78.8
8.8

8.0
18.1

16 (NYS)
Tokyo 23 wards
(1995)
Japan
76.3

76.4
82.9

82.9
4.2
4.3
 
Paris
(1990)
France
72.6

72.7
80.8

80.9
4.0

4.9
 
London
(1991)
UK
73.1

73.2
79.3

78.8
6.3

6.0
 


Life Expectancy at Birth (LEB):

Infant Mortality (IM):
Total Mobility Limitation:

Table 2. Life expectancy at 65 years

   Life Expectancy at 65 Years (Male) Life Expectancy at 65 Years (Female)
New York City
(1990)
US
15.3

15.1
19.0

18.9
Tokyo 23 wards
(1995)
Japan
16.5

16.5
21.1

20.9
Paris
(1995)
France
21.4

16.1
26.2

20.6
London
(1991)
UK
14.5

14.2
18.6

18.0


Sources:

Table 3. Selected health characteristics*

   All large CMSA's & MSA's a Rest of the country
Health Characteristics    
Percent limited in activity 12.4 13.7
Percent with fair or poor respondent-assessed health 8.7 9.4
Disability days    
Restricted activity days per 100 persons 1389.8 1470
Chronic Condition per 1000 persons/year    
Arthritis 113.1 129.9
Deafness 71 90.8
Deformities or orthopedic impairments 121.6 111.6
Heart Disease 71.6 84.1
High Blood Pressure 108.2 121.5
Hemorrhoids 43.6 45.8
Chronic Bronchitis 46.2 49.4
Asthma 44 41.2
Hay Fever 88.6 93
Chronic Sinusitis 114.2 139.7
From: US data from Current Estimates from NHIS 1988, Series 10, # 173. MSA and CMSA data from Health Characteristics of Large Metropolitan Statistical Areas: US, 1988-1989.


a. MSAs are metropolitan statistical areas. The NHIS report contains data for 18 Consolidated Metropolitan Statistical Areas (CMSAs) and 15 (MSAs). The total population represented in the survey is 117,211,000. The definition and titles of MSA's are established by the U.S. Office of Management and Budget (OMB) with the advice of the Federal Committee on Metropolitan Statistical Areas. Since January 1980, each MSA must include at least one of the following: One city with 50,000 or more inhabitants and an area (defined by the US Bureau of the Census as urbanized) of at least 50,000 inhabitants and a total MSA population of at least 100,000 (75,000 in New England). The 1980 standards provide that, within metropolitan complexes of 1 million or more population, separate component areas are defined if specified criteria are met. Such areas are designated primary metropolitan areas (PMSAs), and any area containing PMSAs is designated a consolidated metropolitan statistical area (CMSA).


FOOTNOTES

1R. Horton, "The Infected Metropolis." The Lancet 347 (8995): 134-5, January 20, 1998.
2UN projections cited by E. Linden, "The Exploding Cities of the Developing World." Foreign Affairs (75)1, 1996.
3UN, Department of Economic and Social Information and Policy Analysis, 1995.
4R. Horton, "The Infected Metropolis." The Lancet 347 (8995): 134-5, January 20, 1998.
5Big Cities Health Inventory, 1997: The Health of Urban USA. Produced by the City of Chicago, Department of Public Health.
6See J. Le Grand's paper for English data
7Urban Social Health. Washington D.C: National Association of Public Hospitals, 1995. 8DP Andrulis, "The urban health penalty: new dimensions and directions in inner-city health care." In: Inner City Health Care. Philadelphia, PA: American College of Physicians; 1997.
9R Reading, S Raybould and S Jarvis, "Deprivation, low birth weight, and children's height: A comparison between rural and urban areas." British Medical Journal 307(6917): 1458-1462, 4 December 1993.
10M Senior, H Williams and G Higgs, "Urban-rural mortality differentials: controlling for material deprivation." Social Science & Medicine 51 (2000): 289-305.
11Health in Europe's Capitals (http://www.megapoles.org), p. 30.
12V.G. Rodwin "Population Aging and Longevity in World Cities," CGP Newsletter, Japan Foundation Center for Global Partnership (http://www.cgp.org/cgplink)
13P. Hall, Cities in Civilization. New York: Pantheon, 1998.
14T. Hancock, "The evolution, impact and significance of the Healthy Cities / Healthy Communities movement." Journal of Public Health Policy, Spring 1993.
15The State of the Nation's Cities, Washington D.C.: Department of Housing and Urban Development, 1998.
16Ibid
17B Alexy, B Nichols, MA Heverly and L Garzon, "Prenatal factors and birth outcomes in the Public Health Service: A rural/urban comparison." Research in Nursing & Health 20 (1997): 61-70.
18AG Mainous III, FP Kohrs, "A comparison of health status between rural and urban adults." Journal of Community Health 20(5):423-431, October 1995.
19JM Liff, WC Chow, and RS Greenberg, "Rural-urban differences in stage at diagnosis: Possible relationship to cancer screening." Cancer March 1, 1991.



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