By Graziella Machado
Healthy cities require healthy individuals and safe environments, from conception to old age. This premise is becoming increasingly challenging nowadays since more than half of the world population lives in urban areas. There is an expectation that this number will grow to around two-thirds in 2050.
Socio-economic and environmental conditions, as well as human behavior, affect the spread and impact of infectious diseases. Historically, the population’s expansion, grouping, and living conditions in towns, villages, and cities were known factors that allowed the emergence of epidemics among humans. The increased interaction between individuals from different places facilitated the proliferation of vectors and pathogen reservoirs in the urban context, explaining how urbanization affects the spread of infectious diseases.
Although markets that sell wild animal products are mainly involved in a higher risk of developing zoonoses – an infectious disease that moves from non-human animals to humans -, urbanization also has critical importance for the risk of zoonoses by the destruction of natural habitats and increased proximity between humans and wild animals. In addition, urbanization usually decreases forest cover and may increase the risk of infectious diseases – Amazon rainforest, for example, is crucial for maintaining planetary health due to its pivotal role in regulating the Earth’s climate and its relevance as an ecosystem for the dynamics and control of zoonotic diseases and vector-borne infections.
Population dynamics, poor socio-economic and environmental conditions, on one hand, and anthropogenic action degrading ecosystems, biodiversity, climate, on the other, can give rise to the “perfect storm” for the emergence and spread of human infectious diseases in Brazil and other Amazonian countries. For example, deforestation and urbanization were associated with higher rates of Zika virus infection and Zika-linked microcephaly cases in Brazil.
Thus, urbanization represents a paradox about infectious diseases. On the one hand, urban environments contribute to the spread of diseases due to population density. On the other, urban areas provide better access to health services, which is a factor mitigating for the problems caused by such diseases. Urban contexts, especially in low-income countries, the social and economic environment, including access to economic and educational opportunities, safety and security, and gender equality, are critical determinants of health of city dwellers – factors that determine access to quality health care and, consequently, contribute to ill-health including the emergence of infectious diseases.
The coronavirus is no exception since pandemics originating from zoonoses result from human interference in the environment. In their yearning to reproduce, consume and expand, humanity invades nature – and contributes to phenomena such as Spillover (or “overflow”). The ecological term describes that a microorganism has managed to adapt and migrate from one species to another introducing a new pathogen to the organism, as occurred with the infectious agent that causes COVID-19. An analysis showed that mammalian hosts of emerging infectious diseases were approximately 15 times more likely to use human-modified environments than other competing mammal species, either because of a greater propensity to serve as reservoirs of pathogens or because of increased rates of contact with people.
The World Cities Report 2020 states that “well-planned, managed and financed cities and towns create economic, social, environmental and other non-quantifiable values, which can greatly improve everyone’s quality of life”. In that regard, the pandemic drew the world’s attention to the urgent need to prioritize sustainable urban planning and the development of our cities, given that they are at the epicenter of the COVID-19 pandemic, with 95% of cases found in urban areas, especially in unplanned and informal settlements.
Undeniably, urbanization policies have an increasingly relevant value in the current debate on urgent global challenges, from an economic, social and environmental perspective. For example, efficient traffic policies can contribute to the reduction of carbon emissions, improve health and indirectly contribute to socio-economic opportunities (such as affordable housing) for communities, especially those of low income, marginalized, and others, when local governments increase revenue to regulate land use, planning urban growth, limiting urban sprawl and alleviating overcrowded housing.
Reproductive health and urbanization: links between population dynamics and zoonotic diseases
Besides urbanization, fertility and migration are factors that affect the spread of disease. Increasing population size, density, and unhealthy living conditions can facilitate the transmission of infections. For example, individuals who live very close to each other in the peripheries of large urban centers are at greater risk of contagion. Moreover, these individuals are more exposed to environments that are highly vulnerable to infectious diseases due to poor sanitation and high levels of poverty.
In this regard, urban environments are particularly challenging when we think about reproductive health. This is because places with the highest population density, such as urban slums, are often neglected. Poor sanitation services and the abandonment of these urban areas by the government are concerning realities of the Global South. In addition, when considering the linkages between urbanization, severe environmental degradation and high fertility, the missing link is the socio-economic factor called poverty.
