Directions for Future Health Cities

E170 Fall 2017 final lecture (JMH,KMM,CCC)
• Ready to Roll:
• 1. Provide micronutrients to all consumers
• 2. Combat environmental racism for babies of color to live & thrive
• 3. Change Diets to protect human health and the health of the planet
• Too Big to Fail:
• 4. Finish the Environmental Sanitation challenge so “Clean Cities DO Grow”
• 5. Averting the next zoonotic disease pandemic
• 6. Implement best practices for urban health
• 7. Urban Design for families and communities: housing, immigration and
the Sanctuary City

Theme 1.
Agro-Industrial Partnership to eliminate
micronutrient deficiencies everywhere

• Investing in fortified staples widely consumed by the poor;
• Investing in plant breeding research that will enrich staple crops,
initially rice for Asia.
• Food industry’s products will strengthen developing world as a
global trading partner;
• least cost-effective and sustainable solution .
The Agro-Industrial Partnership

HARVEST PLUS (2004 -- >)-- Target Countries
and Crops
More than four million farming households reached by HarvestPlus by end of 2016. Crops released are high-
yielding with climate smart traits.

Functional Outcomes
•Efficacy trials with provitamin A, iron, and zinc biofortified
crops have also shown improved functional outcomes:
•Improved cognitive function (iron)
•Better work performance (iron)
•Better sight adaptation to darkness (provitamin A)
•Reduced morbidity (zinc)

To Reach Urban Consumers, Growing Interest in
OFSP Processed Products
1) Increased interest in diversified products from OFSP, esp. for urban consumers
2) Food processing can improve bioavailability by disrupting plant tissues, etc.
3) OFSP puree (boiled and mashed) more economically viable than OFSP flour
4) Challenge it to get products highly commercialized
Bread in Mozambique
Power Biscuits in Rwanda
Vacuum-packed purée

Annual VMD Damage to Asia (I)
• Vitamin A – child deaths
• ASEAN (7) : 78,794
• SAARC (4): 484,333
• China/Afgh: 72,976
• Total (13) : 646,203
• Maternal Deaths due to Anemia
• ASEAN (7) 4226 SAARC(3) 25617 O: 3509
• Total (12) : 33,352

VMD Asia (II)
• Iodine Deficiency - Damage
• Lost Productivity ($ M)
• ASEAN 1,074
• SAARC 3,773
• Ch/Afg 862 T 5,625
• Babies Mentally Impaired
• ASEAN 1,353,535
• SAARC 9,639,915
• Ch/Afg 1,478, 412 T 13,471, 871

Approximate Unit Costs of Interventions with Effects on
Nutrition
Cost/
Intervention Beneficiary/Year (US$)
Education (e.g., breastfeeding) $5
Micronutrient supplementation
- iodine $0.50
- iron (per pregnancy) $1.70
- vitamin A $0.20
Micronutrient Fortification
- iodine $0.05
- iron $0.09
- vitamin A $0.05-0.15
Feeding Programs $70-100
(for '000 cals/day)
Community-based Programs $5-10
(home gardening, growth monitoring)
Source: ADB-UNICEF Regional Study on Reducing Child Malnutrition in Asian Countries

Theme 2.
Eliminate Survival Gap for Babies of Color
• USA annual : 23,000 infants die under 1 yr
• Black infants twice as likely to die as whites
• Milwaukee, Wisconsin hot spot for dying black babies (100/yr)
• 3x white rate
• Health Commissioner: “If 100 people died from TB, people would say we have a
public heath emergency”
• Wisconsin Black unemployment 20%, highest in US
• Inner neighborhoods Milwaukee: 62% incarceration black men
• High school suspension rate black students (34%) highest in nation
• Lifecourse Initiative focuses on jobs for men, responsible fatherhood, “safe-baby
sanctuaries in black churches, community gardens and community health
teaching and out-reach (mom-to-mom)

Dana Meadows: Advice on analyzing and improving
systems
Expand the boundary of caring.
Living successfully in a world of complex systems means expanding not
only time horizons and thought horizons; above all it means expanding
the horizons of caring. There are moral reasons for doing that, of course.
And if moral arguments are not sufficient, then systems thinking provides
the practical reasons to back up the moral ones. . . .
As with everything else about systems, most people already know about
the interconnections that make moral and practical rules turn out to be
the same rules. They just have to bring themselves to believe that which
they know.

