My rickshaw driver weaved in and out of traffic with the skill and agility of Houdini, skirting high impact collisions by mere millimeters. What in the world was I doing in Bangladesh? I was there to represent the National Environmental Health Association and moderate ICMA’s USAID-funded CityLinks panel session at the 12th International Conference on Urban Health (ICUH) in Dhaka, May 24-27, 2015. In the midst of the inner city bedlam, I marveled that one thousand people a day move to Dhaka, a teeming metropolis of some 18 million, most who are seemly committed to being on the road all at the same time. One thousand people a day. That’s one city absorbing more people per day than the number who migrate to the entire state of Colorado, over the same time period.

The conference, by all appearances, was overwhelmingly attended by governmental and non-governmental health professionals from Southeast Asia and Africa. The educational program shed light on emerging issues related to the urbanization of the planet, whose citizens are migrating to cities at astonishing rates.  Today, over 50% of the global population is estimated to reside in cities, with those numbers projected to swell to 70% by the year 2050.  The Conference’s timing and content were ideal for those of us in the U.S. public health profession as 5% of the 2800 U.S. local health departments provide preventive services to 50% of the nation’s population. In other words, the U.S. is rapidly becoming a nation of big cities. At the same time, some 60,000 individuals have been removed from the public health workforce, a reduction from 220,000 in 2009, to around 160,000 in 2013. This depletion is partly as a result of the recession and shifting political priorities.  The opportunity to attend the conference and learn from ministries of health who have been engaged in big city issues in under-resourced agencies was fortuitous.

The use of mobile technology and applications in support of public health programming was a central feature of many of the ICUH sessions. A particularly memorable best practice was highlighted by a women’s initiative named “Maya apa”, operated by an NGO in Bangladesh. The app was created as a source of reliable gender-oriented information for girls and women ages 15-25.  Users of the app are able submit anonymous questions to health professionals via their cell-phone. The inquiries often relate to sexuality or of reproductive nature, a subject often taboo within the many cultures in Southeast Asia. Girls and young women can submit their health questions through the application, and receive an answer from a qualified professional within 48 hours. Ironically, boys and men have recently begun to use the service, which is largely staffed by professional volunteers. An application of this nature could potentially be very effective in urban environments in the U.S. as a resource in support of health literacy.

The aging of the global population is a universal phenomenon, a challenge in countries where historically people did not reach their full biological lifespan. As appoint of reference, in 2010 13% of the global population was over age 65, by 2050 the percentage increases to nearly 20%. The population pyramid will transform into the geometric shape of a rectangle in the near future. Age friendly cities will become increasingly desirable destinations to accommodate the changing demographics. The World Health Organization provides guidance on the characteristics of age-friendly cities, a useful resource for urban planners.

As climate change and weather patterns evolve over time, the dual goal of reduced greenhouse gases and livability of the built environment will necessarily be considered as two sides of the same sustainability coin. Buildings represent approximately 40% of global energy consumption as a function of cooking, heating, cooling, and ventilating features.  Building design and renovation are critical considerations as society moves into the future, which must take into account population health.  Adherence to “Well Building” standards is a central feature of the future for urban planners and architects.

Sanitation continues to be recalcitrant issue for much of the world. Considerable progress has been made in providing potable water to the world’s population. While additional progress is desperately needed for the 780 million people who don’t have access to clean water, attendees were surprised to learn that 2.5 billion people don’t have access to improved sanitary facilities. This is worrisome in that some 50% of the world’s malnutrition is related to diarrhea, and some 1 billion people live in illegal or informal settlements.  Menstruation management systems in urban areas is poorly understood and equally poorly managed in many of the world’s urban environments. What we do know is that the girl-child is disadvantaged when basic human biology is not accounted for in crowded city environments. This issue is further exacerbated by poverty, urban poverty in particular, which represents a blind spot for many in the public health professions, particularly environmental health.

Outcomes

NEHA’s attendance at the ICUH gave rise to several outcomes:

• The August-September Executive Director’s column in the peer-refereed NEHA Journal will be entirely dedicated to the practice of environmental health in big cities. The ICUH provided the foundation for the column.

• The next NEHA Annual Education Conference will be convened in San Antonio, Texas in June 2016.  Big City environmental health directors will lead an entire educational session, to be moderated by the NEHA Executive Director. The session will focus on the unique environmental health challenges associated with large urban areas.

• NEHA has been funded by CDC-NCEH to conduct a needs assessment of the governmental environmental health profession in the United States. The needs of big cities will be part of the 2015-2016 survey, which is intended to characterize the state of the profession.

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David Dyjack, Dr.PH, CIH is the Executive Director of National Environmental Health Association (NEHA), a 5,000 member professional association dedicated to the practice of environmental health. Eighty percent of NEHA’s members are employed in governmental public health or one of the seven uniformed services. The remaining 20% are employed in the private sector.