Sharon Friel

Closing the gap in a generation: health equity through action on the social determinants of health

The Commission on Social Determinants of Health, created to marshal the evidence on what can be done to promote health equity and to foster a global movement to achieve it, is a global collaboration of policy makers, researchers, and civil society, led by commissioners with a unique blend of political, academic, and advocacy experience. The focus of attention is on countries at all levels of income and development. The commission launched its final report on August 28, 2008. This paper summarises the key findings and recommendations; the full list is in the final report.

Managing the health effects of climate change

Climate change is the biggest global health threat of the 21st century. Effects of climate change on health will affect most populations in the next decades and put the lives and wellbeing of billions of people at increased risk. During this century, earthﾒs average surface temperature rises are likely to exceed the safe threshold of 2ﾰC above preindustrial average temperature. Rises will be greater at higher latitudes, with medium-risk scenarios predicting 2ﾖ3ﾰC rises by 2090 and 4ﾖ5ﾰC rises in northern Canada, Greenland, and Siberia. In this report, we have outlined the major threatsﾗboth direct and indirectﾗto global health from climate change through changing patterns of disease, water and food insecurity, vulnerable shelter and human settlements, extreme climatic events, and population growth and migration. Although vector-borne diseases will expand their reach and death tolls, especially among elderly people, will increase because of heatwaves, the indirect effects of climate change on water, food security, and extreme climatic events are likely to have the biggest effect on global health.

Public health benefits of strategies to reduce greenhouse-gas emissions: food and agriculture

Agricultural food production and agriculturally-related change in land use substantially contribute to greenhouse-gas emissions worldwide. Four-fifths of agricultural emissions arise from the livestock sector. Although livestock products are a source of some essential nutrients, they provide large amounts of saturated fat, which is a known risk factor for cardiovascular disease. We considered potential strategies for the agricultural sector to meet the target recommended by the UK Committee on Climate Change to reduce UK emissions from the concentrations recorded in 1990 by 80% by 2050, which would require a 50% reduction by 2030. With use of the UK as a case study, we identified that a combination of agricultural technological improvements and a 30% reduction in livestock production would be needed to meet this target; in the absence of good emissions data from Brazil, we assumed for illustrative purposes that the required reductions would be the same for our second case study in São Paulo city. We then used these data to model the potential benefits of reduced consumption of livestock products on the burden of ischaemic heart disease: disease burden would decrease by about 15% in the UK (equivalent to 2850 disability-adjusted life-years [DALYs] per million population in 1 year) and 16% in São Paulo city (equivalent to 2180 DALYs per million population in 1 year). Although likely to yield benefits to health, such a strategy will probably encounter cultural, political, and commercial resistance, and face technical challenges. Coordinated intersectoral action is needed across agricultural, nutritional, public health, and climate change communities worldwide to provide affordable, healthy, low-emission diets for all societies.

Shaping cities for health: complexity and the planning of urban environments in the 21st century

3·4 billion people—about half the world’s population--live in urban areas, and this number might rise to 6·3 billion by 2050.1 The proportion of the global population living in cities will be 60% by 2030,2 a 72% increase in 30 years (figures 1 and ​and2).2). Urban growth will be greatest in Africa and Asia, followed by Latin America and Oceania.5 Even in long-established urban areas in Europe, urban population growth during that period will reach almost 5%.5 This growth will not only result in more megacities (cities of more than 10 million people), increasingly concentrated in Asia, but also in more medium-sized cities, especially in Africa. UN estimates are that about 1 billion people, nearly a sixth of the global population, live in slum-like conditions. With the worldwide population predicted to expand to 9 billion by 2030, the number of people living in slum-like conditions could reach 2 billion.5 Figure 1 World population growth, 1950-2050 Figure 2 Proportion of the world population living in urban areas The understanding of how urban environments affect health outcomes and can produce health benefits is therefore an urgent priority, as recognised by WHO in their declaration of 2010 as the Year of Urban Health. From this perspective, there are reasons to be optimistic. The idea of the so-called urban advantage encapsulates the health benefits of living in urban as opposed to rural areas. However, factors such as economic growth and associated urban expansion cannot be relied on to drive improvements in health outcomes. Health improvements need to be actively planned for. The Healthy Cities movement has appreciated this fact and generated much action. Assessments have, however, pointed to a gap between aspirations and outcomes and limitations in the coherence of the models behind action. In response to this problem, the UCL Lancet Commission met from November, 2009, to June, 2011, bringing together an interdisciplinary team of experts to under stand how better health outcomes can be delivered through interventions in the urban environment in cities across the world, and to generate policy recommendations. We began with the definition of health as both the absence of ill health and the presence of mental and physical wellbeing,6 and the urban environment as the physical context within which urban activities take place, including the material fabric of buildings and infrastructure and their spatial organisation. The Commission focused on the potential for shaping the urban environment for better health outcomes; we explicitly did not address the issue of health-service provision within cities, but acknowledge that this is a key component of urban policy. We undertook expert-led reviews of available studies and desk-top research into the connection between urban planning and health in more than a dozen cities, with additional information provided by Commission members who have experience of working in many of these cities. The work informed discussions at monthly meetings with experts in public health, planning, architecture, building physics, engineering, development studies, anthropology, and philosophy. The Commission developed an approach based on complexity thinking—an approach that looks at the interconnected elements of a system and how that system has properties not readily apparent from the properties of the individual elements—and used this approach to develop proposals for an effective way forward. We begin by addressing the arguments around the urban advantage idea and then review the work of the Healthy Cities movement in the promotion of action for urban health. We then set out a complex systems approach for the understanding of how urban environments affect urban health, followed by five short case studies of urban interventions: the inter-related domains of sanitation and water management, building standards and indoor health, transportation and the links to mobility, urban form and the urban heat island effect, and the promotion of urban agriculture. We then turn to the implications of our analysis for urban governance if effective interventions to improve urban health are to be delivered, concluding with recommendations for policy and practice.

