India’s urban population is estimated to reach 675 million in 2035, the second highest in the world. Although there is widespread recognition that cities have been fuelling India’s rapid rise to economic superpower status, almost all are failing their inhabitants in terms of delivering on health, environmental and equity targets.
Urban India and multiple health risks
India’s urban inhabitants experience multi-scalar health risks including the world’s highest levels of air and noise pollution, limited greenery, lack of access to sidewalks and parks that limit active lifestyles, archaic modes of transport that contribute to air pollution, pernicious access to nutritionally dense unhealthy foods and unprecedented exposure to toxic chemicals and heavy metals. This concatenation of exposures dramatically magnifies health risks for heart disease and diabetes, referred to as cardiometabolic disease, especially when combined with a lack of physical activity. Of all behaviours well known to mitigate the development of cardiometabolic disease, physical activity is by far the most effective deterrent. Not surprisingly, the cities of India are amidst an epidemic of historic proportions in these disorders.
Addressing the diverse and multi-scaled social, environmental, and infrastructure risk factors that contribute to cardiometabolic risk in cities, by transforming the design of the built local environment as well as provisioning systems, represents a new paradigm for public health. Globally, there are seven key physical provisioning systems that provide food, energy, mobility-transportation, housing, green infrastructure, water and waste management that lie at the core of human health, well-being, equity and sustainability. Dysfunctional provisioning systems consume more than 90% of the world’s water and global CO2 emissions and facilitate an estimated 19 million premature deaths annually. The socio-spatial-political design of urban provisioning systems in India, many of which are legacies of a colonial past, manifests in and exacerbates social inequalities in cities, by class, race, age, migrant and disability status, translating to vast disparities in health risks and outcomes. Based on the primal importance of India’s cities for its future, a new narrative for improving health and well-being in cities is needed. This is reflected in several high-level policy frameworks, such as the United Nations Sustainable Development Goals (SDG) framework, the New Urban Agenda, and the Health in All Policies approach.
Double or triple-duty actions
Investments such as clean energy and electric mobility which are underway in India offer a once in a lifetime opportunity to improve health through their immediate and dramatic impact of air pollution levels, while also helping meet India’s climate and equity goals. While these developments are extraordinarily important, the magnitude of their impact on health outcomes is at risk of being limited, if not simultaneously accompanied by changes in other provisioning systems such as food, mobility and green infrastructure.
Indeed, studies show that even small changes in the latter systems may have a large catalytic effect on health and productivity and serve as double-duty or triple duty interventions. For example, making way for safe walking and biking lanes, pavements and no-car zones, can help not only improve physical activity and reduce sedentary lifestyles but also reduce the risk from air pollution. Regular physical exercise has been to effectively mitigate the impact of other risk factors such as poor diets, particularly those rich in calories and saturated fats. The dietary ingestion of excess calories without adequate physical expenditure fuels a vicious cycle of insulin spikes, excess fat deposition that together with inflammation sets the stage for heart disease. In this regard, it is well known that exercise may not only help expend excess calories, promoting weight loss and reducing diabetes risk but also act as an effective bulwark against heart disease.
Walking and biking on many Indian roads is not only hazardous but also nearly impossible, as sidewalks are overwhelmed by building and human waste, parked vehicles or street hawkers. Health impact studies indicate that the health and economic benefits of increasing mobility and active transportation vastly exceed that which may be divined by transitioning to electrifying transportation alone.
Towards holistic urban policy
Studies that have modelled the economic and health impact of the clean energy transition in the transportation sector are currently based almost entirely on the reduction in air pollution and its associated health impact. Ensuring that the transition to electric cars also paves the way for active transport options such as walking paths and bicycling lanes may not only provide a mechanism to connect the “last mile” but the health and consequent economic benefits of active transportation accrue on top of the benefits of reducing air pollution, making such investments even more economically viable.
Thus, increasing active transportation by any means must be a critical component of a clean energy policy. Similarly, policies that encourage fresh fruits and vegetables and limit sugars and salt in beverages, which may have the largest impact on health outcomes such as obesity, Type 2 diabetes (T2D) and cardiovascular disease, may help contribute to not only better health outcomes but also economic productivity. Urban policies are powerful public health interventions that can serve to promote population health. Health is, unfortunately, an afterthought in most national urban planning policies and mostly non-existent in national urban policy documents from lower and middle-income countries.
Unhealthy diets, reduced physical activity and air pollution in cities in India pose a greater risk to morbidity and mortality than most other risk factors combined including drugs, tobacco, alcohol and accidents. These need to be dealt with on a war footing if India is going to make progress in its fight against cardiovascular disease, obesity and T2D. This will necessarily entail a street fight.
Dr. Sanjay Rajagopalan is Chief, Cardiovascular Medicine, Chief Academic and Scientific Officer, University Hospitals, Harrington Heart and Vascular Institute, Director, Case Cardiovascular Research Institute, Herman Hellerstein, MD, Professor of Cardiovascular Research, and Professor, Department of Medicine and Radiology, Case Western Reserve University