DALY SAVED < $25:
• Iron/folate fortification: $22/DALY*
• Salt iodization
• Daily (and probably weekly) oral iron for pregnant women
• EPI Plus (Child Immunization + Vitamin A)
• School Health (esp.iron/deworming)
• Health, Nutrition and Family Planning Information
• Breastfeeding promotion
____________________
* Horton (2006)
Nutrition & Health Investment which are Cost-Effective

Full Immunization – Rates among Poor and Rich
in 44 Countries
75.7
56.5
81.1
64.4 66.9 66.6
38.3
33.6
29.8
42.2
39.6
64.2
48.3
72.9
0
10
20
30
40
50
60
70
80
90
100
East Asia, Pacific
(3 countries)
Europe, Central
Asia (4 countries)
Latin America,
Caribbean (9
countries)
Middle East, North
Africa (2 countries)
South Asia (4
countries)
Sub-Saharan Africa
(22 countries)
All Countries (44
countries)
Poorest Quintile Richest Quintile
%ofChildrenFullyImmunized

Direct interventions need to have an effect very early in life (stunting
6-24 mos)
-2
-1.75
-1.5
-1.25
-1
-0.75
-0.5
-0.25
0
0.25
0.5
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age (months)
Z-score(NCHS)
Africa Asia Latin America and Caribbean

Inequality and Health Disparity
• Poor neighborhoods can kill people
• Black women in Chicago: death rates from breast cancer 68% higher than whites;
social isolation, stress hormones, poor access to screening and therapy blamed
• Might apply to raised rates of inner-city diabetes, stroke & CVD
• A Harlem male and a poor Asian farmer have same life expectancy
• Despite the NHS, the poor live a decade less than the well-off in the UK
• But country folk live 2 years longer, shrink wealth gap
• Work-related injuries are under-reported (U.S. OSHA ) by 2/3rds, occupational
medical care sub-standard
• Developing countries often reduce their health budgets by the amount that donors
provide

SDG #5: A Continued focus on women
• Limited success of MDGs
• SDG #5: Achieve gender equality and empower all women
and girls
• Some specifics:
• Recognize and value unpaid care and domestic by
providing services and infrastructure
• Promote shared domestic responsibilities
• Equal opportunities for participation & leadership
• Equal rights to economic resources property ownership
and natural resources
• SDG # 6: Pay special attention to the needs of women and
girls and those in vulnerable situations

Impacts on Women and In Utero Environment
• Mothers with Type 2 Diabetes have
an increased risk of:
• High Blood Pressure and preeclampsia
• Higher risk of miscarriage or still birth
• Risks to child:
• Organ malformation
• Overly large babies (nerve damage)
• Higher risk: childhood obesity &
diabetes

Early Childhood is Critical for Motor, Mental, and Language
Development

Intergenerational Impacts of Maternal Welfare(1)
• Disease and malnutrition: In utero
environment compromised
• Early interactions between
mother and child are critical to a
child’s future: When a mother is
exhausted, depressed, or anxious,
the quality and quantity of
mother-child interaction declines
• 2012 Study: Window of
opportunity: 0 to 4 years
Neglect results in decreased brain size. Enlarged
ventricles are associated with stunted neural
development and atrophy.

Intergenerational Impacts of Maternal Welfare (2)
• 2015 study confirms that poor sanitation is
associated with adverse pregnancy outcomes
(APOs)
• APOs: low birth weight, prematurity, death
• India has the highest number of premature
births
• 667 women in India studied: 60% no access to
toilets; 40% with a household toile but
infrequent use
• Estimated 7x greater of APOs with no latrine
use
• But need both access and behavior change

Jane Jacobs: “Impossible to create a
community without networks”
• July 1995 Chicago heat wave killed 739 mostly elderly, mostly
African-American (e.g. Englewood)
• BUT Auburn Gresham NBHD one of lowest death rates in the city
• Highest death rates? Healthy old folks living alone
• “wellness checks, neighbor-to-neighbor house checks, referrals to
emergency services. Aging and sick were not left alone.” Betty Swanson,
resident
• Survival rate of seniors related to depth of their social networks
• Same in Paris Jl-Aug 2003: 15 K died because children on holiday, isolated
from families
• Bigger networks function better because there’s always a default person
outside the family ready to respond

The Strength of Weak Ties
• Boston Job market: close friend only 17%, casual contacts 83%
• Pullman Porters (20K blacks) – weak link to connected clients (+++)
• Darwin: altruists will out-compete others
• Internal trust breeds economic success (Germany Sweden, Norway)
• Max Planck Institute: most people are ‘conditional altruists’, BUT
• 5% egoists will halve altruistic actions
• “Positive Deviance: (M.Zeitlin): (i) Viet farmers healthy babies (greens and shrimp) (ii)
smoker among non-smokers (iii) non-immunized baby among immunized (iv) Thai social
taboo re: water pot
• Changes in behavior motivate attitude change
• (+++) Neighbor hoods: best school performance -- > best health, lowest crime and teen
pregnanc y rate
• Impact spreads to adjacent neighborhoods ”3 degrees of influence”