Beside of other influencing factors, high rates of population density reflect an inadequate reproductive planning program in terms of availability, affordability and accessibility, especially when it comes to contraceptive services to avoid unplanned pregnancies – not planned by the couple or by the woman in terms of timing spacing of children or choice of family size. Challenges related to availability, accessibility, and acceptability of a broader range of contraceptive methods constitute the main reasons for the unmet need of family planning, related unwanted pregnancies, and ill-health for the mother and the children. As a result, more than 200 million women and girls experience an unmet need for contraception, meaning they lack access to modern contraceptive services or even information on preventing or postponing pregnancy. As a result, 76 million unplanned pregnancies and 40 million abortions, half of them illegal and unsafe, occur each year worldwide,
It is imperative to make reproductive services an integral part of universal health coverage and more accessible in low resource settings. In developing countries, this progress is even more uneven because funding continues scarce and existing programs and services fail to meet the concerns and needs of their users. The poorest women and/or couples have the highest fertility, the lowest contraceptive use and the highest unmet need for contraception, contributing to an increased number of unplanned pregnancies, especially among girls and adolescents without access to adequate information and effective contraceptive services.
Evidence that has accumulated over several decades shows that women have between 5% and 35% fewer children and space their pregnancies further apart when reproductive planning programs are in place. High-quality reproductive planning services provided to the population with adequate access and availability of contraception could lead to sustainable development.
The universal access to reproductive and sexual health and rights can represent an important entry point to reach most of the Sustainable Development Goals – health (promoting well-being for all involved, especially for the mother-baby binomial when reduces the risks of maternal and newborn deaths), education prospects and human capital among adolescent girls (preventing the teenage pregnancies, enabling that girls to stay in school and could also improve access to food and reduce hunger by decreasing the dependency ratio).
The access to modern contraception can also spur the economy (facilitating access to better opportunities in the labor market and generating economic empowerment), protect the environment and contribute to overall poverty reduction. Studies show that socio-economic conditions influence the risk of contracting COVID-19, just as they affect nearly all other health indicators. So, improving access to reproductive health services also increases families’ general resilience and preventive measures to pandemic dynamics.
In this way, the solutions and investments that promote keeping girls in school deserve to be highlighted because data consistently demonstrate that educating girls has a significant impact on reproductive behavior, including contraceptive use, improving gender equity and empowering girls to engage in decision-making that affects their families and the development of their communities.
Other resources involve applying new technologies that offer opportunities to fill the gaps in the provision of reproductive health services, elucidating and solving the assistance failures found by the current model of reproductive planning in the world. Among the developed approaches, is Digital Health – that is, the use of information and communication technology resources to produce and make available reliable information about the state of health. Examples of digital solutions in reproductive planning are the use of devices to improve the collection and monitoring of routine data, such as applications, digital experience tools, social networking applications, Internet of Things, and Artificial Intelligence.
Thus, Digital Health solutions can contribute to improving professional workflows, help to identify areas where reproductive planning services can be optimized, adequately advise patients on available contraceptive methods and contribute to informed choices in reproductive health, which increase compliance and effectiveness of the methods. Concerning health information technology, the studies present the most diverse tools – blog as a visual aid, models of e-Learning platforms, clinical use applications for data collection, spatial analysis applications, interactive voice calls, data algorithms decision aid, telemedicine, and telehealth, among others.
Clearly, including reproductive health into urban planning could be a relevant contribution to achieving the goals of sustainable development and urbanization, as meeting this demand in reproductive planning can slow population growth, thus reduce demographic pressure on the population and the environment, improve health and socio-economic status and consequently contributing to the prevention of zoonotic diseases. In critical pandemic times, holistic solutions that reduce the immediate risk of new similar occurrences and reduce poverty, environmental degradation, and pressure on natural resources are to allow the synergy of actions so essential to achieving planetary health.
About the author: Graziella Machado is an Italian-Brazilian physician and biologist, a master’s researcher at the Federal University of Health Sciences of Porto Alegre (UFCSPA) with a focus on Public Health, Digital Health, and access to equitable health for Sustainable Development, with a focus on Reproductive Health and Reproductive and Sexual Rights. She recently became a Planetary Health Ambassador at the University of São Paulo/Brazil and a member of the Brazilian Planetary Health Club, with education and women leadership projects in planetary health at an undergraduate level.