1. FREDERICK M. BURKLE, JR., MD, MPH, DTM, FAAP, FACEP PROFESSOR & WOODROW WILSON SENIOR PUBLIC POLICY INTERNATIONAL SCHOLAR SENIOR FELLOW & SCIENTIST PUBLIC HEALTH, URBANIZATION, AND CLIMATE CHANGE: The Common Thread of Public Health Emergencies ~

2. Harvard Humanitarian Initiative “ Disasters that adversely impact the public health system and its protective infrastructure related to water, sanitation, shelter, food, health, & energy”* § …Protective threshold is destroyed, overwhelmed, not recovered or maintained, or denied to a population… § Primarily measured as “indirect & preventable” morbidity & mortality PUBLIC HEALTH EMERGENCIES * Burkle, 2008, Institute of Medicine

3. Harvard Humanitarian Initiative 21 st CENTURY: State of Public Health Infrastructure Globally, public health infrastructure and systems have disappeared, declined, or failed to keep pace with demands. Deficient dwellings; aged infrastructure Unavailable infrastructure & capacity to respond in crises/disasters: especially potable water, food, & sanitation Ecological & environmental changes

4. UNITED NATIONS INITIALLY PROJECTED THAT HALF OF THE WORLD’S POPULATION WOULD LIVE IN URBAN AREAS BY 2015-17

5. URBAN POPULATION DOMINANCE OCCURRED IN 2008

6. Harvard Humanitarian Initiative RAPID URBANIZATION Public health physical and social protections fall below threshold levels resulting in a public health emergency status Determinants: population, population density, capacity of public health infrastructure & system Most evident in megacities of least urbanized continents of Asia and Africa

7. Harvard Humanitarian Initiative RAPID URBANIZATION Urbanization rates vary greatly across the world USA & United Kingdom have far higher urbanization rates than China or India But have far slower annual urbanization rates since much less of population is living in rural areas Rapid urbanization is unsustainable Rapid urbanization is unsustainable

8. Harvard Humanitarian Initiative URBANIZATION THRESHOLD Urban role in economic wealth creation for the country depends on continuous production of ecological goods & services from somewhere else An extensive external resource base of goods & services must be available & grow if urbanization grows While this was possible at one time, the resource base sustaining the human population is now in steady decline

9. Cities over 10 Million; density, not population, is most sensitive indicator (e.g., Port-au-Prince, Haiti) > Density based on minimum of 2,000 people/sqKm > Mumbai:30,000/sqKm Unplanned urbanization in which public health infrastructure & system installed after urbanization Primary forces leading to public health emergency: > Land cover conversion > Urban topography devoid of forests/parks > Pollution MEGACITIES

10. Harvard Humanitarian Initiative POPULATION EXPOSED TO CONFLICT RM Garfield, J Polansky, FM Burkle, Jr LESS DECLARED WARS…BUT MORE PEOPLE EXPOSED TO CONFLICT THAN EVER BEFORE

11. Harvard Humanitarian Initiative 2000s I. Currently, many populations fleeing from sustained levels of “conflict intensity”in failing post-conflict countries internally displaced populations (IDPs) II. Increasing numbers of internally displaced populations (IDPs) migrating because of severe climate-related changes Current patterns of IDP migration are regional rather than international Current patterns of IDP migration are regional rather than international

12. CHANGE IN MIGRATION TRENDS FROM REFUGEES TO INTERNALLY DISPLACED POPULATIONS (IDPs) Spiegel, et al, LANCET, 2010

13. INTERNALLY DISPLACED MOVE TO URBAN AREAS IN LEAST DEVELOPED COUNTRIES Spiegel, et al, LANCET, 2010

14. CONTRADICTIONS of GLOBALIZATION 6% of population are urban 6% of population are urban squatters in Developed countries squatters in Developed countries 78% of population are urban 78% of population are urban squatters in the Developing world squatters in the Developing world “Urban Diseminities” range from 35% to 93% “Urban Diseminities” range from 35% to 93%

15. Harvard Humanitarian Initiative GLOBALIZATION & URBANIZATION* ‘have & have not’Increasing health inequities & widening gap between ‘have & have not’ populations invisible”Produced an “invisible” population: population demographics and access to health are relatively unknown major security issue”“Health for many has become a major security issue” *Schneider: Global PH & Int Relations, Aus J of International Affairs, 2008 **Burkle: Globalization & Disasters: PH, State Capacity & Political Action J. of International Affairs, 2006

16. Harvard Humanitarian Initiative WORSENING HEALTH INDICATORS

17. Harvard Humanitarian Initiative URBAN SLUMS Highest Worldwide Under age 5 Mortality Rates (U5MR) & Infant Mortality Rates (IMR) Urban shanty towns: > 900 M vulnerable to cyclones, flooding, & > 900 M vulnerable to cyclones, flooding, & earthquakes earthquakes > Growing at 25M/year: in disaster prone areas > Growing at 25M/year: in disaster prone areas > Mumbai: 1600 new families/day > Mumbai: 1600 new families/day Sanitation ignored; infectious diseases more prevalentSanitation ignored; infectious diseases more prevalent *

18. URBAN HEATLH WORKFORCE CRISIS

19. Harvard Humanitarian Initiative EMERGENCIES OF SCARCITY: WHAT WILL MATTER IN 2015-20? ENERGYENERGY WATERWATER “distributional conflicts” & “land grabbing” already occurring by import dependent countries Intense “distributional conflicts” & “land grabbing” already occurring by import dependent countries FOOD

20. Harvard Humanitarian Initiative PUBLIC HEALTH REDEFINED rural to urban areasHumanitarian assistance has moved from rural to urban areas NOT urbanHumanitarian community is NOT prepared to protect the urban public health infrastructure…or system Not prepared to handle “emergencies of scarcity”

21. Harvard Humanitarian Initiative REDEFINING PUBLIC HEALTH Disasters keep governments honest by defining the public health & exposing its vulnerabilities (Burkle, 1973) Global Health: Scarcity (climate change impacts, energy, water, food) now defines the public health of many countries Current Public Health Solutions:  Reduction in growth rates (empowering women)  Ensuring social protections  Decrease carbon emissions adapt  Populations called upon to identify vulnerabilities…learn how to reduce them ( adapt )…redefine resilience  If doesn’t work: Must have strong migration policies in place

22. Harvard Humanitarian Initiative GLOBAL PUBLIC HEALTH RESEARCH REDEFINED inter-disciplinary, inter-sectoral, inter-ministerialMust be integrative: inter-disciplinary, inter-sectoral, inter-ministerial integrative researchDo not leave Global Health research to policy makers & practitioners who are poorly prepared to interpret strengths & weaknesses of integrative research Global health is a ‘composite field’ Maclachlan, Globalization & Health 2009

23. Harvard Humanitarian Initiative CONCLUSIONS “Public health emergencies must be seen as the common thread of many inter-related climate & urbanization crises” (Burkle, 2004) Do not assume that non-health decision makers (e.g., engineers, urban planners) understand the impact of urbanization on health strategic & securityPublic health must be seen as a strategic & security issue…that deserves an international monitoring system (G20 Global Impact & Vulnerability Act) (Burkle, 1973)

24. THANK YOU!!