Equity in Health and Health Promotion in Urban Areas

From the beginning, the concept of public health is deeply connected to the social development of mankind, focusing on housing and now, during COVID-19 pandemic and the POST-COVID transition, we are witnessing the exacerbation of all those phenomena of social inequality that have clearly highlighted the structural lack of public spaces and services in the most disadvantaged areas of cities. It is therefore necessary to contribute to the improvement of the living conditions of the beneficiary populations not only to ensure the satisfaction of the primary needs for development, but also to make communities less vulnerable to the climate-environmental emergency. Actions outlined by the major international institutions, which through the UN 2030 Agenda provides for the integration of three dimensions of sustainable development—environmental, social and economic.

Recent years of the Covid-19 pandemic have seen a proportional increase in the amount of time we spend in our homes each day. In spite of this, urban dwellers continue to spend-although varying from area to area of the world-many hours outside their homes for work, daily needs, recreation, and social relationships. This implies that the urban environment, both tangible and intangible, has several factors that can be both protective and risky for health. As highlighted in the 2016 Quito Conference, health can be the pulse of the new urban agenda for sustainable urban development [1]. It is not easy to take stock of where we are. On a global scale, there still seems to be a limited ethical-cultural awareness, a lack of political attention and thus of resource allocation, an insufficient capacity to use innovative choices and technologies and to actively involve local communities in decision-making processes and in the implementation of possible interventions. On the other hand, there are numerous positive experiences of urban realities that have produced convincing efforts in recent decades to make our cities more livable and healthy. Let us hope that the 2030 agenda proposed by the United Nations on the Sustainable Development Goals can really exert a driving role in this direction. A real willingness to set in motion virtuous processes to guarantee us a better quality of urban life, including by agreeing to revise our development and consumption patterns, will make all the difference.

This paper explores the theme of socio-spatial exclusion through two concepts from contemporary critical sociology: that of territorial stigmatization and that of abyssal social exclusion. These concepts are used to interpret a specific urban context characterized by marked socio-spatial inequalities: the city of Rio de Janeiro, Brazil. The dynamics of socio-spatial segregation are analyzed with particular reference to the issues of urban security and access to social and health services. The case of Rio de Janeiro, which has a paradigmatic value because of the deep urban division between asfalto and favelas, has here the function of stimulating the analysis of certain dynamics also found in other urban contexts globally. We then go on to discuss the relevance of activation and knowledge processes located in “bottom-up” civic and democratic participation practices to counteract the dynamics of social exclusion and foster equitable access to urban healthcare and security.

In the international scientific arena, there is a clear understanding of the impact that the social gradient can have on the wellbeing of the population, as well as the consequent higher frequency of mortality and morbidity in the most vulnerable and discriminated population groups based on their social and economic position. By embracing the ecological perspective of health, this paper will attempt to connect the phenomenological paradigm of redefining the concept of the body with that of urban suffering, understood as an interpretative category of the encounter between the suffering of individuals and the social fabric in which they live. By drawing on various fields of studies and a multi-systemic approach, the authors attempt to show how the phenomena of gentrification can be seen as a form of structural violence that reinforces inequalities.

The urban context of the city of Rome is the result of an urban but also socio-economic stratification. From the frenetic development of the central areas at the end of the nineteenth century, up to the building speculation of the first half of the twentieth century and throughout the sixties, Rome today is characterized by highly urbanized areas, and dispersed nuclei of cities in an area of over 1200 km². Municipalities XIII and XIV constitute in this a real representative cross section of the Roman context. The dense fabric of the more central historical periphery becomes gradually more rarefied, re-aggregating around the GRA motorway ring, and then dispersing again into the countryside to the north. Within this fabric there are areas of Public Residential Housing (PRH), built between the 40 and 70 s, which still today constitute, in the perception of the population, real “urban islands”. These are characterized by a lower socioeconomic level than the surrounding deprived areas, and a significant increased risk level regarding the access rates to the emergency room and hospitalization. All this in the context of an evident centre-periphery gradient of these indicators, which can be correlated not only with socio-economic indicators, but with the development of these portions of the city itself. The complexity of the historical and urban stratification of Rome makes this methodology capable of reading in depth the socio-economic dynamics with an impact on health, and of effectively planning health, territorial and hospital services.

Cities play a vital role in promoting health, as most of the world’s population lives in urban areas. Urbanization and city planning are both factors that must be considered to improve the health of communities. Walkability is a measure of how friendly an area is to walk. The Walking Suitability Index of the Territory (T-WSI) measures the pedestrian viability of the streets of a environmental islands. It includes 12 indicators, distributed into four categories: practicability, safety, urbanity, pleasantness. The goal of this study is to establish a model of connection between universities, local authorities, and health institutions to improve the walkability of urban areas. Five Environmental Islands were identified in the Municipality of Roma Capitale. First step concerned multidisciplinary training, sharing the goal between professionals in both the health and non-health fields. The theoretical acquisition, for Public Health personnel, on the use of the “walkability” assessment tool T-WSI was concretized by applying the assessment in training inspections. The on-site measurements showed that the main critical issues in terms of unfavorable factors for walking are the obstacles on the sidewalks, concerning the safety of pedestrian crossings and protection from vehicular speed. Measurement was associated with a characterization based on census data, obtained from satellite imagery. It is important to develop tools that are easy to apply and that can be easily used, also by health personnel. This is necessary in the light of recent developments in the Italian regulatory framework, and international guidelines, toward a growing integration of professional skills with the common objective of Urban Health.

