Distinguished participants, Ladies and Gentlemen, Good Morning
On behalf of the World Health Organization I offer my congratulations to the China Society for Strategy and Management Research for organizing this important and timely meeting.
Urbanization has always been a potent political, economic and social force that has shaped the fate of human populations throughout history. Despite this, the impact and interaction between urbanization and health is not often recognized or well understood.
Throughout history, the growth of cities has been linked to the development of trade. For example, as early as 300 B.C., cities on both sides of the Silk Road flourished as gold, precious stones, glass, jade, bronze, iron, ivory, exotic animals and silk were traded across the region that once separated China from Europe and Western Asia. In China, this was when the Warring States were brought to an end by the Qin state, which unified China to form the Qin Dynasty. The capital was set up in Chang An, which rapidly developed into a large city, now Xian.i
Along with Chang An, this period was characterized by the emergence of other great capital cities that served as the power base of medieval empires: Pataliputra (in India), ancient Rome, its eastern successor Constantinople (later Istanbul), and successive Chinese, Islamic, and Indian capitals. These cities were considered huge because they approached or exceeded the half-million population level. It is estimated that ancient Rome had a population of around 1 million people by the end of the last century BC, which is considered the only city to reach that number until the Industrial Revolution.ii
History also tells us in the 1300s, the Silk Road that brought life to trade and fostered prosperity among many great cities on its eastern and western borders, also brought disease and death along its path. One of the most devastating epidemics in history: the plague or "Black Death" spread across Europe from China, killing what writers of that time claimed was "a third" of the entire population of the continent, an estimated 20 million people.iii
Outbreaks of plague in China were reported in the early 1330s. The plague struck the Chinese province of Hubei in 1334. During 1353-54, more widespread disaster occurred throughout the Mongol/Chinese empires.iv Wherever the plague struck, cities, as the centers of trade and commerce, were the hardest hit.
Health challenges brought about by urbanization in China
Much has changed over the past seven centuries. And yet there are striking parallels that we must revisit. Then as now, urban living offers the fulfillment of a dream for a better life and better health. Cities serve as magnets for people. The glamour and glitter of cities, symbolize jobs, economic opportunity, freer lifestyles and diversity.
Then as now, this dream can easily become a nightmare. This could be true in urban China, as it is in many other urban areas in the world.
On one hand, urbanization in China is essential for sustained economic development and poverty reduction. Urban growth is accompanied by clear opportunities of efficiency gains in economic activities. Moreover, urbanization supports job creation in construction, manufacturing and services, providing opportunities for underemployed farmers as well as for unemployed urban residents to take on new jobs. In return, with government support the farmers who remain working in rural areas should be able to expand their land-plots and raise their incomes. Ideally, the benefits of urbanization should accrue to those who live in the cities and in rural areas as well.
The global experience, however, is that the accelerated rate of urbanization has made it increasingly difficult to plan urban growth and provide for the needs of a rapidly increasing urban population. In most urban areas, it is becoming increasingly difficult to strike a balance between the demands of economic growth, social development and environmental sustainability.
Allow me to cite a few examples for China.
Unabated and unplanned urban growth in China's cities creates environmental pressures that impact on health. Congestion and high population density in cities are associated with water, land and air pollution. A recent World Bank Report states that 16 of 20 most polluted cities in the world are found in China. It is estimated that a third of China's urban population is exposed to severely polluted air. This contributes not only to respiratory illness, but has been strongly linked to higher rates of cardiovascular disease.
Less than 20% of urban garbage is properly disposed. This situation creates breeding grounds for vectors of disease. Improper waste management, poor housing, and informal settlements are all conducive to the spread of infections. Against the backdrop of globalization and modern air travel, it is now easier for people, viruses and other microbes to cross borders and penetrate cities where hundreds of thousands of people can become at risk for infection in a matter of hours. As it was in the era of the plague, cities have become the entry point for potential pandemics. We witnessed this in recent years with the outbreak of SARS. Now we face the threat of a human pandemic of avian influenza.
