Dr Geoff Bates is a Research Associate in the Institute for Policy Research at the University of Bath.
Many facets of the urban environment affect our health, such as the quality and density of housing, access to services and commodities, and access to green space. All have been highlighted by evidence emerging from those researching the impact of and risks related to COVID-19. The pandemic has escalated the existing inequalities in our urban environments and those who are most vulnerable to poor health have been often worst affected. It has emphasised the need to reduce health inequalities in our towns and cities, and to tackle factors that make us vulnerable not only to infectious disease outbreaks, but non-communicable diseases associated with poor quality urban environments.
No aspect of the urban environment has been more discussed in this context than air quality, which has long been discussed as a problem to address by policymakers. Evidence from studies in the UK and internationally suggests that exposure to air pollution is an independent risk factor for COVID-19 infection, hospitalisation and death. On the other side of the coin, the lockdown measures in response to the crisis led to prolonged reductions in transport use, and subsequent improvements in urban air quality have been recorded. While not sustainable, this window of enforced changes to our behaviour has inadvertently provided evidence on the impact of reduced car activity on urban areas.
Commentators have expressed hopes that such evidence might lead to meaningful policy change with the aim of improving the quality of urban areas and bringing about health and social benefits for those who live and work in them. Infectious disease is likely to be a dominant narrative impacting on many policy areas as countries internationally seek to learn from the pandemic and future proof against such outbreaks. Importantly, outbreaks of this nature and the significant negative outcomes they bring are to a certain extent preventable if policies can address the underlying factors that make us vulnerable.
History tells us that health crises can indeed be a spark to inspire significant long-term changes in policy and society. Pandemics of the past have started society down the path towards social, health and economic changes. The Black Death terrified and devastated 13th Century England but led to the introduction of a series of policies that ended serfdom and introduced waged labour (although this was not necessarily an improvement for the workers of the day). More recently, the 1918 Spanish Flu outbreak led to increased attention on public health surveillance and population health, and has been linked to the ideas that led to the eventual formation of the NHS and provision of free health care at point of delivery for all.
We know that health crises can lead to great improvements in urban environments. Cholera outbreaks and concerns about sanitation in 19th Century London led initially to the first Public Health Act in 1848 and later Joseph Bazalgette’s designs to develop London’s sewer systems. This improved the quality of the city’s environment considerably (the so called ‘Great Stink’ of 1858 was the result of the Thames becoming so filled with waste that in summer it’s stench infected large amounts of the capital) and helped eliminate cholera from the city. On a national level, concerns for the health of the new Victorian inner-city populations amongst the smog, fumes and high-density housing of newly industrialised cities contributed to the development of the first public parks with all the physical and mental health benefits we know that they bring.
There is however no guarantee of lasting positive change following crises events. Often referred to as ‘critical junctures’, such moments in time provide windows of opportunity for policymakers to drive changes in what may be long-established policies, but can also merely lead to a continuation of the status quo. While researchers are generating evidence that supports the case for those calling for measures to improve air quality, this evidence alone may be insufficient to drive change. We have after all known for a long time that exposure to air pollution leads to poor health outcomes. Car use is increasing again as commuters return to work and travel restrictions are lifted, habits are likely to become re-established and there is a danger that attention could shift.
Many other narratives beyond the need to improve urban air quality are developing in the context of COVID-19 and may compete for attention, such as the role of Public Health England and the centralised nature of England’s public health system; the value of the NHS and attitudes towards privatisation of health services; and the case for establishing a universal basic income. It is unlikely they will all develop into meaningful policy changes, which would require sustained political will and motivation.
However, one ‘advantage’ that those seeking to influence policy change in this area have is that air pollution has long been a theme in urban policy and is already a well-established concern. Utilising new evidence on the impacts of urban air quality on COVID-19 outcomes can build on existing support for action to mitigate the impacts of climate change and create better environments.
Public support is likely to be very important to drive change. The Faculty of Public Health recommend raising public awareness about air pollution to increase the pressure on policymakers as the most effective way to improve air quality. Those seeking to influence policy can develop powerful narratives around the potential to future proof against both the impacts of infectious disease and the coming climate crisis by improving urban air quality.
Narratives based on the anticipated climate crisis and improving the health of those who live and work in our urban areas have gained some public support, but health is rarely embedded in policies acting on our urban environments. Perhaps mitigating the impacts of future infectious disease pandemics at this time will be a more influential narrative to drive urban policies that protect and improve health, such as those aiming to improve air quality in the coming years.
All articles posted on this blog give the views of the author(s), and not the position of the IPR, nor of the University of Bath.