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Future-proofing health and health-proofing the future of cities

Tolullah ‘Tolu’ Oni is an urban epidemiologist at the Medical Research Council Epidemiology Unit at the University of Cambridge and a Next Einstein Forum Fellow and World Economic Forum Young Global Leader.

I was working in public primary care human immunodeficiency virus (HIV)and tuberculosis clinics in Khayelitsha, one of the largest urban informal settlements in South Africa. An important component of this clinical research was providing care to people living with HIV who presented for primary healthcare. Over this time, I was struck by what was almost a type of role play run on a daily basis between healthcare workers and patients. The script runs as follows: doctor, “your blood pressure is poorly controlled and you need to eat better”; patient, nodding agreeably, “I promise to do better.”

Credit: Tolu Oni

The advice I would give my patients in that clinic essentially took no notice of the availability of the food for the regimen I was prescribing. I didn’t account for the fact that, in this area of the city, to exercise more could lead to risking life and limb. There was a shared understanding that the environment beyond the walls of the clinic is to be ignored.

As if people were solely patients. This was the moment I turned from thinking about disease to thinking about health.

Imagine for a moment a town that has a problem with fires, which is worsening. The fire department would quickly fail to deal with the daily onslaught. Over time, the townspeople would learn more effective ways of fighting fire, build more fire stations with faster fire engines, train more firefighters. All hands on deck, they would cry! They would then improve, learn to re-build, detect new fires, build better fire escape routes....

But through all these laudable and necessary efforts, one should be thinking: “why do we have all these fires?”

That is what was happening, back in 2007, in that clinic in Khayelitsha. After this work, I established the Research Initiative for Cities Health and Equity, an urban health research group at the School of Public Health and Family medicine at the University of Cape Town.

This was a marked pivot from my previous research focus on tuberculosis/HIV epidemiology at the Institute of Infectious Diseases and Molecular Medicine at the University of Cape Town. The Research Initiative for Cities Health and Equity focused on the exposures in the urban environment that could do better at supporting health creation.

I now focus my research towards better understanding of how urban exposures contribute to health and how to better co-design, with diverse stakeholders, interventions in the environment to create health and enable healthy choices.

My interest in the prevention of non-communicable diseases is driven by a desire to confront the complexity of improving health in the future. Can we inoculate ourselves with the very cities that are negatively impacting our health, consciously designing them to create health for the entire population in the long term?

There is undoubtedly a tension between research to address the problems of today—which are plentiful—and research to protect the health of tomorrow. The latter is more abstract and requires a very different approach to research—exposures and outcomes are seemingly disconnected in time and space. I continue to learn new methods to push the boundaries of how research is conducted, to be simultaneously timely and slow.

Along the way, I worked to develop partnerships across sectors and disciplines and with non-academic partners in the co-design and co-production of new knowledge. I have learned the importance of writing—to help set the research agenda and raise awareness of this approach. And because health does not merely trickle down, I recognize the need to leverage collaborations to aspire, inspire and conspire, taking deliberate steps to align the vision, strategy and interventions in cities towards creation of health.

In late 2019, I was in residence as an Iso Lomso fellow at the Stellenbosch Institute for Advanced Study, where I convened government, private sector, non-governmental organization and multilateral organization representatives from eight cities for a Healthy Cities in Africa workshop. As part of this residency, the founding director of the institute, Bernard Lategan, addressed the fellows.

The words he used to explain the rationale for the establishment of the Stellenbosch Institute resonated with me: “If we focus on what is, we are condemned to repeating what was. But if we focus on what is possible, we stand a chance of transcending what is.”

I remain driven by the potential for urban development in rapidly growing cities to create equitable opportunities to embrace choices that protect the health of people and the planet in the long term. This healthy city future is possible and necessary in Africa’s rapidly urbanizing spaces and places. Once my research plays some role in transcending what is, towards health-proofing the future of cities, I’ll be content to retire.

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Correspondence to Tolullah Oni.

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Oni, T. Future-proofing health and health-proofing the future of cities. Nat Med 26, 304 (2020).

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