Modern city life is also characterized by an over reliance on motor vehicles. People walk less and lead sedentary lifestyles while city planners make more room for their growing vehicles fleets at the cost of cycling paths and green areas. Inactive lifestyles combined with increased consumption of fast food with high salt and fat translates into a rising burden of chronic diseases. The demand for and cost of treating chronic diseases, in turn, increases the burden on the local health systems and on the budgets of municipal governments, health insurance schemes and especially the many households that suffer from the lack of a comprehensive health insurance.
Ironically, the people who serve as "engines of economic growth" in cities, are usually exposed to the greatest environmental and lifestyle risks and threats. Vulnerable and exposed populations within cities may be invisible and may fall through the cracks, escaping government's support. The growth of migrant populations in cities is a case in point. It is estimated that there are 120 million migrant workers in China today. While migrants play a crucial role in the economic development of cities they do not have fair access to public services like health or education, contributing to their already worse maternal and child health indicators.
Opportunities for action on Healthy Urbanization in China
It has been said that "timing is everything". It is an opportune time for China to seriously consider what it can do to ensure that the dream of a better life in China's cities does not turn into a nightmare.
WHO's experience in Seoul, Korea leading up to the Olympics in 1988 has lessons that are useful for China. Seoul used this opportunity to address serious water and air pollution problems in the city. There was wide and popular support from government, the private sector and the citizenry to clean up one of its dirtiest rivers, the Han River. Seoul invested in 3 sewage treatment plants for the river and moved many of its small-scale industries into industrial parks. WHO supported experts who helped Seoul develop regulations for an automobile and inspection maintenance programme to reduce motor vehicle pollution. At the same time, a new refinery was built to reduce dependency on imported natural gas and large commercial buildings were asked to shift to use cleaner fuels for heating. The subway system was completed and traffic flow improvements were put in place.
Sometimes, a city just needs the right reason at the right time, to do the right thing.
Healthy urbanization: a framework for action in China
Ladies and gentlemen,
Today, the world's population is nearly 6 and a half billion people. Close to half of them live in cities. In the year 2020, it is expected that 55-60% of China's population will reside in urban settings, embarking on one of the largest population move in history with nearly 300 million people settling down in urban areas over the next 15 years. Clearly, rapid urbanization is a major determinant of China's health today as it will be in the future.
Can China's urbanization put people and their health first? We believe that it is possible. The Scientific Concept of Development of the China Government provides an excellent platform as it rightly considers urbanization not only as means to further boost economic growth but also as means to improve people's life.
How to move from a Scientific Concept of Development to healthy urbanization is a challenge, but possible when approaching it in a step-by-step approach and applying global best practices. The World Health Organization's Healthy Cities approach outlines a few basic principles that pave the way for healthy urbanization, these include multi-sectoral action, promotion of evidence based policies, community participation and strong local political commitment to health.
In China, WHO feels that the overall impact of urbanization on people's health can greatly be improved when Government policies (1) promote quality of urban life, (2) ensure environmental sustainability, (3) promote health awareness, (4) ensure equitable access to basic health services, and (5) enhance accountability for both local government officials and people working in private enterprises for people's health
In addition, we believe that the private sector has an important role to play as well the urban citizens themselves. Ultimately it is the people who carry the responsibility for their own health and that of their dependents.
Based on the above WHO developed a framework detailing some of the actions required to move towards an urbanization process that will maximize people's health and well being. We have attached this framework to the handout of this speech.
Let me end with a few simple policy imperatives that could deliver major health benefits in the process of urbanization.
- Become less dependent on cars, and promote walking and cycling, construction of bicycle lanes and footpaths and more universal access to public transport
- Develop, promote and enforce people's safety, either way in their working place (occupational health safety), or on the road (road safety), or in the hospital (patient safety) or from the food they eat (food safety), or from the exposure to the environment (environmental health safety); including making public places smoke free
- Introduce a river clean-up campaign that would bring back the fish and marine life in the rivers of China's major cities
- Establish pricing mechanism for utilities that can help to rationalize consumption of water and energy
- Ensure equitable access to essential health services and finance a basic health care package. And ensure access at least for the migrant workers and the most vulnerable. Such a health package could be financed through health insurance and/or the government directly
Healthy urbanization need not start as a grand plan. It can start with a few simple policy imperatives that everyone can translate into action: the government, the private sector, the people themselves.
