Urban Development and Human Health
Urbanization is the process whereby a society changes from a rural to an urban way of life. It also refers to a gradual increase in the proportion of people living in urban areas.
Industrialization took place in the middle of the eighteenth century and the start of the nineteenth century, leading to a transformation in geographical areas, economic growth, and the abandonment of agrarian society. Since industrialization started, cities have continued to develop and have become the urbanized areas that we know today. Cities’ growth can be attributed to two phenomena; (1) the migration of rural populations to urban areas in a search for a better quality of life and employment opportunities, and (2) the expansion to areas surrounding cities (Nnebue et al. 2014).
Urbanization has been linked with economic and technological developments; with these advances, populations in rural and urban areas aspire for job opportunities, cultural diversity, technology, education, and healthcare accessibility, which are inherent to urban settings. Technological advances can be seen as the enemy or as an ally, specifically when considering the subject of employment. Continuous changes in workforce abilities or workforce needs may increase unemployment, with impoverishment of the populations living in the cities and declining housing and life quality. Usually, individuals of the lowest socioeconomic status do not have financial savings, or they have low wages that do not cover their basic needs. Adequate urbanization planning should consider the current necessities of the population to assure sustainability and a healthy city for human population. Several challenges currently exist in the development of healthy cities that can address their populations’ needs.
It is expected that 68% of the world’s population will be living in urban areas by 2050. Urban population centers with rapid development and more than 10 million residents are defined as megacities. By 2030, it is expected that there will be 41 low-income and middle-income megacities (Jowell et al. 2017). Current megacities include Tokyo, with 37 million inhabitants; New Delhi, with 29 million inhabitants; Shanghai, with 26 million inhabitants; and Mexico City and Sao Paolo, with 22 million inhabitants (United Nations 2018). These megacities are usually “dual cities,” where a part of the population has access to the privileges that accompany economic growth but the other segment of the population (which usually is the majority) lives in slum-like conditions, thus resulting in an inequity increase (Roy 2002).
Impact of Urbanization on Human Health
The World Health Organization (WHO) defines health as a “state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political belief or economic and social conditions.” Therefore, the link between human health and the environment must not be ignored.
The fulfillment of urban population needs is associated with an increase in households, leading to overcrowding, inadequate sanitation, air pollution, and climate change. In turn, there are further impacts to human health from an increasing prevalence of vectorborne diseases, asthma, allergies, respiratory diseases, cancer, cardiovascular diseases, stroke, foodborne diseases, heat-related morbidity and mortality, human developmental effects, neurological disease and disorders, and weather-related morbidity and mortality (Khaniabadi et al. 2017; United Nations 2018; Nnebue et al. 2014).
Non-communicable Diseases and Traffic Injuries
Due to sedentary lifestyles, long working hours, long hours spent in traffic, long-distance commutes, and affordable access to processed food (high-calorie diets), the population experiences increased body mass index. This lifestyle leads to an increase in risk factors (e.g., high blood pressure, high cholesterol, obesity) for non-communicable diseases such as diabetes and cardiovascular diseases in children and adults (Jowell et al. 2017).
With urbanization, mobility needs to be increased between distant areas; however, the construction of new roads leads to exploitation of lands and a decrease of green areas. Road construction creates an increase in traffic, leading to poor air quality, physical inactivity, and decreased road safety (Katz et al. 2012). To limit the number of individually-owned motor vehicles, some countries are investing in eco-friendly public transportations systems to decrease environmental contamination, increase physical activity, and decrease traffic injuries, which are currently ranked as the eighth leading cause of mortality (World Health Organization 2018).
Respiratory allergies are triggered by seasonal and climatic components. The amount of ground level ozone and fine particle pollution (PM2.5), increased carbon dioxide (CO2), increased temperatures due to vehicle emissions, use of green areas, climate factors, and living near roadways are factors that can lead to adverse respiratory responses. Individuals might present with symptoms such as coughing, breathing difficulties, irregular heartbeat, chest pain, throat irritation, bronchitis, emphysema, and asthma. Children, the elderly, pregnant women, and individuals living in areas near roadways are at an increased risk of developing respiratory system problems. Environmental protection policies, such as building regulations, decreased reliance on self-owned vehicles, decreased indoor and outdoor air pollution, and regulation of greenhouse gases emissions, could have a positive effect on the environment and human health (Portier et al. 2010).
