Bloomberg and public health: did he get it right?

While welcoming the support from Michael Bloomberg for a new city-focused global public health initiative, David Satterthwaite and Sarah Colenbrander raise concerns about what is not included.

A Coca-Cola sign outside a small town in Benin. Bloomberg’s new health initiative will support cities to reduce the consumption of sugary drinks, but this isn't the biggest health challenge facing low-income urban residents (Photo: Lorena Pajares, Creative Commons via Flickr)

Michael Bloomberg, the billionaire and former mayor of New York, has launched a global initiative on public health. It includes US$5 million support from Bloomberg Philanthropies as well as technical support for cities that choose to focus on one of 10 public health issues. Forty cities have joined this initiative and more will follow.

Much needed support for public health

More attention to public health in cities is urgently needed. This issue has long been neglected by national governments and international agencies. So Bloomberg's commitment is hugely welcome. 

Under this new initiative, cities can receive support to:

  • Create a smoke-free city (including a 100 per cent ban in all public places) and a ban on tobacco advertising
  • Reduce sugary drink consumption
  • Promote healthy food for all (reducing salt intake)
  • Create walkable, bike-able, live-able streets
  • Increase enforcement of drink driving laws
  • Create access to cleaner fuels for cleaner indoor air
  • Establish lower speed limits for road traffic and increase seat-belt and helmet use, and
  • Monitor non-communicable disease risk factors.

These are important projects. They can deliver quick and substantial health benefits, with enough political support. They are cheap compared to (for instance) extending water supply systems.

But does this list really address the biggest public health challenges facing cities today?

Identifying public health priorities

Most cities in sub-Saharan Africa and many in Asia have massive deficits in the basic infrastructure of public health: piped water and good quality toilets in each home, functioning drains, paved roads and paths and household waste collection.

Many cities are actually going backwards, as the proportion of their population with access to basic services has fallen. Conditions were better in 1990 than today.

Around a billion urban dwellers live in under-served informal settlements. They usually lack access to good quality healthcare and emergency services too. Their homes are often at high risk of accidental fires and built on land that floods repeatedly.

Families struggle with very high infant, child and maternal mortality rates, as well as serious disease burdens from communicable diseases. Malaria, dengue fever, diarrhoeal diseases (and others associated with contaminated food or water), intestinal parasites, acute respiratory infections and tuberculosis.

These risks would be much less prevalent if people had basic infrastructure and services.

Learning from mayors in the global North?

As mayor of New York, Bloomberg oversaw several significant public health initiatives: limiting public smoking and alcohol access, calorie counts on menus and cutting salt in pre-packaged foods.

But very few of the world's urban residents live in cities like New York.

In several of the 40 cities that have signed up for Bloomberg's support, a large proportion of their population live and work with far more pressing public health agendas.

For example, around half of Mumbai's population live in informal settlements or very overcrowded housing (usually in a poor state of repair). They lack safe, accessible, affordable water and many other basic services. Large sections of the population in Accra, Bangalore, Dhaka and Kampala face comparable problems.

This is not to say that Bloomberg's list is irrelevant. Reducing indoor air pollution and better road traffic management in particular can bring major health benefits, especially for low-income groups.

But it is clear that this agenda does not primarily address the needs and priorities of those in informal settlements.

Learning from urban residents in the global South

There are few studies of the health problems facing those living in informal settlements. Most health-related data comes from national sample surveys with sample sizes too small to show the health problems in each informal settlement. They only give 'averages' for national urban populations, hiding the very large differences between income groups.

The evidence gaps make it difficult for decision-makers and donors to identify and choose health priorities. For example, it is possible that official statistics have under-estimated the contribution of non-communicable diseases. This would justify the health initiatives that Bloomberg has chosen to support.

Ultimately, it is the people living and working in informal settlements that need to shape health interventions to serve their needs and priorities. The many organisations and federations of slum/shack dwellers in Asia and Africa are already working with municipal governments to document public health issues, such as provision for piped water, toilets and drains in their settlements. They have produced very detailed profiles of more than 7,000 informal settlements

These community-led processes generate the data needed to understand health priorities and develop health plans. What about a US$5 million fund to support these health initiatives? 

Organised groups of shack dwellers have produced robust evidence on life in informal settlements across South Africa. These data could inform effective, targeted health programmes that meet the needs of low-income residents

Bloomberg does already support one initiative related to this. The Data for Health programme works with countries to strengthen birth and death data, so policymakers can analyse and use those data to inform their decisions.

If this project can improve the data on deaths, causes and locations – even in informal settlements – it will show the extent and nature of health burdens from communicable diseases. This might show how much we have under-estimated their contribution to premature death (especially infant, child and maternal).

We would hope that this evidence will motivate policymakers and donors to focus on the fundamentals of good public health in cities: access to basic infrastructure and services for all urban residents. And as the Sustainable Development Goals say, "leave no-one behind". 

David Satterthwaite (david.satterthwaite@iied.org) is a senior fellow in IIED's Human Settlements research group and visiting professor at the Development Planning Unit, University College London; Sarah Colenbrander (sarah.colenbrander@iied.org) is a researcher in IIED's Human Settlements research group

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