Tolu Oni, Estelle V. Lambert, and Kent Buse
The COVID-19 pandemic has precipitated a global humanitarian crisis, the nature of which has brought health and economic disparities sharply into focus and opened a wide-ranging human rights dialogue. This includes tensions between individual and collective rights to health (quarantine, movement restrictions, and shelter-in-place laws); the balance between the right to health and the right to education (with school closures) or to earn a living wage; and maintaining access to healthcare for non-COVID conditions.
These fundamental rights are enshrined in the International Covenant on Economic, Social and Cultural Rights with the Siracusa principles providing guidance on balancing these tensions. However, in 2000, General Comment 14 clarified that the right to health extended beyond access to health care to incorporate the underlying social determinants that enable people to “lead a healthy life”. This includes the right to a healthy environment to support healthy eating and active living. While the right to healthy food security is well-recognised and vital, this blog focuses on the notion of physical activity security which should be viewed as working in synergy with the right to healthy foods.
In 2018, the World Health Organization (WHO) published Global Action Plan on Physical Activity (GAPPA). The Plan’s purpose was “to ensure that all people have access to safe and enabling environments and to diverse opportunities to be physically active in their daily lives, as a means of improving individual and community health and contributing to the social, cultural and economic development of all nations.” However, access to such environments are beyond the reach of a growing proportion of urban residents globally, and are exacerbated by rapid urbanisation, for example in Asia and Africa. In response, the term physical activity insecurity has been coined, positioning physical activity as a rights-based issue. Further, there is a need for intersectoral policies that promote the co-benefits of physical activity beyond health and Sustainable Development Goal (SDG) 3, to, amongst others, sustainable inclusive cities (SDG 11) and climate action (SDG 13).
The COVID-19 pandemic has shed light on the pre-existing spatial inequalities in cities. For example, in high density cities such as Lagos where low-income communities reclaimed public spaces such as large public roads, rendered safe due to road closures during lockdowns, for group exercise. Despite a clear need, there is limited availability of guidelines to encourage physical activity in the context of COVID-19 responses. The WHO strategic preparedness and response plan missed the opportunity to incorporate a health foresight approach to set out guidelines to protect access to healthy environments, including physical activity and food. Their plan therefore failed to mitigate the unintended consequences of violations of this right.
Uniting diverse actors on the path to recovery
As societies set a path to recovery, the challenge is to harness and sustain the often-impromptu initiatives that emerged during the pandemic. As outlined here diverse actors have a role to play.
Scientists: While the need for actionable science during a crisis is clear, less appreciated is the need for strategic science advice on how built environments can be disrupted during the crisis. Scientists can generate evidence to prevent negative impacts on physical activity and to build population health resilience. One example is the guidelines for physical activity during and beyond the COVID-19 pandemic developed by a global academic consortium under the umbrella of the African Physical Activity Network. Its implementation framework adopts an intersectional lens, considering accessibility and availability dimensions of access for different population groups. In the midst of a crisis, scientists can and should play a pivotal role in providing evidence and monitoring the health impact of pandemic-related actions. This serves as an important accountability function in protecting and improving the right to healthy environments for all. These functions require scientists to work in full partnership with affected communities.
Communities and civil society: In many cities, civil society organisations are playing a leading role in holding the government accountable, pushing for a people-centered approach to use of public space. For example, the Open Streets movements, founded in Bogota but since replicated in cities across Latin America, Africa and North America have pushed for car free days that create temporary safe spaces for physical activity. Post-pandemic, sustained efforts by these civil society organisations will be necessary to increase and sustain the demand for healthy environments as a right. In particular, it will be crucial that the voices of youth are privileged, championed and amplified as agents of positive societal change.
Governments: An agenda for green and just recovery post-COVID-19 was developed by C40 and signed by over 40 mayors globally. Their agenda adopts a right-based approach to achieve equitable access to safe, healthy public spaces. This joined-up approach to the right to health highlights the need for significant reform of governance for health, identifying opportunities to adopt a syndemic approach to protecting health while addressing and mitigating climate change impacts. For example, a right-based approach to non-motorised transport policies would ensure equitable access to walkable built environments and clean air. The recent finding of the contribution of air pollution to mortality in under 5-year-olds and those with co-morbidities in Lagos reinforces the importance of healthy environments and its synergies with planetary health and climate change mitigation. Importantly, governments should simultaneously provide the space and resources for civil society to engage with new development initiatives, as well as making healthy environment impact assessments compulsory on these initiatives as part of their tendering process.
Private sector and multilateral development finance institutions: As urban infrastructure and urban development projects are often driven by the private sector, it is vital that these actors (in urban development, construction, and finance) recognise a healthy environment as a cross cutting priority. The commercial determinants of health have been well described in the context of the food system and harmful products, and this should be extended to environments conducive for physical activity; in essence increasing or hindering health and well-being. Accordingly, these actors should prioritise the inclusion of health impact assessments of their initiatives. Beyond avoiding harm, changes to the environment should adopt a systems approach to consider unintended consequences on health and to promote positive health outcomes. Multilateral development finance institutions could champion such initiatives. For example, the Africa Development Institute of the Africa Development Bank’s policy matrix for inclusive health included a call for a Marshall plan for planetary health in cities. Such a plan would align investments in urban infrastructure and development with health and sustainability. Investments and loans for urban infrastructure projects should have explicit accountability mechanisms in place to protect the right to healthy environments.
Multilateral organisations: Institutions such as WHO play an important role in setting and shifting norms around health. For example, the WHO manifesto for health recovery post-COVID-19 promotes green recovery including the need to build healthy liveable cities. Unrelated to the pandemic, the resources to integrate health into urban and territorial planning has been jointly published by WHO and UN Habitat. Multilateral organisations must champion the right to healthy environments, and have strategies to protect this right as part of emergency preparedness, planning, and response and not just as part of recovery.
The initiatives that have emerged in response to COVID-19 highlight the need for foundational institutional disruptions and intersectoral initiatives. The gender gap in physical activity and the impact of gender norms on access to physical activity must also be recognized so that all genders have access to safe and inclusive environments.
Adopting a rights-based approach, the recently launched Call to Action for Reclaiming Comprehensive Public Health highlights the importance of co-creation and collaboration across sectors, disciplines, and borders. The different stakeholders identified in this blog have the opportunity to merge their expertise, perspectives, and resources to develop tailored approaches to ensure the right to healthy environments is a central tenet of emergency response and recovery.
Tolu Oni, MRC Epidemiology unit, University of Cambridge, UK and Research Initiative for Cities Health and Equity (RICHE), School of Public Health and Family Medicine, University of Cape Town, South Africa
Estelle V. Lambert, Health through Physical Activity Lifestyle and Sport Research Centre (HPALS), Department of Human Biology, University of Cape Town, South Africa
Kent Buse, Professor, Global Healthier Societies Program, The George Institute for Global Health, University of New South Wales, Sydney