Exposure to toxic chemicals due to volatilization or water contamination after temperature increases is suspected to have an impact on cancer. Rising temperatures and ultraviolet (UV) light exposure is associated with an increased incidence of basal cell and squamous skin cancer. UV radiation’s carcinogenic potential is increased with concomitant exposure to toxic chemicals and high temperatures (Burke and Wei 2009; Tucker 2009).
Cardiovascular Disease and Stroke
Individuals with pre-existing cardiovascular conditions are at risk of experiencing an exacerbation of their disease (stroke, arrhythmias, chest pain, acute coronary syndrome) due to exposure to temperature changes (hot and cold). Furthermore, increased ozone levels make O2 → CO2 exchange difficult and can alter pulmonary and cardiac normal function (Bassil et al. 2009; Ebi et al. 2004; Gong et al. 1998; Kysely et al. 2009; Schwartz et al. 2004).
Heat-Related Morbidity and Mortality
When tall buildings are the predominant type of construction in a city, an urban heat island effect is created, in which the temperature is warmer in the city than in areas around the city due to absorption, generation, and released heat. Urban residents might present with symptoms such as exhaustion, heat cramps, heat stroke, and death. Public health preparation for heat waves may decrease mortality risk. Strategies for green areas that can regulate urban heat temperature must be proposed. The implementation of air conditioning is a dilemma: on the one hand, it help the body’s temperature regulation in high heat; however, on the other hand, greenhouse gas emissions adversely affect the environment and health (Brazel and Quattrochi 2005; Bolund and Hunhammar 1999; Davis et al. 2003; Ellis 1976; McGeehin and Mirabelli 2001; Patz et al. 2008).
Mental Health and Stress-Related Disorders
In urban areas, the continuous stress caused by competitiveness, violence, and insecurity can deteriorate mental health and promote physical inactivity by causing fear of public area exposure. Gender inequity in urban settings is a risk for women, who may be victims of sexual violence and contract sexual transmitted diseases (Srivastava 2009; Trivedi 2002).
Neurological Diseases and Disorders
Toxic chemicals, such as lead and leach used in building materials, greenhouse gas emissions, pesticides, coal-fired power plants, fossil fuel metals (e.g., arsenic, mercury), and biotoxins are released into the air, water and food sources. The ingestion of neurotoxins (e.g., algal toxins; Pseudonitzchia spp.) in seafood can lead to symptoms such as amnesia, numbness, respiratory paralysis, and neurodegeneration (Bronstein et al. 2009; Gustin and Ladwig 2004; Wang 2008).
Vectorborne and Zoonotic Diseases
Urbanization facilitates the propagation and transmission of diseases due to population density and climate changes (e.g., humidity, soil moisture, water temperature, salinity, acidity). Some examples include the severe acute respiratory syndrome outbreak in 2004, influenza AH1N1 in 2009, and the Ebola virus, which rapidly spread in urban settings with high-density populations. Dengue hemorrhagic fever and malaria are two vectorborne diseases that thrive with climate changes and growing population. Nevertheless, improvements have been made with the implementation of prevention programs, vaccination programs, sanitation improvement, and environmental regulations (Portier et al. 2010; Vlahov and Galea 2002).
Sanitation in impoverished urban areas is often lacking, which facilitates the spread of waterborne diseases. Diarrhea, immunologic, neurologic, hematologic, metabolic, pulmonary, ocular, and nutritional clinical manifestations can be caused by microorganisms (e.g., amoebas, protozoa, viruses, parasites, bacteria) and neurotoxins found in water. The populations that are most at risk of suffering severe complications and even death are children and pregnant women (Batterman et al. 2009; Meinhardt 2006).
Urban Children’s Health
Exposure to environmental hazards at an early age can lead to decreased birth weight, neurobehavioral problems, and asthma. Children are a vulnerable group because they are more likely to be exposed to situations where they can absorb toxic molecules from the air, water, ground, dust, or food, presenting acute symptoms or chronic disease as a result of continuous exposure to hazards (Firestone and Amler 2003). Poor urban communities are the most vulnerable to environmental hazards, waterborne diseases, and long-term exposure to outdoor and indoor pollution due to long working hours and long-distance commutes.
