Data and density: Two advantages cities have in boosting health equity

Improving health and health equity for vulnerable populations requires addressing the social determinants of health. In the US, it is estimated that medical care only accounts for 10-20% of health outcomes while social determinants like education and income account for the remaining 80-90%.

Place-based interventions, however, are showing promise for improving health outcomes despite persistent inequalities. Research and practice increasingly point to the role of cities in promoting health equity — or reversing health inequities — as 56% of the global population lives in cities, and several social determinants of health are directly tied to urban factors like opportunity, environmental health, neighbourhoods and physical environments, access to food and more.

Thus, it is critical to identify both true drivers of good health and poor health outcomes so that underserved populations can be better served.

Place-based strategies can address health inequities and lead to meaningful improvements for vulnerable populations.

In New York City, life expectancy for city residents since 2019 has dropped from 82.6 years to 78 years. Health inequities mean life expectancy can be 10 years worse between populations living in neighbouring zip codes.

Initial data analysis revealed a strong correlation between cardiovascular disease risk in city residents and social determinants such as higher education, commuting time, access to Medicaid, rental costs and internet access.

Understanding which data points are correlated with health risks is key to effectively tailoring interventions.

Determined to reverse this trend, city authorities have launched a “HealthyNYC” campaign and are working with the Novartis Foundation to uncover the behavioural and social determinants behind non-communicable diseases (NCDs) (e.g. diabetes and cardiovascular disease), which cause 87% of all deaths in New York City.

A data-driven approach to understand the non-clinical factors that influence health outcomes is key. This data can then be used in partnership with cities to create decision support tools for urban policy, planning and partnerships.

The Novartis Foundation’s AI4HealthyCities initiative combines data from health systems and health-influencing sectors and applies advanced analytics and AI to provide decision-makers with insights into the drivers of chronic health risks and inequities. Working with Microsoft AI for Health, the Novartis Foundation is trialling the approach across six cities in Europe, Asia and North America.

Importantly, the models, like the one being trialled in New York City, can predict the impacts and cost savings of specific interventions, for example, public health campaigns to promote physical exercise or tackle obesity, to enhance internet access to low-income households, or to improve public access to green spaces. Until now, no comprehensive evidence-based data existed to suggest which combination of factors should be addressed to maximize health impacts for a given context or population.

There’s no shortage of challenges. The greatest is accessing the right datasets, often scattered across countries, sectors and databases. Data privacy is an important priority. The best insights are gained by linking data on social determinants with health outcomes at individual level. This requires governments to link that data, anonymize it, then make it available while protecting privacy.

The Novartis Foundation aims to validate the data insights by testing innovative interventions that address the main drivers of health outcomes and then to codesign new population health roadmaps with equity at the centre. Each of the AI4HealthyCities participating cities has agreed to translate the data insights into action and scale those interventions that are successfully validated.

One third of the Colombian capital Bogotá’s women — 1.2 million women — carry out full-time unpaid care work. These caregivers are trapped in “time poverty”, often unable to leave the house because those they care for are entirely dependent on them.

They are among the city’s most vulnerable: 90% are low-income, 70% do not pursue secondary education, 33% are deprived of free time for self-care and none has economic autonomy.

Yet if paid, these unrecognized women would account for 13% of the city’s GDP, and 20% of Colombia’s GDP. Meanwhile, over 250,000 of them suffer from diagnosed illnesses — largely for reasons beyond their control.

When Claudia Lopez was elected Bogotá’s first female mayor, her ambition was to transform the capital of Colombia into a “caring city”. She realized that if the burden of caring for others prevented 1.2 million women from leaving home to access vital services, the authorities would have to bring the city and its services to them instead.

Mayor Lopez initiated “Care Blocks” — areas within the city that centralize several types of services and activities for women, including vocational and educational training to improve their marketable skills, psychological and legal aid, exercise and dance classes, bike and swimming lessons and free laundry service.

The Care Blocks service offers professional care for their care-receivers, removing barriers to access imposed by care responsibilities. All services within the Care Block can be reached easily within a 15-20 min walk and are close to women’s homes.

Bogotá Care Blocks play to the strengths of a dense urban setting by pioneering a cluster approach to reaching people in need, all with a gender focus. The city has already opened 21 Care Blocks, with a target of 45 Care Blocks by 2035. It has also invested in 2 Care Buses to reach caregivers and care-receivers living in rural and peripheral areas.

Care Blocks targeted outcomes are based on 3R’s:

· Recognize caregivers’ contribution to society.

· Redistribute care work more equitably between women and men.

· Reduce caregivers’ burden so they no longer have to put their lives and health on hold to care for others.

Beyond improving the health of caregivers and providing them with access to opportunities previously beyond their reach, Mayor Lopez has a loftier goal: to transform entrenched gender inequalities — so that Bogotá’s women have more time for themselves and more autonomy over their lives. To this end, there are also cultural workshops on caregiving with men and women called, We Can All Learn to Care.

While cities are often seen as a source of health equity challenges, using urban proximity and density as an opportunity to tackle health inequities can help the most vulnerable populations.

Through spatial interventions and harnessing data, public, private and civil society leaders can work at the city scale to improve health outcomes for the most vulnerable.

Author contribution from Jonathan Walter, freelance writer.