Healthy urbanization can be a reality in China. It can start by putting people's health first.
Thank you.
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i http://www.ess.uci.edu/~oliver/silk.html
ii http://en.wikipedia.org/wiki/Cities
iii http://historymedren.about.com/library/weekly/aa032698.htm
iv http://en.wikipedia.org/wiki/Black_Death
A Vision for Healthy Urbanization in the 21st Century:
Challenges and Opportunities for China
Dr Henk Bekedam
WHO Representative, China
Healthy urbanization: a framework for action in China
China's Scientific Concept of Development rightly considers urbanization not only as means to further boost economic growth, but also as means to improve the life of people in China. In this context, given the health risks associated with urbanization, it is very appropriate and necessary to put people's health squarely on the urbanization agenda.
Putting people's health on the urbanization agenda is, however, a very complex task that requires concerted government policy actions across many sectors.
Specifically, in order to alleviate the impact of urbanization on people's health, government policies need to promote quality of urban life, environmental sustainability, health awareness, equitable access to basic health-related services and accountability of local government officials and people working in private enterprises for people's health.
A. Quality of urban life
International experience suggests that to promote quality of urban life, government particularly needs to act in three related areas:
First, design and develop urban peripheries for people as well as for economic activity. This includes, moving industries out of the city centers and synchronizing the emergence of jobs in industries with housing and public infrastructure/services in urban peripheries.
Second, design and develop user-friendly transport network. In this context, it is crucial to support public transport network and space for bicyclists and pedestrians, and thus reduce the necessity and advantages of relying on own car.
Third, provide suitable space for physical activities and recreation. Cultivating green areas and "escape zones" in urban centers and peripheries encourages people to stay fit and healthy.
B. Environmental sustainability
To promote environmental sustainability in urban development, government needs to enforce strict measures toward environmental protection and support environment-friendly investments.
Specifically, it is a crucial role for the government to enforce environmental standards, and invest into systems and projects improving the use of energy and energy conservation. In particular, the government needs to establish adequate pricing mechanisms for utilities to end the wasteful use of energy and water that is associated with blanket price subsidies. Similarly, the government needs to enforce energy-efficient construction practices. Critical are also investments into municipal waste management and environment-friendly technologies.
C. Health awareness
As urbanization is changing people's lifestyles, promoting health awareness is critical. The government particularly needs to act on two accounts.
First, disseminating health information and promoting healthy lifestyles. Easy access to information about nutrition, healthy habits, and health risks can positively affect people's behavior. To be effective, information dissemination needs to be complemented with active policies to support early child development, and sports and healthy habits in schools; and to nurture the positive image of healthy lifestyles. For instance, cycling to work would be again a sign of advancement and not backwardness!
Second, developing and enforcing adequate health-related regulations. This important task involves all relevant sectors. It involves the market. It involves developing system to manage people's safety: traffic safety, environmental safety, occupational safety, patient safety, food safety and making public places smoke free.
Finally, it involves mechanisms toward quality and cost-control in the health system.
D. Equitable access to essential health services
The possible negative health effects of urbanization underline the importance of enabling all people to have access to essential health services.
In this context, it would be appropriate for government to make a package of basic health services accessible to all people in urban areas, urban peripheries and rural areas (residents and floating population alike). This package of basic health services needs to cover public health functions and services - including the prevention of chronic diseases - and essential clinical services. To finance equitable access to basic health, the government will need to ensure full funding for the basic package of health services - through health insurance, medical financial assistance schemes and its own budget.
E. Accountability for people's health
In order to align the performance of local governments, public sector enterprises and agencies and private sector entities with the agenda of healthy urbanization, government needs to establish clear accountability for people's health.
In both the public and private sectors, agencies and enterprises need to bear responsibility for the health effects of their policies and actions.
With respect to health services, health providers and local governments need to be accountable for ensuring equitable access, acceptable quality, safety, and fair price.