City growth has taken place in low- and middle-income countries, where the population encounters inequity. Thus, health care for the poor population may not be accessible. In developing countries, laborers cannot afford to lose a workday to visit a doctor, causing unattended diseases to get worst or become chronic. Usually, people only go for screening once their disease is advanced and prevents them from working. In most developing cities, healthcare access and quality of services may differ within the socioeconomic strata of the city (Montgomery and Hewett 2005). Providing accessible high-quality healthcare will result in healthier, productive, and competitive individuals with same opportunities and a subsequent inequity gap decrease. Nevertheless, in developing countries, more vaccinations programs, health promotions, and interventions are likely to be offered in urban settings (Leon 2008).
Currently, there are some frameworks to increase environmental quality and health quality in urban centers, as discussed in Section 5.
Urbanization, the Environment, and Health
Urbanization’s contributions to the environment can be positive and negative. Population growth should be accompanied by improvements in the economic sector, leading to a decrease in poverty. With a growing population, differences in service delivery between urban and rural areas should also be considered. Urban areas are expected to have better access to and higher quality basic services, even in the public sector (Borrazzo et al. 2003).
According to the United Nations Environment Programme, environmental hazards due to rapid industrialization can be classified as either traditional hazards that are linked to poverty, such as biological and water contamination, poor sanitation, indoor smoke, rampant disease vectors, deficient food hygiene, unsafe waste disposal, and social exclusion; or modern hazards that are attributed to unsustainable patterns of development, such as smoking, transportation hazards, outdoor air pollution, soil pollution, water pollution, inadequate waste management, climate change, ozone layer depletion, acid rain, overuse and misuse of chemicals, unbalanced diets, and industrial machinery (Firestone and Amler 2003).
It is known that urban areas have a different atmospheric composition, which locally affects human health. Nevertheless, urbanization contributes to climate change, making a substantial environmental impact globally (Pataki et al. 2003; Zhou et al. 2004). Urban areas also experience the urban heat island phenomenon, which is linked to the amount of heat that urban areas produce, absorb, and then release into the atmosphere due to the building concentration and lack of green spaces (Arnfield 2003; Wang et al. 1990). Therefore, megacities usually are 5–11 °C hotter than non-urbanized areas. As we explained in the previous section, people living in these areas may experience symptoms such as dehydration, exhaustion, heat cramps, heat stroke, and death (Jowell et al. 2017).
According to the WHO, in 2017, approximately 4.2 million deaths were attributed to outdoor air pollution and 3.8 million deaths were due to household exposure to smoke from dirty cookstoves and fuels. Today, 91% of the world’s population is living in places where air quality exceeds WHO standards.
Particulate matter (PM) matter is a mixture of liquid and solid particles of organic and inorganic substances, such as sulfate, nitrates, ammonia, sodium, chloride, black carbon, mineral dust, and water. The size of PM diameter plays an important role in disease pathogenesis: PM10 (less than 10 microns) can penetrate the lungs, whereas PM2.5 (less than 2.5 microns) penetrates deeply into the blood stream. Individuals who are exposed to PM may experience lower respiratory tract infections, cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer (Jowell et al. 2017; Kan et al. 2012; World Health Organization 2006; Zhang et al. 2013). The WHO-recommended exposure levels are annual means of 10 μg/m3 of PM2.5 and 20 μg/m3 of PM10.
Ozone (O3) at ground level is formed by a reaction of nitrogen oxide pollutants from vehicle and industry emissions and volatile organic compounds (VOCs) with sunlight. Asthma may be exacerbated from high ozone exposure (Khaniabadi et al. 2017; World Health Organization 2006). The WHO-recommended exposure level is an 8-h mean of 100 μg/m3.
The main sources of nitrogen dioxide (NO2) are heating, power generation, and combustion from vehicles and ship engines. Long-term exposure represents a risk for bronchitis in asthmatic children and inflammation of the airways (Faustini et al. 2014; Khaniabadi et al. 2017; World Health Organization 2006). The WHO-recommended exposure level is an annual mean of 40 μg/m3.
Domestic heating, motor vehicles, and power generation are the main sources of sulfur dioxide (SO2), which is produced from the burning of fossil fuels and the blending of mineral ores that contain sulfur. Symptoms such as coughing, eye irritation, mucus secretion, asthma exacerbation, chronic bronchitis, and predisposition to respiratory system infections can manifest in populations exposed to high concentrations of SO2 (World Health Organization 2006). The WHO-recommended exposure level is a 10 min mean of 500 μg/m3.