Theme 3.
Reversing Global Obesity Crisis

Obesity Jumps Globally since 1990

OBESITY EPIDEMIC
• 700 Mn including 106 Mn children
• More obese adults than underweight
• NO NATION HAS REDUCED ITS OBESITY RATE IN 35 YEARS
• “The diet is killing us”
• an epidemic of diabetes and heart disease
• Food industry: unprecedented power in LDCs: pushing out subsistence
crops
• MNCs: Incentives to grow sugar, corn, soybeans for packaged foods (up
25%) and meat
• Fast Food cons’n 2011 – up 30% global 21% USA
• THAT’s IT!!

REVOLUTION IN DIETS
• A. Land Use and Environmental Protection
• Grains and meat: disappearing biodiversity
• Land grabs and virtual water capture
• Shifting role of animals from grazers to fast food
• Habitat destruction directly caused but largely ignored
• B. Food, Health and Sustainability
• Global reach of food production and disease
• Antibiotic resistance and zoonotic emerging
disease/pandemic?
• WHO: meat class 1 carcinogen
• Impacts on lifespan from overconsumption
• “One Health” for Ecosystem Protection

Livestock Emissions – Global

Farming forests and grasslands could reduce
wildlife species by a third

• Could farmed animals be the most significant driver of climate
change?
• If the whole world adopted the OECD appetite for meat, we’d need
75% more agricultural land than the world possesses (Vaclav Smil)
• Chatham House: the 2oC limit Paris accepted cannot be met w/o
reducing meat eating
• And “the market is failing”
• Switch livestock industry subsidies to plant-based alternatives?
• Apply a carbon tax on meat?

Animals Produced for Annual Consumption
Current
• T: 65 Bn
• Chickens 60 Bn.
• Cows 300 Mn*
• Pigs 1.4 Bn
• Ducks & turkeys 3.5 Bn
• Sheep & goats 1 Bn.
• That’s 9 animals per person per year
on the planet! Who knew?
• * T: stock 400 Mn (1900) – 1.5 Bn
2015 - 2050
• Consumption doubled last 50 yrs
• Expected to double again
(projected demand incl 3-4 Bn
new consumers)?
• Unsustainable?? YES

Global Footprint (FAO)
Emissions (CO2-e)
• Methane 2.8 Bn T
• Manure 700 MnT
• C stores lost “
• Crops (feed) 2.6 GT
• Transp crops/meat 100 MnT
Efficiency (100 g cooked meat)
• Cow 450 g protein
• Pig 110 g
• Chicken 75 g
FOOTPRINT (per kg meat)
• Cattle 16 Kg CO2
• Sheep 13
• Pig 5
• Chicken 4.4

WHO: Meat Considered a Class 1 Carcinogen
• Red meats (beef, pork, veal, lamb) and processed meats bacon,
sausage, hot dogs) in the same category of cancer risk as tobacco
smoking, asbestos and ionizing radiation
• Risk jumps the more you eat, e.g. 1.8 oz meat daily -- > 18% higher
risk colorectal cancer
• See Lancet article posted on Canvas
• This would force a recasting of the previous analysis (completed
2002) to reflect much higher cancer and heart disease deaths and
much higher economic costs from exploding meat consumption

Clip : Dr. Marco Springmann
• Oxford Martin Programme on the Future of Food
• 4:32 minutes
• https://www.youtube.com/watch?v=MMnyFURBKAo

Trade, Junk Food and Nutrition Injustice
•Globalization is a double-edged sword

Burdens of Lack of Clean Water: Increased Soda
Consumption and Diabetes? (1)
1971: “I'd like to
teach the world
to sing
In perfect
harmony;
I'd like to buy the
world a Coke
And keep it
company;
That’s the real
thing.”

Burdens of Lack of Clean Water: Diabetes? (1)
Double or triple digit percent increase of soda
consumption in developing countries since 2009
“[A]ccess to clean
drinking water is
limited, so soda
becomes a viable
alternative . . . .
People will say, 'We
don't have anything
else to drink.‘”
Dr. Lee (Director of
the Global Obesity
Prevention Ctr; Johns
Hopkins University.)

