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Summary Samenvating van Alle Stof for Geographies of Health
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The covid-19 pandemic and health inequalitiespandemics have been experienced unequally with higher rates of infection and mortality among the
most disadvantaged communities—particularly in more socially unequal countries
life expectancy amongst the poorest groups was already declining in the UK and the USA and health
inequalities in some European countries have been increasing over the last decade.50 It seems likely
that there will be a post-COVID-19 global economic slump— which could make the health equity
situation even worse, particularly if health-damaging policies of austerity are implemented
again. It is vital that this time, the right public policy responses (such as expanding social protection
and public services and pursuing green inclusive growth strategies) are undertaken so that the COVID-
19 pandemic does not increase health inequalities for future generations.
ranging from unequal experiences of lockdown (eg, due to job and income loss, overcrowding,
urbanity, access to green space, key worker roles), how the lockdown itself is shaping
the social determinants of health (eg, reduced access to healthcare services for non-COVID-19 reasons
as the system is overwhelmed by the pandemic) and inequalities in the immediate
health impacts of the lockdown (eg, in mental health and gender based violence). However, arguably,
the longer-term and largest consequences of the ‘great lockdown’ for health inequalities will
be through political and economic pathways.
We argue that for the most disadvantaged communities, COVID-19 is experienced as a syndemic—a
co-occurring, synergistic pandemic that interacts with and exacerbates their existing NCDs and social
conditions. (non-communicable diseases)
Health geography: supporting public health policy and planning.
Health geography views health from a holistic perspective encompassing society and space, and it
conceptualizes the role of place, location and geography in health, well-being and disease.
Understanding geography, including the arrangement of health services and the location and nature
of environmental exposures, is crucial in assessing the interrelations inherent in many health-related
risk exposure.
with quantitative studies closely aligned with epidemiology and qualitative studies aligned with medical
sociology and social sciences.
Policy derived from geographic research can fall victim to ecological fallacy, in which incorrect assumptions are
made about people based on aggregated data about their communities.22 This may result in the misapplication
of policy targeting specific groups of people or places.
The modifiable areal unit problem, which is a potential source of error, arises when an identified geographic
pattern is partly a consequence of the size and shape of the areal units of the study.
,Neighbourhoods and health; what do we know? What should we do?
work on neighbourhoods and health has rediscovered and emphasized the role of “the environment” in health.
It has redefined the environment to encompass not only traditional environmental exposures (like air pollution)
but also other elements of the physical environment (like walkability or access to green spaces) and the social
environment (like social connectedness or violence).
The first is that neighbourhood socioeconomic and racial/ethnic composition is related to potentially health
relevant neighbourhood physical and social environments,2,3 such as walkability, access to healthy foods,
recreational resources, tobacco availability and advertising, aesthetically pleasing green and public spaces, and
levels of social connectedness and safety.
A second fact is that these environmental features are related to mechanistic pathways
linked to health. Probably the most compelling evidence we have is for the impact of walkability on walking
behaviour. Food purchasing is not restricted to local neighbourhood environments.
interventions based on what we know to date? The fact that neighbourhood environments are
likely to affect multiple different health outcomes through a large set of interrelated mechanisms suggests that
the most impactful interventions are likely to be those that can trigger changes across multiple dimensions.
One prime example is policies that holistically improve the physical quality of neighbourhoods; for example,
policies that simultaneously improve the conditions of housing, that create attractive public spaces, that
enhance walkability, that reduce reliance on automobile transportation, and that promote mixed land use.
A second example is policies that promote mixed income neighbourhoods and reduce residential segregation
by social class.
This is distinct from gentrification, which does not benefit groups that are forced out of their neighbourhoods.
The most impactful and sustainable interventions are those that alter the functioning of systems that create
spatial inequities to begin with. The tangible and visible physical inequalities of neighbourhoods as well as the
extent to which they are segregated by class are in my view critical levers that can trigger multiple changes.
But if we are looking for the greatest and more sustainable effects across a range of communities, then more
fundamental systemic interventions are needed. The more systemic interventions are also likely to have other
social benefits, including effects on educational outcomes or quality of life more generally. That may be as
important or more important than health, or that could themselves impact health.
Shaping cities for health: complexity and the planning of urban environments in the 21 st century.
The so-called urban advantage—a term that encapsulates the health benefits of living in urban as
opposed to rural areas—has to be actively created and maintained through policy interventions. Furthermore,
average levels of health hide the effect of socioeconomic inequality within urban areas. Rich and poor people
live in very different epidemiological worlds, even within the same city. And such disparity occurs in both high-
income and low-income countries.
• Cities are complex systems, so urban health outcomes are dependent on many interactions
• The so-called urban advantage—whereby urban populations are, on average, at an advantage compared with
rural populations in terms of health outcomes—has to be actively promoted and maintained
• Inequalities in health outcomes should be recognised at the urban scale
• A linear or cyclical planning approach is insufficient in conditions of complexity
• Urban planning for health needs should focus on experimentation through projects
• Dialogue between stakeholders is needed, enabling them to assess and critically analyse their working
practices and learn how to change their patterns of decision making.
, City governments should work with a wide range of stakeholders to build a political alliance for urban
health. In particular, urban planners and those responsible for public health should be in communication
with each other.
• Attention to health inequalities within urban areas should be a key focus when planning the urban
environment, necessitating community representation in arenas of policy making and planning.
• Action needs to be taken at the urban scale to create and maintain the urban advantage in health outcomes
through changes to the urban environment, providing a new focus for urban planning policies.
• Policy makers at national and urban scales would benefit from undertaking a complexity analysis to
understand the many overlapping relations affecting urban health outcomes. Policy makers should be alertto
the unintended consequences of their policies.
• Progress towards effective action on urban health will be best achieved through local experimentation
in a range of projects, supported by assessment of their practices and decision-making processes by
practitioners. Such eff orts should include practitioners and communities in active dialogue and
mutual learning.
A substantial body of research shows that the planned provision of green infrastructure supports good physical
and mental health through the reduction of air pollution and heat stress, and the provision of opportunities for
physical activity, social encounters, and engagement with nature.
Although Toronto’s physical geography readily supports vegetation, its green
infrastructure is also a result of a proactive and opportunity-alert local government policy.
First, city governments should work with a wide range of stake holders to build a political
alliance for urban health. Such stakeholders should include all those able to deliver urban change for health
in active dialogue. In particular, health officials and practitioners need to be in dialogue with urban planners
and managers at all levels.
Second, attention to health inequalities within urban areas should be a key focus of
planning the urban environment. Such eff orts will necessitate community representation in forums of
policy making and planning for urban health and might need local government to support under-resourced and
less well organised sections of the urban population.
Third, action needs to be taken at the urban scale to create and maintain the so-called urban advantage in
health outcomes through changes to the urban environment. Frameworks for planning in cities should
explicitly incorporate urban health goals and policies aimed at the improvement of urban health, as a signal to
key decision makers of the importance of action for urban health.
Fourth, policy makers at national and urban scales would benefit from undertaking a complexity analysis to
understand the relations between interventions that affect the urban environment and urban health
outcomes, identifying bidirectional relations of causality, feedback loops, and tensions between objectives, and
being alert for the unintended consequences of their policies.
Finally, progress towards effective action on urban health will be best achieved through local experimentation
in a range of projects, supported by assessment of their practices and decision-making processes by
practitioners. Such eff orts should include practitioners and communities in active dialogue and mutual
learning. Interventions such as impact evaluation and indicator sets should be used judiciously to strengthen
such assessment
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