Increased exposure to polluting fuels, biomass fuel (wood, dung, agricultural residues), coal, and kerosene from activities such as cooking and heating are linked to acute lower respiratory tract infections in children and chronic obstructive pulmonary disease, ischemic heart disease, stroke, and lung cancer in adults.
Polycyclic Aromatic Hydrocarbons
Polycyclic organic matter is formed from incomplete combustion in cook ovens, diesel engines, and wood-burning stoves. Lung cancer can result from long-term exposure (Cave et al. 2018; Perera et al. 2014; World Health Organization 2010).
Carbon monoxide is produced by the incomplete combustion of carbon (wood, petrol, coal, kerosene, and natural gas). Carbon monoxide enters to the blood and binds to hemoglobin. Because carbon monoxide has an affinity for oxygen, its binding decreases oxyhemoglobin, thus leading to tissue hypoxia. A single exposure to high levels of carbon monoxide can be lethal (World Health Organization 2010).
Methane emission results from an incomplete combustion of biomass, biofuel, and fossil fuels in simple stoves, open fires, or wick lamps. Individuals who are exposed to high concentrations of methane suffer from headaches, dizziness, nausea, tachycardia, fatigue, and, in severe cases, convulsions, coma, or death (World Health Organization 2010).
Lead components can be found in paint, solders, plumbing material, ceramics, ammunition, gasoline, cosmetics and batteries. Children and pregnant women are particularly vulnerable to lead. Reduced growth of a fetus and premature birth are effects of exposure to this chemical. Children may experience slowed growth, learning and behavioral problems, anemia, and hearing problems (Flora 2002).
Asbestos is a natural mineral used mainly for building purposes as isolation material. Exposure to asbestos is the only known cause of mesothelioma; hence, this mineral is considered to be a carcinogen. Individuals exposed to asbestos are also at high risk of developing asbestosis or lung cancer (Perez et al. 2018).
Volatile Organic Compounds
When solid or liquid VOCs evaporate, the compounds are released into the air. Usually, they are colorless, but they have a perceptible odor or scent. Some commonly known VOCs include acetone, benzene, butanal, dichlorbenzene, ethanol, formaldehyde, terpenes, xylene, and toluene. VOCs can be found in common products such as varnishes, paint, air deodorants, scented candles, nail polish, glue, stoves, cigarettes, laundry detergents, glass cleansers, floor lacquers, wax, and pesticides. Symptoms of exposure to VOCs are nose irritation, headache, fatigue, nausea, dizziness, loss of coordination, and eye and nose irritation (World Health Organization 1989).
Moisture Build-Up, Mold and Bacterial Growth
Defects in the construction of buildings, insufficient ventilation, and lack of insulation can produce mold and bacterial environments. Individuals with hypersensitivity to these substances experience rhinorrhea, throat and eye irritation, and coughing. In some cases, severe lung infections or diseases may develop in immunocompromised patients (Heseltine et al. 2009; Mendell et al. 2011).
International Urban Planning Frameworks
As a result of failed urban planning, some urban areas are experiencing overpopulation, decreased access to food and water, a lack of basic services, and increased contamination in environmental systems, which contributes to climate change. Therefore, urban planning frameworks have been created, such as the WHO’s Healthy Cities and Urban Governance Programme, United Nations Agenda 21, and the United Nations Environment Programme. According to the World Commission on Environment and Development (also known as the Bruntland report 1987), sustainable development is defined as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”
In 1986, WHO started the Healthy Cities planning project to design policies and strategies for improving health and reducing health inequities in cities. This project adapts to the WHO’s health definitions, which consider the involvement of environmental, social, economic, physical, and psychological factors. Principles of the WHO Health for All strategy must be included in planning, such as equity, health promotion, intersectoral action, community participation, supportive environments, accountability, and peace. Regardless of the aim of a city’s health plan, its legislative autonomy is recognized; hence, each city might have topic priorities on the political agenda, allowing the plan to be shaped to the city’s needs. Intersectorality between private and public stakeholders, such as local organizations, international organizations, governments, communities, and lobbyists is needed to recognize activities in which these sectors might have an influence. Close relationships in a horizontal and vertical approach are imperative to create policies and reforms that could lead to a sustainable city planning.