Burdens of Lack of Clean Water: Diabetes? (2)

Mexico: Did necessity become cultural?
• Mexicans consume the most soda
• 2000-2015: huge gains in rural access
to clean water (74% to 92%)
• Children fed soda:~ 10% zero to 6
months; at age 2, ~80%
• One of the highest rates of childhood
obesity
• Culture vs. Necessity vs. Marketing:
• Mom’s like chubby kids; shows they are
well taken care of vs.
• Lack of clean water vs.
• Heavy marketing

Ad: Even Mexico’s indigenous
people’s need Coke

Trade: Poor Countries Import Obesity
-- > The Mexican Case after NAFTA
• NAFTA abolished trade barriers for investment, IPRs, government
procurement
• No domestic content required for foreign firms
• “Nutrition transition” in Mexico exploded through free trade
• Obesity (adults) now 32%> USA; 25% school-age kids, 33% Mexican
teens, 40% kids in Mexico City; fattest in Latin America. Why???

Mexico (2)
•1991-- > US exports meat, corn, soy 2-6X higher;
sugary drinks up 40%, fruits and veg down 30%,
processed chicken up 50%
•Mexico 3rd largest recipient of US FDI in
processed food and beverage industries
•Mexico now resembles US industrialized
food system: fat people starved of good
nutrition

Mexico (3)
•Actions: implement WHO WHA resolution “ to
address the potential challenges that trade
agreements may have on health.”
•Require HIA for proposed agriculture trade policies
•US Congress study nutritional outcomes of Ag
export expansion in LDCs
•Strengthen protection for public health, safety and
environment in food sector

Brazil Goes Obese (2): 2007-2017
• 58% overweight
• 20% obese
• 300,000 new Type-II Diabetes cases/yr
• Food & Beverage industry 10% GDP, employs 1.6 Mn
• 2006: ANVISA (= Brazil FDA) proposed new anti- packaged foods’
regulations and supported WHO exclusive BF to 6 mons policy
• BR Assn Food Industries (w Nestle etc) paid $160 Mn to Br Congress and
the Presidential candidates
• after election ANVISA replaced w Cargill VEEP, regulations went away
• Called “censorship”, “violation of free speech”
• 11 law suits pending to block ANY new Govt from fighting food industry

Brazil Goes Obese (3)
• 2010: Br Court ruled ANVISA has no authority to regulate food industry
• ANVISA reg to prevent food giants from sponsoring sports and music
concerts REVERSED
• 2012: Coca-Cola sponsors “Lose Weight Brazil” campaign
• Big hit in Rio, Sao Paolo and Brasilia
• Street violence keeps kids inside: TV and snacks!!
• 2015: Brazil catching up !!
• % obese kids: Brazil 9.5% ( tripled since 1980)
• USA 12.5%

Food Industry Quotes
• Ahmet Bozer (CEO Coca-Cola): “ Half f the world’s population hasn’t had a Coke in the last 30
days. There’s 600 Mn teenagers who haven’t had a Coke in the last week, So the opportunity for
that is huge.”
• Mike Gibney (Nestle nutrition adviser): “We’re not going to get rid of all the factories and go back
to growing all grain. It’s nonsense. It’s not going to work.”
• Nestle employs 21K door-to-door food vendors in Brazil, 9K products . Corporate Goals? “create
shared values/ create micro-entrepreneurs/send a positive message about nutrition”
• Favorite seller? “Chandelle Pacoca peanut-flavored pudding 3.5 oz = 20 grams sugar = WHO
recommended daily limit
• Food industry mergers (Tyson-Hillshire Brads etc) are eliminating the competition.
• Barry Popkin (UNC): “emblematic of an insidious new era – companies ae not leavng an inch of
country aside”

Nestle junk food packages paid by ‘Bolsa Familia’
(Brazil Government income supplement)

Three Degrees of Influence: Obesity
Obesity Network Impact on Health Risk
• Framingham Heart Study: life
expectancy lowered 7-8 years
• Obesity tripled to one-third American
adults (half century)
• ~ $200 Bn/yr spent on obesity-related
health issues
• Friendship is key “risk”
• My “friend”: my risk up 57%
• 2 friends in a network: risk up 171%
• Target people at center of social
clusters: surround high-risk people
with good behavior (non-obese, non-

Nutrition Interventions for Obesity and Overweight
• School-based training for improving diet and activity levels
(e.g. Singapore)
• Extension workers to teach traditional cooking methods (e.g.
South Korea)
• Dietary Guidelines for nutritional well-being (e.g. China)
• Nutritious meal planning for public schools
• Mass Media (e.g. campaign to reduce overweight in Brazil)
• Food Labeling
• Agricultural research to decrease the fat content of livestock
products
• Focus on preschoolers before it’s too late to correct –many US
public schools are training 4-5 yr olds for good diet and
exercise
• Yo, Diabetic Nation! At a YMCA near You ( 128 total)