Living environment, and especially dwellings, affect health in several ways end represent a key social determinant of health. The current COVID-19 pandemic has further highlighted its relevance. Factors linked to housing and neighborhood conditions that influence health, can be grouped into broad categories: the health impacts of residential instability; those related to housing internal conditions; the health impacts of context in which dwelling is located; the housing affordability. Many answers to these requirements can be offered by co-housing and social housing and Authors describe same examples from international experiences. These problems nowadays need to be assessed with a multidisciplinary approach, because of the complexity and wideness of its components. To guarantee good health standards it is also necessary to direct political and administrative choices to improve the overall conditions of the neighborhood and of the buildings, and, to dispose of a clear and updated regulatory system, since key factor to ensure health and social justice.

The studies carried out for the cities of Quito, Cairo, and the region of Baghère within the master course ‘Aedification—Large territories—Cities’ at the École Nationale Supérieure d'Architecture de Grenoble raise the question of good living, well-being, and health by relying on punctual architectural proposals that take into consideration the environment on both a large and small scale. The main theme of the three sites is violence against women and all people in precarious situations. For the capital of Ecuador, the northern slope of the Panecillo hill is host to project hypotheses that fit into abandoned buildings with high heritage value. As an extension of these attempts, the opportunity to rethink informal housing through innovative prototypes is inspired by local know-how. For the Egyptian capital, Bab el-Wazir Street is imagined through a new dynamic between social programs and heritage programs for a reinterpretation of vernacular architecture. In the Tanaff valley in Senegal, the small town of Baghère invites reflection through initiatives built for a more peaceful society. In each case, good living, well-being, and health are questioned as a central concern to offer the best possible quality of life to the most disadvantaged people.

“We for Us” is the motto used by activists of social movements and urban collectives from favelas and peripheries in Brazil. The motto demarcates that, in the absence of public policies, the residents need to organize themselves to supply collective services and means of consumption necessary for their well-being in the territory. The COVID-19 pandemic that devastated and transformed the world from 2020 onward found Brazil amid a process of dismantling the state apparatus in charge of public policies that transform rights-in-law into rights-in-exercise. The existence of the national health system (SUS) is considered the most democratic and inclusive policy built after democratization in Brazil. But its renewed base of social support and successful institutionalization and development of state capacities were unable to sufficiently serve the populations in favelas and peripheries to face the health, economic, and social crisis caused by the pandemic. Community organizations reacted to this situation by mobilizing internal and external resources. Many actions took place as part of the biopolitics of resistance, based on mobilization and social organization in collective measures aimed at compensating the government's omission. Other initiatives were developed as part of insurgent citizenship, claiming the protection of rights and demanding the government's effort to meet the population's needs.

For much of the past 20 years, our research and design work has primarily concerned relatively discrete interventions: individual structures, from the vertical gym to collective housing; connective tissue, such as the Metro cable car; and neighborhoods, like Khayelitsha in South Africa. But all the while, we were thinking and talking about the city, about what participatory urbanism might mean and be in the twenty-first century. The rigid separation of formal and informal, planned and ad hoc, wealth and poverty, makes no sense to us. Those distinctions are inherently unstable politically, economically, and geographically; marginalization is a social and physical phenomenon, a kind of illness afflicting the civic body. The disconnect between formal and informal has at least two root causes. One is organic: cities grow outward, like the ripples in a pond when one drops a pebble in the middle. Like the ripples, the encircling neighborhoods grow weaker and less coherent the farther they are from the center. The other cause follows the law of unintended consequences: infrastructure, especially transportation, creates barriers between the haves and the have-nots, in the interest of improving vehicular movement. Even where public transportation and pedestrian bridges provide access across highways and six-lane boulevards, neighborhoods are still cut off from one another, preventing mingling and sharing.

Good health for All is one of the main targets of the Sustainable Development Goals, ensuring quality of care for all people, including of course people with disability. Migrants with disability represent an invisible group of individuals who are forced to leave their countries. Data on refugees and asylum seekers with disability are lacking. They have poor access to rehabilitation health services, but in Italy there are law and policies to guarantee healthcare. The lack of standardized assessment of vulnerability represents the main barrier to organize specific service within the community involving migrants them-selves and institutions. National stakeholders are urgently called to cooperate for removing barrier to rehabilitation and assistive technology for refugees with disability. Main actions should be considered health literacy and empowerment of migrants, collecting data on health, disability and assistive technology, and organize community-based rehabilitation programs.

In this short final contribution, we propose a theoretical-conceptual framework useful for understanding how the various contributions of the volume compose an organic vision of the role of multidisciplinarity and integration. They are indispensable levers for promoting health and health equity in cities. Effective concepts and practices are strongly emerging in the international literature to make the experiences and traditions of research and intervention that have been presented even more well-founded and transferable. New leadership and greater participation are required by the complexity of the problems that urban systems will have to face. Similarly, investments should increase in methodologies centred on strengthening capabilities, through the growth of social capital and empowerment. Furthermore, the importance of the cultural and organizational dimension increases, which can make integration processes dynamic and effective. Finally, recommendations are proposed, which, according to our experiences, constitute learning to be valued, to make the participation of professionals, citizens and institutional and social actors in the improvement of urban ecosystems effective and transformative.