Urban planning strategies
Stockholm, Sweden (Europäische Kommission & Generaldirektion Umwelt 2010)
Transportation dependent on renewable fuel. Since 1990, greenhouse emissions diminished by 25%. Goal: Greenhouse gas emission free by 2050.
Stockholm Parks Program: Planning of households close to a park in order to provide residents with a healthy environment and well-being.
Wastewater management: Advanced treatment to remove phosphorus and nitrogen. The biogas produced in the wastewater treatment plant is used for public buses, taxis, and private cars, while the heat produced in the sewage water is used for domestic heating purposes.
Hammaby Model: An eco-friendly system for handling energy waste and water. The incineration of combustible waste is used to produce electricity and the district heating system.
Waste management: Food waste is specially recycled as biogas, used as fertilizer or compost, or converted into natural gas.
Hamburg, Germany (Europäische Kommission & Generaldirektion Umwelt 2012)
Energy: Energy grids and networks. The alliance for living in Hamburg converts apartments from old energy systems to an energy-efficient system, with increased implementation of wind power.
Air pollutants: With “My Tree–My City,” trees are planted to decrease carbon emissions. Public transportation and the use of fuel cell hybrid technology are increased. Discount fees are implemented in Hamburg Port to incentivize enhancements of new ship technologies for control of harmful emissions.
Waste management: A recycling campaign will lead to a lower carbon footprint.
Copenhagen, Denmark (Europäische Kommission & Generaldirektion Umwelt 2014)
Green energy: Investments for green-growth projects. Wind energy provides 31% of the electricity.
Air pollutants: Free bike-share program, extension of metro lines.
Noise: Implementation of noise-reducing asphalt.
Waste management: 58% of the waste is recycled and 40% is used as fuel for the heating network.
In 1993, the United Nations launched Agenda 21, a United Nations programme of action for sustainable development, with a focus on human health and well-being. Agenda 21 aims to address social and economic development relationships, resource management, strengthening the participation of major groups, and means of implementation. Social and economic development covers challenges such as international cooperation, poverty, sustainable consumption, population health, settlements, and integrating the environment and development. Resource management includes the atmosphere, land resource planning, deforestation, fragile ecosystems, rural development, biodiversity, biotechnologies, oceans, fresh water, and waste management.
The project had two phases between 1987 and 1998. In the first phase, cities developed initiatives for creating health for all city levels. In the second phase, city policies with specific targets for equity and sustainability were formulated and implemented.
Today, people are exposed to environmental hazards due to a lack of urban planning, which has made cities unsustainable. Therefore, international institutions have created frameworks as a tool for governments to plan and design sustainable and healthy cities. These frameworks ensure that the cities take into account health in all policies, with the aim of producing secure and healthy environments that will assure the population’s physical, social, spiritual, emotional, and mental well-being.
Goals to reduce the prevalence of non-communicable diseases have not yet been achieved in some countries. Attempts to control non-communicable diseases may have failed because most health promotion plans rely on a theory of change, in which a healthy lifestyle consists of two main factors: healthy nutrition and physical exercise. This theory of change encounters challenges as a result of urbanization, where green spaces have been transformed into roads, houses, and shopping centers, among others; thus, the population is left without safe spaces to exercise. Also, as part of the economic growth, processed food has become accessible and affordable, which has created a barrier to healthy food habits.
The Ottawa Charter for Health Promotion was developed in 1986 to advocate for health promotion actions by building healthy public policies, creating supportive environments, strengthening community actions, developing personal skills, and reorienting health services. Urbanization produces changes in eco-system dynamics that not only have local impacts but also global impacts that induce climate change, which plays an important role in natural disasters and human health as discussed previously. It is important that governments and stakeholders start joining forces to promote public health interventions and consider changes in public policies for transportation, building construction, and regulation of greenhouse gas emissions.
Even though urbanization results in economic growth, an equity gap remains in most cities. Special attention to improving households, the environment, sanitation, healthcare accessibility, and education is imperative in order to provide equal opportunities to all socio-economic classes within the city. Disadvantaged populations also should be able to enjoy the benefits of urbanization.
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