Book Review

Cities and the Health of the Public

N Engl J Med 2007; 356:972-973March 1, 2007

Article

Cities and the Health of the Public
Edited by Nicholas Freudenberg, Sandro Galea, and David Vlahov. 364 pp. Nashville, Vanderbilt University Press, 2006. $79.95 (cloth); $34.95 (paper). ISBN: 978-0-8265-1511-7 (cloth); 978-0-8265-1512-4 (paper).

The relationship between urban residence and health is highly complex, and it is becoming increasingly so: 80% of us who live in developed countries are located in cities, whereas in developing countries the crowding of people into cities — whether or not jobs and housing are available — has created a series of urgent humanitarian crises.

This difficult subject is addressed in this book, whose three editors provide the introductory and final chapters and the overarching theoretical framework. They are academic researchers in public health — Nicholas Freudenberg, the leading and senior editor, Sandro Galea, a physician and epidemiologist, and David Vlahov, an infectious disease epidemiologist — and they have solicited chapters from 21 other scholars with similar backgrounds.

Defining a city is not easy. The editors consider several formulations and propose a conceptual framework based on the global trends and local determinants that result in public health activities, which in turn lead to outcomes that are strongly influenced by urban living conditions. The formulation to which they return most frequently is that urban living conditions — the daily life experiences of people living in cities — are “the primary, proximate, and most remediable determinant of health of urban populations.” Physicians may have difficulty with this definition, since it does not mention modern evidence-based medicine, specific preventive measures and treatments, or the therapeutic efforts of an army of health care providers, misguided though we have often been in the past. My favorite definition of a city is captured in the title of a 1968 essay by Richard Meier that was published in the journal Daedalus in 1968: “The Metropolis as a Transaction-Maximizing System.” It makes you think.

In the interest of full disclosure, I acknowledge a personal stake in this subject, since it absorbed my attention 30 years ago (Urban Health in America. New York: Oxford University Press, 1976). From that perspective, this book has much new information to offer, some enlightening chapters, and impressive bibliographies at the end of each chapter. But the gap between social science and medicine, which the editors recognize — and deplore — seems to be as great as it was a quarter-century ago. The social science vocabulary is often different from medical language (with “trends” and “determinants” taking the place of “risk factors” and “evidence-based practice”), contributing to a sense of strangeness when these perspectives, which should be complementary, at times seem almost alien.

A couple of the chapters in the book have particular relevance to medicine. One is chapter 4, “The Urban Physical Environment and Its Effects on Health,” written by two social scientists and a physician who have both medical and social science degrees. These contributors offer refreshingly concrete data about the improvement in mortality achieved in New York City since 1800. They attribute this public health success to specific interventions in sanitation, housing, land use, and regulation of water and air quality, but they caution that much remains to be done. Likewise, chapter 8, “Cities, Suburbs, and Urban Sprawl: Their Impact on Health,” written by another contributor who has both medical and public health credentials, documents the problems introduced by the automobile, which has led to the suburbanization of most American cities, urban sprawl, loss of farmland, and many other health-related physical and social changes.

In brief, this is a book that will be of interest to social scientists but also worth consulting for physicians with practices that involve urban health. The distance between the social sciences and medicine can also be recognized in medicine and medical education. The creation of separate schools of public health at the beginning of the 20th century gave a valuable boost to the discovery of the specific causes of several important diseases, as well as to their prevention and treatment. However, it also contributed to the reduced emphasis on public health in the curricula of most medical schools and in the awareness of most practicing physicians.

Amasa B. Ford, M.D.
Case Western Reserve University, Cleveland, OH 44106