Figure 8. Food Policy Instruments for Controlling Dietary Fat
Stage of the
Food System
Food Production
Food
Processing
Food
Distribution
and Marketing
Food
Consumption
Examples Used in the Dietary Fat issue
• Feed grain subsidies for feedlot animals
• Dairy price supports
• Export incentives for U.S. vegetable oil
• Restrictions on beef imports
• Beef grading (changes from choice to
select)
• “Standards of identity" changed for low-fat
milk and yogurt
• Food label descriptors (eg "low fat", etc.)
changed for fluid milk, ice cream
• Changes in milk marketing orders
• Use of "% lean" claims on ground beef
• Restaurant labeling of menu items with "low
fat" claims
• Harmonization between the FTC and FDA
on ads using fat "descriptors“
• Fat descriptor information on food label
• Dietary guidelines
• Food Guide Pyramid
• Promotion of cheese, ice cream, milk, beef,
pork
Types of Policy
Instrument
• Commodity price
subsidies/supports
• Import/export quotas
• Meat grading
standards
• “Standards of identity“
• Food labeling
• Marketing orders for
dairy
• Food labeling
• Food advertising
• Food labeling
• Dietary Information
Campaigns to public
• commodity promotion
boards
Effectiveness in
controlling fat intake
• negative
• negative
• uncertain
• uncertain
• positive
• positive
• quite positive
• negative
• slightly negative
• slightly positive
• uncertain
• positive
• positive
• quite positive
• negative
Adapted from Sims 1998

U.S. toddler obesity down 43%
• Large study of low-income kids by CDC
• Among 2-5 year olds (age when obesity settles, hard to reverse (5X
more likely obese adults)
• 8% obese (2012), from 12% (2004). Why?
• Maybes: consuming fewer Kcals from sugary beverages; federal WIC
program reduced fruit juices, cheese, eggs, increased fruit&veggies
• Michelle Obama channels the Thai Princess??

Sugar Tax Needed (U.K. Plan)
• Reduce added sugars by 40% (2020)
• No targeted marketing processed sugary
drinks & food to kids
• Ban junk food sports sponsorships
• Reduce saturated fat 15% in processed
foods (2020)
• Limit availability and portion size I
markets
• Implement a sugar tax to shift diet
preferences
• Create an independent agency to ensure
accountability for good nutrition
• Action on Sugar proposal (2014)

BBC Horizon: Should I Eat Meat?
• Interview with Simon Fairly, livestock farmer in Dorset, England
• Video Clip start 41:54
• End 49:10
• https://www.youtube.com/watch?v=qSRNSZMpgjE
• Simon makes the case that limiting meat consumption can save
human health and the planet. Are you persuaded? What’s the first
step?

ASIAN EPIDEMIC OF
CHRONIC DISEASES
COSTS TO CHINA’S ECONOMY

• Fetal and infant insults interacting with subsequent shifts
toward positive energy balance
• Poor sanitation led to stunted adults
• Shifts in the structure of diet
• Food subsidies a factor: meat, fats, sugar
• shifts in physical activity
• obesity and diabetes trends; prevention weak
• morbidity and mortality shifts
• Cost model described for China
Underlying Trends Leading to Increased
Non-communicable Diseases
University of TorontoThe Nutrition Transition
The University of North Carolina
at Chapel Hill

“METABOLIC PROGRAMMING”
FROM EARLY LIFE
A range of country studies (U.K., Sweden, US, India,
among others) have reported that LBW infants in later
life had increased hypertension, coronary heart
disease, adult-onset diabetes, and auto-immune
thyroid disease.
More than 30 studies show a relationship between
lower height and increased hypertension.
Overall, the evidence of adverse long-term effects of
maternal, fetal, and infant malnutrition is very strong.

2.7
20.8
24.0
42.2
54.6
46.9
0
10
20
30
40
50
60
Fiji Islands Sri Lanka People's
Republic of
China
Indonesia Bangladesh Viet Nam
Percentage
Figure 2: Prevalence (%) of Stunting among Children Aged 2 to 6 years in Asian Countries and the Republic of Fiji Islands.
These data are the most recent available for each country in the 1990s; e.g., 1993 for the Peoples Republic of China,
Indonesia, and Viet Nam
Sources: Indonesian Family Life Survey, 1993; Viet Nam Living Standards Survey (1992-1993); People’s Republic of China Health and Nutrition Survey (1993); Fiji:
provided by the Pacific Commission

