A majority of the world's population now lives in cities, and non-communicable disease is becoming the biggest health problem. This means governments need to coordinate policies better
When I was a medical student at the University of the West Indies heart attack cases were rare. Students would have gathered round a patient to see this unusual phenomenon up close.
Now heart attacks are, along with diabetes and other non-communicable diseases, a fact of life in the Caribbean. It is a story we know from other parts of the world: Caribbean economies have grown and demographics have evolved. Urban areas are expanding – and life in the Caribbean is changing for ever.
Obesity is often used as the example for the sort of medical condition that accompanies urban life. In this respect, the Caribbean is no exception. Not only are we experiencing a surge in cardiovascular disease and diabetes, but the age at which the conditions are being diagnosed is getting younger; even children are affected by them.
Often the spread of communicable, infectious disease is linked to urbanisation as more people live in towns and cities and overcrowding becomes a problem. But the situation is changing and those non-communicable diseases, often associated with affluence – or 'revealed by affluence', as some say – are at the centre of this transition.
The reality is that, all over the world, growing urbanisation is inevitable. In theory, the fact that people live closer to health providers in an urban setting should lead to greater health service delivery and equity. But this is not always the case, and delivering public health in urban areas, across emerging economies, while achieving the needed policy coordination across all levels of government, is a huge and largely unaddressed challenge.
This was a point made repeatedly at the Emerging Markets Symposium on Urbanization, Health and Human Security, held at Oxford University in mid-January. The keynote speaker, Prof Sir Michael Marmot, president of the British Medical Association, had a simple message for countries about the need to better coordinate policy between government ministries: 'Every minister is a minister of health,' he said. Sustainable and affordable housing, water and sanitation, waste management, education, transport, parks and conservation areas: all these directly affect urban health. In addition to coordination across government ministries, national and city governments could coordinate their work better.
All of this is true of the Caribbean – but the link between urbanisation and health is perhaps more apparent in places like Brazil, India, Pakistan and China, where demographic and socioeconomic change in urban areas are taking place on a much larger scale. Governments in such countries have to make key decisions on the organisation of health: what is the right division between public and private sector delivery of healthcare? How to support an insurance industry while health demands are changing at a tremendous pace? What kind of fiscal framework could improve preventive measures?
The pace of urban change also means governments need to innovate to deliver affordable health services to large numbers of people. Low cost mobile communications, used by people trained with basic diagnostic skills and linked to health information systems, could benefit vast numbers of people; and centralised patient registers and data gathering for demographic forecasting and planning, for healthcare purposes and for public health frameworks, hold enormous potential. In this sense, we must also think of urban spaces as an opportunity for health: more people can be reached at once, in new ways, and hopefully at a lower cost.
However, as recent floods in Brazil – and Australia – have shown, cities can be vulnerable to natural disasters, epidemics and other causes of large-scale social breakdown. Urbanisation carries with it a whole set of policy and planning imperatives.
A majority of the world's population now lives in cities, producing a vast array of opportunities, but also dangers, challenges and responsibilities. As the balance of the global economy tips to new parts of the world, where the challenges of urbanisation are developing on an unprecedented scale – greater than anything that confronted European and American cities in the 19th and 20th century – we should call for governments to explore new paths for delivering those sanitary and social measures necessary for the health of their citizens, and to rethink how they organise themselves at city, national and international level to do so.
• Sir George Alleyne is chancellor of the University of the West Indies, director emeritus of the Pan American Health Organisation and UN special envoy for HIV/Aids in the Caribbean
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