A systemic approach to urban health: why, how, and what for?

Diez Roux’s paper is interesting in many ways, characterized with “opened questions” more than “authoritative proposals” (as we often encounter). She explains in clear and illustrated terms the relevance of adopting a systemic approach to “urban health” in order to understand the complexity of the relationship between urban space, ways of life and health. Sharing Diez Roux’s point of view, I wish to briefly present three sets of additional questions.

A systemic approach: why?

A systemic approach could be a way to overcome the limits of “risk factor epidemiology”, even if researchers have paid attention to multi-factorial determinants and multi-scale understanding of contextual and local determinants of health. Classical epidemiology can describe health changes, health dynamics, and spatial and social health inequalities, but cannot analyze the social and environmental process involved in the production of these situations. A systemic approach could highlight the complexity of the interrelations, interactions, and retroactions that characterize urban health.

A systemic approach: how?

However, is a systemic approach able to provide (by construction) an understanding of the processes at the origin of urban health dynamics or urban health inequalities? The word “approach” is original: is it a concept? A method? A tool? Beyond a naïve “natural interdisciplinary point of view”, is it possible to adopt a systemic approach without hypothesis (and of course an explicit hypothesis: we know, as does Popper, that when a hypothesis is not explicit, it is implicit and irrefutable…). Ana Diez Roux offers concrete research methods, including a controlled hypothesis based on which a systemic approach could be developed, but on very well-defined and controlled research questions… not so different from what researchers are used to do.

A systemic approach to urban health could be a way to understand the interrelations between two complex systems: Cities and Health. It could be (and it should be!) an opportunity to bridge the gap between these two spheres. First, we would need to define:

(i) What is “urban” (size, characteristics, limits/physical, economic, social, and cultural characteristics) and what would be an “urban system”, considering health issues. While experts in urbanism and urban planning define these concepts differently according to their research questions, their categories (legal versus illegal, center versus periphery, etc.) are not always relevant to health.

(ii) What is “health” (not only diseases, causes of death, etc.) and a “health system” (not only the healthcare system), and what are the specificities of health in the urban context? Health experts have no global or definitive definition and have no clear ideas on the impact of quality of health on urban systems, or the impact of the healthcare system’s organization and activities on urban system dynamics.

(iii) What is the complex interface between “Cities” and “Health”? We still do not really know how to look at cities in terms of health. A factor such as high population density could be a relevant risk factor in some cases (TB, measles) and a protective factor in others (malaria). Living in a peripheral settlement provides an opportunity for better access to fresh food but acts as a handicap for accessing the healthcare system. We still do not know how to analyze the interrelations between urban dynamics and health changes, e.g. how urban segregation impacts health inequalities, or how the population’s health status (premature death, avertable morbidity) impacts urban dynamics.

A systemic approach: what for?

A systemic approach could help decision-makers, because such a global approach highlights the interdependence between urban planning and public health and underlines the need for an inter-sectoral approach to health determinants and an assessment of consequences of each urban management decision on health (even its unintentional consequences).

Still, doesn’t this “ecumenist” approach run the risk of an ahistorical and apolitical understanding of the real stakes in urban health, social and territorial inequalities (e.g. social domination and segregation), and different actors’ strategies to deal with the city and public health?

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