0
500
1000
1500
2000
2500
3000
3500
1962 1967 1972 1977 1982 1987 1992 1996
Energyintake(kcal)
Energy from added sugar
Energy from added
vegetable oil
Energy from added animal fat
Energy from protein
Energy from alcohol
Total energy intake
Energy from carbohydrates excluding added sugar
Note: Values are presented as 3-year average.
Figure II-15 Trends in Total Energy Intake and the Sources of
Energy, Lower Low Income Countries of Asia
at Chapel Hill

Health Costs of Diet-related
Chronic Disease
• Costs of cancer, diabetes, hypertension, stroke,
CHD
• INCLUDES: human costs of early death, economic
costs of early death, economic costs to health care
system
• EXCLUDES: economic costs of lost days of work
and lower productivity due to morbidity
at Chapel Hill

Human costs of diet-related chronic disease in China
1995
• 2.5 m deaths (43.2% of all
deaths)
• 1.04 m cancer deaths
• 0.35 m CHD deaths
• 1.11 m stroke deaths
2025
• 7.63 m deaths (52.0% of all
deaths)
• 3.77 m cancer deaths
• 1.45 m CHD deaths
• 2.41 m stroke deaths
at Chapel Hill

The economic costs of diet-related chronic disease
2.4
0.3
0
0.5
1
1.5
2
2.5
3
% loss in GDP
China
Sri Lanka
China’s economic cost of diet-related
chronic disease is 2.4 percent of GDP
Note: GDP loss likely to be much higher when taking
into account morbidity Popkin, Horton and Kim 2000)

Theme 4. Finishing the Environmnental
Sanitation Challenge
• Science at its best
• Broadened to encompass the whole environment
• Recovery and recycle economic goods for equitable development

‘Sanitation Rated the Greatest Medical
Advance in 150 Years’
• British Medical Journal survey 11,000 readers
• Followed by antibiotics & anesthesia
• Chadwick and Snow were on to something
• BMJ’s survey of diarrhea diseases in LDCs: death and damage reduced by
one-fifth directly and more if reversed child stunting included
• BUT….
• The individual commode only gets us so far
• Indian kids from rich families are still stunted and cognitively compromised
• The challenge NOW to cleaning up the refuse entirely
• Then “ Clean Chicken WILL Grow”!

Megacity resource and waste flows as a percentage of world values.
Christopher A. Kennedy et al. PNAS 2015;112:5985-5990
©2015 by National Academy of Sciences

What is the current situation worldwide?
Solid waste management examples from:
■ Jakarta
■ New York
■ Lagos
■ Tokyo
■ Sao Paulo
■ Amsterdam

.
A short video on urban waste

.
JAKARTA
.
Jakarta: Nowhere to go but up
Due to the lack of formal recycling, waste pickers are key to reduce
the amount of waste

Jakarta: Nowhere to go but up
-The country has grown significantly in the last years
-Many of this waste is directed to Bantar Gebang (one of the largest landfills
worldwide)
-Lack of proper work conditions for the waste pickers
-Yakarta is one of the countries that more plastic dispose into the ocean
-Waste pickers have an important role within the waste chain.
https://www.washingtonpost.com/graphics/2017/world/global-waste/?utm_term=.229326d5ded1

New York: A bold goal in the Big Apple: ‘Zero Waste’
-One of the top world´s mega-cities on waste production
-High population density creates big challenges
-Food waste is a significant problem in the NY (and US)
-Recycling is higher than in other US cities but still limited
-A “Zero Waste initiative” has been signed “under Mayor Bill de Blasio”
-” The city’s goal is to eliminate the transfer of garbage to out-of-state landfills by
2030.”

JAKARTA
.
Lagos:
works to slow a rising tide
’

Lagos: works to slow a rising tide
-One of the fastest growing cities in the world (21 mill pple)
-They receive illegal waste from Europe and US
-Waste pickers are also vital to the city
-Landfills are out of capacity
-Very little organic waste on the trash
-Waste is used as a filling compound to reclaim land and build more houses

Tokyo: Short on space, Tokyo gets proactive’
-Tokyo metropolitan area is one of the most populous in the world (36 mill
pple)
-Advanced technologies for recycling
-There are 48 incinerators
-They capture the heat to supply energy for different purposes
-There are also 12 landfills around the city

JAKARTA
.
Sao Paulo:
relying on people power

Sao Paulo: relying on people power’
-It has around 21 million people
-More waste has been generated as the level of income of some groups have
increased.
-Garbage picker/scavenger” is an official profession
-The type of recyclers are divided in plastic, can and paper
-They are organized in cooperatives

JAKARTA
.
Amsterdam:
looks to burn less, recycle more

Amsterdam: looks to burn less, recycle more
-It has 900.000 people
-Most of the waste is incinerated at the moment
-New facilities have been developed to recycle more plastic
-The Netherlands is currently importing waste from UK
-Paper and glass are very well recycled in the city additional efforts will be
required for food.

SOLUTIONS
-All cities and their residents are different therefore multiple solutions working
synergically will be required to solve the Solid waste management problem
-Close loops of waste management should be incentivized
-Appropriate air and water pollution controls should be enforced to guarantee a
long term sustainability performance
-Waste picker play an important role in the developing world, to keep many of
the cities that they serve running. Adequate safety and other working
conditions will be required to make it sustainable.

Theme 5. New Bird Flu Strain Spreads Oct 17

Fifth “Wave” H7N9 infections China 9/16 -- >
• 1600 infected positives, 40% died
• Viral lineages: Yangtze and Pearl after rivers were influenza has spread
• Earlier versions
• H5N1 avian flu (2005): 860 infected, half died, 16 countries, still
circulates Egypt and Indonesia
• H1N1 (2009) “swine flu” Mexico, infected factory farms all over US

Animal Production and Waste Out of Control

Rob Wallace : “Big Farm, Big Flu”
• HxNx: global dispersion
• Mom&pop chicken coops and wild, migrating fowl are not the pandemic risk
• New strains appear to be adapted to industrial poultry production near urban
centers
• Molecular adjustment: evolving new attributes fit for infecting poultry
• New H5Nx : influenzas adapted to intensively raised poultry i.e.
• Genetically homogeneous
• Cities low immunity among working poor
• Urban pandemic risks increasing
• Wild fowl migrations disrupted by loss of coastal estuaries, mangroves and
wetlands

(KM) New Infections101:
Launch Pads are Urban
• Taiwan study:
• Human behavior can increase risk, even urban areas.

URBANPOPULATIONPLANNING
• m
•Appropriate public project siting of water, sanitation,
wastewater management, integrated w/ ENA, community
health IEC outreach
•Expansion of public housing w/ inbuilt WSS, enforced
ventilation, infrastructure
•School health programs on diet and exercise to prevent
child obesity
Tianjin, PRC  Diabetes
OatChoco
•Strengthen regulation and inspection of food businesses
•Drop subsidies of cheap fats and sugars
•Centralized fortification of essential foods esp. baby foods
THEME 6. Best Practices: Urban Health
CITIESASDRIVERSOFVALUESSHIFT
98

E170 Fall 2017 final lecture (JMH,KMM,CCC)
• Ready to Roll:
• 1. Provide micronutrients to all consumers
• 2. Combat environmental racism for babies of color to live & thrive
• 3. Change Diets to protect human health and the health of the planet
• Too Big to Fail:
• 4. Finish the Environmental Sanitation challenge so “Clean Cities DO Grow”
• 5. Averting the next zoonotic disease pandemic
Bringing it all together:
• 6. Implement best practices for urban health
• 7. Urban Design for families and communities: housing, immigration and
the Sanctuary City

Healthy Cities
WHO, 2016
• As defined by WHO:
“A healthy city is one that is continually creating and
improving those physical and social environments
and expanding those community resources which
enable people to mutually support each other in
performing all the functions of life and developing to
their maximum potential.”
• Over 1000 cities designated worldwide

But the type of home you are in matters…

And the connections within the city….

Healthy Cities are hyper-connected
• More recently, focus on “social, innovative and smart cities” (Boulos et
al, 2015)
– Barcelona – Save $75 Million on water, lighting and parking management due to
smart city designs – but saved countless more on health costs
• Technology isn’t an panacea, though – need impact assessments

Healthy Cities are hyper-
connected
• Also need a redesign if possible:
• Waste bins, internet, environmental
sensors – all to increase productivity
and efficiency of services.
• Superblock: residents have priority,
cars limited to 6 mph!

Healthy Cities are … Super Cities?

China Healthy
Cities –
One option

Via Verde Condo Complex (South Bronx)
• model green affordable urban housing (opened 2012)
• Garden-covered roofs: orchard, F&V gardens
• Energy-efficient (30%upgrade), pro-health design
• Health center, pharmacy, gym, community room, kitchen, children’s
playroom, community rooms, amphitheater
• Rents and co-op apartments priced on affordability to clients
• Healthy materials
• 80% materials’ recycled
• Access to schools, shopping, sports fields, public transit

Access to green space, 151 affordable
housing rentals and nutritional resources
(Rosen, 2017).

Theme 7. Cities can be protective
• Must provide the following:
• Opportunities (Economic, Social)
• Access (To food, water, transport)
• Resources (Food, water, energy, internet?)
• Support (All the above, emotional, physical?)
Thanks to Michael Kilmurray for this!

References:
1Sugiyama et al. (2008). 2Graph from De Vries, et al, (2013)
Urban nature exerts a strong positive influence on
mental health issues that arise with displacement
Social cohesion explained 20-40% of the
relationship between quantity of public
greenspace and health indicators.1
114

Green space
and mental
health
115

Loss of the stars?
Harming health?

• m
Internal displacement adds pressure
Add title
118

• m
● Critical risks: maternal health, reproductive health, nutrition, and
immunizations (Williamson, 2017).
● Long term: mental health, asylum status, recognition of educational
status, integration
Influx of residents require servicesURBANPOPULATIONPLANNING
119

Metabolic realignment for survival
• We must realign the metabolism of cities to
adapt to shifting populations, services and
needs.
• Increased displacement, with perturbations?
E.g. war, climate change.
• Case Mongolia (2016): “Reaching Every
District” strategy delivering an integrated
package of health services, given shifting
social context of populations. (Lhamsuren et
al, 2012)
• Focus on the social determinants of health
and social values of populations.
• Case US (2017): Sanctuary cities provide hope
and stability.
120

New Home, New Values, New Governance & Design
• Historically, GDP/$ metrics of human value
→ De facto city design of segregated, under-
served, sick neighborhoods
• Emerging evidence: Equity/Quality of life
correlated with Productivity
• Solution: Design urban spaces &
governmental institutions to effectuate
“people-centered” prosperity
• Substantive equity follows procedural
equity
• Risks of status quo: social unrest, health,
economic productivity/cycle of poverty,
human dignity
121
UN Habitat (2013)

• m
Devolution of climate change action from
national to city level (adieu Paris!)
CC Action Plan for 40 (but more!) cities
Text here about C40 Cities Mayors Summit
Urban sustainability leadership devolving from national level
CITIESASDRIVERSOFVALUESSHIFT
122

Cities along the sustainability spectrum
Copenhagen
Bangkok
New Delhi
Chicago 123

To be sustainable,
cities must be a
permeable membrane
From the New York Times
(2010)

Cities as a membrane
• Membrane for:
• Water (flooding, freshwater, sewage)
• Migration (people, ideas, energy)
• Energy (fuels, foods, and factories)
• Etc. (Iaconesi and Persico, 2012)
• Cities can also self-regulate (like a cell) (Johnson, 2002)

Cities as a membrane
• Luckily: human interaction and
production scales super-linearly (above
linear).
• This is a multiplicative increase, and is a
function of the network dynamics.
• Consider for disease prevention and
other viral phenomena (Schlapfer et al, 2014).
• For example, behavior change and urban
development.
• The communication networks can be a tool
for positive and negative change.

The case of China: migration
• Over 10% of China’s population
migrates for labor.
• In search of better jobs and
opportunity.
• 57% of these people obtain a job in
the city from a friend or relative.
• 45% are between 16 and 25, two-
thirds male (due to traditional
division of labor).
• Hukou (household registration, 户口)
does not account for this.
• Thus, a “floating population” (Wu et al,
2013; CFR, 2009).
• A pressure in the membrane –
but also an opportunity

Tianjin Eco-City, China
• How do we adapt to such an
influx?
• Build new infrastructure –
increases jobs
• China has produced a number
of eco-cities, sparking global
interest.
• However, eco-city projects such
as the Tianjin Eco-city did not
address the movement of
worker populations throughout
the city.
• Sao Paulo – map of the
impoverished core

Tianjin Eco-City,
China – Video

From Eco-City to Sanctuary
City
• Sanctuary areas produced a greater
number of stable immigrants (Ceubula, 2015)
• Associated with lower cost of living, and
greater humidity (?)
• Also associated with better well-being
estimates.
• Have to address OARS!
• Social networks are more secure
• This can support ongoing efforts such as
Tianjin Eco-city.
• Summary: The path for China’s workers
through sanctuary from hukou?

China’s
Approach to
Healthy
Cities

Summary:
• Sanctuary areas can provide a path to lower cost of
living, better well-being, greater exercise and
green-space access (Ceubula, 2015).
• This can support Healthy/Smart cities.
• While protecting migrants and those at risk
• Climate change
• Conflict
• Summary: The path of China’s megacity workers
from sanctuary to hukou as an example for cities
globally.

James Baldwin
“ NOTHING CAN BE CHANGED
UNTIL IT IS FACED ”

Knowing is not enough;
we must apply.
Willing is not enough;
we must do.
Johann von Goethe

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