Smart food policies for obesity prevention

Prevention of obesity requires policies that work. In this Series paper, we propose a new way to understand how food policies could be made to work more effectively for obesity prevention. Our approach draws on evidence from a range of disciplines (psychology, economics, and public health nutrition) to develop a theory of change to understand how food policies work. We focus on one of the key determinants of obesity: diet. The evidence we review suggests that the interaction between human food preferences and the environment in which those preferences are learned, expressed, and reassessed has a central role. We identify four mechanisms through which food policies can affect diet: providing an enabling environment for learning of healthy preferences, overcoming barriers to the expression of healthy preferences, encouraging people to reassess existing unhealthy preferences at the point-of-purchase, and stimulating a food-systems response. We explore how actions in three specific policy areas (school settings, economic instruments, and nutrition labelling) work through these mechanisms, and draw implications for more effective policy design. We find that effective food-policy actions are those that lead to positive changes to food, social, and information environments and the systems that underpin them. Effective food-policy actions are tailored to the preference, behavioural, socioeconomic, and demographic characteristics of the people they seek to support, are designed to work through the mechanisms through which they have greatest effect, and are implemented as part of a combination of mutually reinforcing actions. Moving forward, priorities should include comprehensive policy actions that create an enabling environment for infants and children to learn healthy food preferences and targeted actions that enable disadvantaged populations to overcome barriers to meeting healthy preferences. Policy assessments should be carefully designed on the basis of a theory of change, using indicators of progress along the various pathways towards the long-term goal of reducing obesity rates.

Global environmental change and health: impacts, inequalities, and the health sector

Human pressures on the environment are damaging the world’s biophysical and ecological systems. A J McMichael and colleagues discuss the resulting unequal effects on health and set out strategies to help prevent and lessen the harm

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles

Non‐communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public‐interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two ‘process’ modules, that monitor the policies and actions of the public and private sectors, seven ‘impact’ modules that monitor the key characteristics of food environments and three ‘outcome’ modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches (‘minimal’, ‘expanded’, ‘optimal’) to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

The Health Equity Dimensions of Urban Food Systems

There is increasing recognition that the nutrition transition sweeping the world’s cities is multifaceted. Urban food and nutrition systems are beginning to share similar features, including an increase in dietary diversity, a convergence toward “Western-style” diets rich in fat and refined carbohydrate and within-country bifurcation of food supplies and dietary conventions. Unequal access to the available dietary diversity, calories, and gastronomically satisfying eating experience leads to nutritional inequalities and diet-related health inequities in rich and poor cities alike. Understanding the determinants of inequalities in food security and nutritional quality is a precondition for developing preventive policy responses. Finding common solutions to under- and overnutrition is required, the first step of which is poverty eradication through creating livelihood strategies. In many cities, thousands of positions of paid employment could be created through the establishment of sustainable and self-sufficient local food systems, including urban agriculture and food processing initiatives, food distribution centers, healthy food market services, and urban planning that provides for multiple modes of transport to food outlets. Greater engagement with the food supply may dispel many of the food anxieties affluent consumers are experiencing.

Global health equity and climate stabilisation: a common agenda

Although health has improved for many people, the extent of health inequities between and within countries is growing. Meanwhile, humankind is disrupting the global climate and other life-supporting environmental systems, thereby creating serious risks for health and wellbeing, especially in vulnerable populations but ultimately for everybody. Underlying determinants of health inequity and environmental change overlap substantially; they are signs of an economic system predicated on asymmetric growth and competition, shaped by market forces that mostly disregard health and environmental consequences rather than by values of fairness and support. A shift is needed in priorities in economic development towards healthy forms of urbanisation, more efficient and renewable energy sources, and a sustainable and fairer food system. Global interconnectedness and interdependence enable the social and environmental determinants of health to be addressed in ways that will increase health equity, reduce poverty, and build societies that live within environmental limits.

Unequal weight: equity oriented policy responses to the global obesity epidemic

The health professions need to spearhead a concerted intersectoral response to obesity, say Sharon Friel, Mickey Chopra, and David Satcher