Why We Need Urban Health Equity Indicators: Integrating Science, Policy, and Community

As the world urbanizes, global health challenges are increasingly concentrated in cities. Currently, over 80% of the population in Latin America already lives in cities. The African urban population is projected to double in the next decade and China has urbanized in thirty years at a rate it took Europe and North America a century [1]. Rapidly growing new cities and increasingly segregated older cities in the global north and south are contributing to health inequities. Urban planning and policies can influence population health by supporting or stymieing opportunities for employment, housing security, political participation, education, protection from environmental risks, access to primary health care, and a host of other social and physical determinants of well-being [2]. As the World Health Organization (WHO) and UN-HABITAT acknowledged in the 2010 report entitled ‘‘Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings’’, where in a city you live and how that city is governed can determine whether or not one benefits from city living [3]. Measuring the forces that contribute to urban health is one challenge for promoting more healthy and equitable cities. Burden of disease estimates have tended to focus on the whole world or specific geographic regions [4,5]. These data can mask intra-city differences and global data may not be relevant to inform national or municipal policy making. Public health has developed metrics for single pathogenic exposures or risk factors, but these measures often ignore both community assets that promote health equity and the cumulative impacts on health from exposure to multiple urban environmental, economic, and social stressors [6,7]. Recognizing these population health challenges, the United Nations (UN) Commission on Social Determinants of Health (2008) called for ‘‘health equity to become a marker of good government performance’’ ([8], p. 11) and for the UN to ‘‘adopt health equity as a core global development goal and use a social determinants of health indicators framework to monitor progress’’ ([8], p. 19). More recently, the 2011 World Social Determinants of Health Conference and the Pan-American Health Organization’s Urban Health Strategy called for the development of new urban health equity indicators that track the drivers of health inequities across place and time, particularly within a city neighborhood [9] (Box S1). In this paper, we briefly outline an approach for promoting greater urban health equity through the drafting and monitoring of indicators. We draw examples from the cities of Richmond, California, and Nairobi, Kenya. More specifically, we argue that participatory indicator processes hold the potential to shape new healthy and equitable urban governance by: