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Asari 2

Medelln,Colombia:
UrbanPlanningasPublicHealthIntervention
MarisaAsari
PH160/ESPMC167
Section104LilaRubenstein
5/11/15

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Abstract
ThecityofMedelln,Colombiaexemplifiesthedisproportionatenegativehealth
impactsofurbanizationoninformalsettlements,andprovidesacasestudyfortheexamination
ofurbanplanningasaformofpublichealthintervention.Rapidpopulationinfluxand
inequitableurbanexpansioninMedellnhaveresultedinagrowinghealthgapbetweenthe
urbanpoorandurbanmiddleclass.Inthepast50years,thegrowthofsociallyandphysically
isolatedinformalsettlementsexacerbatedexistingsocialstratificationslinkedtohealth
disparities.Inequitiesleadtopoorerhealthoutcomesinviolentandpovertystricken
communities,andcontributetoadoubleburdenofrisingchronicandinfectiousdisease.Since
1990,Medellnhasmadeeffortstoaddresstheissuesofextremepovertyandcrimethrougha
seriesofmunicipalurbanplanningprogramsthatinvestintheupgradingandrevitalizationof
affecteddistrictsorcomunas.Thispolicybriefseekstoexpandtherelevanceofurban
developmentinMedellnsinformalsettlementsbyexploringitstheoreticalandpracticalimpact
onthesocialdeterminantsofhealth.PartAexplorestheuseofintentionalurbaninfrastructure
andincreasedsocialcohesioninMedellnasformofpublichealthintervention.PartBargues
forthealignmentofpublichealthandurbanplanninginthedevelopmentofequitable,area
specific,andcomprehensiveresponsetogrowinghealthinequitiesinurbanpopulations.

PARTA:TheCaseStudyofMedelln,Colombia
Introduction

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Onceknownasthemurdercapitaloftheworld,Medellnisinfamousforitshistoryof
violence,corruption,andagrowinggapbetweenthepoorandrich.Thesecondlargestcityin
Colombia,Medellnisamajorcenterofurbanization,experiencinganincreaseinpopulation
fromapproximately300,000to2.5millionsince1950(MedellnComoVamos,2015).Asthe
cityrapidlyexpands,unequaldistributionofresourcesandlimitedsocialmobilitypushesurban
settlerstowardstheoutskirtsofthecity,intoviolent,impoverished,andisolated
neighborhoods.The
marginalizationoflow
socioeconomicstatus(SES)groups
intounderdevelopedand
overpopulatedareasfurther
deepensthedividebetweenthe
lowestandhighestsocioeconomic
classes,leadingtohighlevelsof
socialdiscontinuity.
Medellnisdividedinto6zonesflankingeastandwestoftheRiverMedelln,which
flowssouthtonorththroughthecenterofthecity.The6zonesarepartitionedintoatotalof16
smallercomunas,andtheruralmostareasofthecityaredividedinto5corregimientos.The
furthesteasternandwesterncomunascontainlargeinformalsettlementcommunitiesand
populationswithsignificantlylowerSESthanthoseincentralareas.Notoriousforviolence
andconcentratedpoverty,theoutermostcomunas,namelynortheasternComunas1and2along
withwestcentralComuna13,poseaparticularconcernforcityplannersandpolicymakers.

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SocialDeterminantsofHealth
TheWorldHealthOrganizationdefineshealthasastateofcompletephysical,mental
andsocialwellbeingandnotmerelytheabsenceofdiseaseorinfirmity(WHOConstitution)
and,theextenttowhichanindividualoragroupisabletorealizeaspirationsandsatisfy
needs,andtochangeorcopewiththeenvironment(HealthPromotion:ADiscussion
Document,Copenhagen:WHO,1984).Determinantsofhealthcannolongerbelimitedto
genesordirectaccesstohealthcare,andareincreasinglylinkedtosocialandenvironmental
factors.Presentdayindicatorsofhealtharebetterdescribedbyanindividualsgeographical
locationthangeneticcode.Correlationbetweenplaceandwellbeingraisestheadditional
question,whatisitaboutcertainregionsthatcausespoorhealth?
UnderstandinghealthconcernsposedbyinformalsettlementsinMedellniscriticalto
viewingurbanplanningasarelevantpublichealthstrategy.LowSESpopulationsininformal
settlementsfacegreaterriskofbothinfectiousandchronicdisease.Highlevelsofsocial
isolation,toxicstress,lossofprotectivehealthfactors,andexposuretodiseasecausingagents
contributetopoorhealthoutcomesinthecitysinformalsettlements.Amyriadofphysicaland
socialrisksariseintheseareas,includinginadequateaccesstosanitation,safewater,and
healthservices,hazardousorpollutedenvironments,insecurehousingtenure,lackof
educationalopportunityandlowsocialmobility,highlevelsofinterpersonalandgangrelated
violence,andbothphysicalandsocialisolationfromdevelopedareas(Unger,Riley,2007)
(Calderon,2008).Althoughdirectexposuretodiseasecausingagents,sanitation,cleanwater,
andaccesstohealthcareareimportantpredictorsofhealth,socialfactors,namelysocial

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inequality,showanincreasing
correlationtohealthoutcomesofurban
populations.

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Concentratedpoverty,violence,andpoorconnectivitycreateaphysicalandsocial
dividebetweenpopulationsatoppositeendsofMedellnssocioeconomicgradient.InlowSES
populations,disadvantagemanifestsphysicallyintheformoftoxicstress,allowingsocial
experiencestoimpactbiologicfunction.Theaccumulationoftoxicstressandbuildupof
negativeexposuresoveranindividuallifecourseoccursthroughcumulativepathwaysand
daytodayexperiences(Halfon,2002).
Toxicstressincreasesallostaticload,
definedastheconstantwearandtearonthe
bodyasaresultofenvironmental
conditionsthatexceedphysiological
capacityandleadtobiologicchangesthat
increaseapersonsriskfordisease
(Williams,1997).Morespecifically,highallostaticloadislinkedtoelevatedriskforchronic
conditionssuchashypertension,highdensitylevelcholesterol,cardiovasculardisease,
decreasedphysicalcapacity,andseverecognitivedecline(MacArthurFoundation,2009).
Heavyallostaticloadandtheinstanceofchronicdiseasemayalsoweakentheimmune
systemsabilitytofightinfection,thereforeincreasingsusceptibilitytoinfectiousor
communicabledisease(KiecoltGlaser,1995)(CDC,2011).Throughthismechanism,toxic
levelsofstressallowsocialinequalitiestogetintothebodiesofmarginalizedpopulations,
creatingadoubleburdenofbothchronicandinfectiousdisease.
Infectiousdiseaseistheprimaryfocusofthehealthagendaintheworldspoorest
countries.However,urbanpopulationsindevelopingcountriesfacerisingratesofchronicand

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noncommunicablediseases,inadditiontohistoricallyhighratesofinfectiousdisease.Ona
globalscale,thereexiststhecommonperceptionthatchronicdiseasesresultfromindividual
lifestylechoices,andthattheytendtoaffectolderpopulationsinmoredevelopedareas(Yach,
2004).However,chronicdiseasessuchasdiabetes,cancer,andcardiovasculardiseaseareall
risingcausesofmortalityandmorbidityinthedevelopingareasoftheworld.Inthese
populations,mortalityratesfromischemicheartdiseaseareprojectedtohaveincreasedby120
percentforwomenand137percentformenbetweentheyearsof1990and2020(Yach,2004).
AccordingtodatacompiledbytheGlobalBurdenofDiseaseproject,betweentheperiodof
1990and2010,diarrhealdiseasesshoweda61percentdecreaseinColombia,whilemortality
ratesduetoischemicheartdiseaseincreasedby20percent(GlobalBurdenofDisease,2010).
DatafromtheGlobalBurdenofDisease,thoughnotrevealingofnuancesatthecityand
communitylevel,illustrateanationalshiftsupportingtheglobaltrendofrisingchronicdisease.
In2004,thefiveprimarycausesofmortalityinMedellninrespectiveorderwere
violence,ischemicheartdisease,chronicrespiratorydisease,stroke,anddiabetes.Intheyear
2011,theprimarycauseswereischemicheartdisease,violence,chronicrespiratorydisease,
stroke,andpneumonia(AlcaldadeMedelln,2004,2007).Atthecitylevel,between2004
2011,chronicdiseasesandviolenceremainedtheleadingcausesofmorality.However,
differencesatthecomunalevelareimportanttounderstandingthedistributionofnegative
healthoutcomesacrossthesocioeconomicgradientinMedelln.Comunas1,2,and13,targets
ofinitialurbanupgradingprojects,showedcomparativelyhigherratesoftuberculosisrelated
deathandcomparativelysimilarratesofmortalityfromischemicheartdiseaseagainsthigher
SEScomunasintheyear2011(AldcaldadeMedelln,2011).Thoughtuberculosisand

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ischemicheartdiseasedonotsingularlyrepresenttheburdenofinfectiousandchronicdiseases
acrossthecomunasofMedelln,theirunequalcontributiontomortalitymayaddtothepublic
healthdiscussiononthedoubleburdenofdiseaseandpotentialhealthimplicationsofequitable
urbanplanning.
SocialUrbanisminMedelln:TheoryandPractice
Inthefaceofdeeprootedsocialinequities,Medellnsrecenturbandevelopment
strategiesfocusonintegratingthemostvulnerablecomunaswithinthecity.Initialmunicipal
initiativestoaddressgrowinginformalsettlementsandtheresultingissuesofpoverty,
violence,andpoorhealthtookformasProgramaIntegraldeMejoramientodeBarrios
InformalesorIntegralProgramfortheImprovementofInformalSettlements(PRIMED),a
programdevelopedandimplementedbythecitygovernmentin1991.Thisprogramoutlined
itsmainobjectivesasneighborhoodupgrading,housingimprovement,physicalrisk
mitigation,relocation,legalizationoftenure,andpromotionofcommunitydevelopment
(Calderon,2008).Thoughtheprogramgainedalevelofinternationalrecognitionasamodelof
urbanupgrading,PRIMEDfellshortinexecutionatthecommunitylevelandwasultimately
terminatedbeforeaccomplishingmanyofitscoregoals.Despiteitsshortcomings,PRIMED
aidedindrawingcivicattentiontothecomplexityofaccumulatedriskfactorsinMedellns
mostdense,povertystricken,andviolentareas.
PRIMEDimportantlynamedpromotionofcommunitydevelopmentasacentral
municipalobjective,however,failuretoworkthoughacommunityinclusiveframework
becameanobstacletoitsoverallimplementationandsuccess.Bornoutoffrustrationswiththe
localgovernment,communitylevelorganizationsandgroupsstrengthenedintheaftermathof

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PRIMEDstermination(Calderon,2008).Outofcommunityefforts,anewadministration
underMayorSergioFajardotookofficein2004withhopestoeradicatecorruptionand
clientelismattheinstitutionallevel,whileworkingonthegroundtochangetheskinofthe
city(Echeverri,2009).TheurbandevelopmentstrategyoftheFajardoadministrationfocused
onmakingMedellngovernableandparticipatory,socialandinclusive,andtocreatespacefor
theencounterofitscitizens(Calderon,2008).
Urbanupgradingduringtheperiodof20042007wasbuiltontheconceptofsocial
urbanism,whichseekstolaythefoundationforahealthycitybyaddressingissuesofsocial
andeconomicinequality,increasingconnectivityandinclusivity,andbuildingunitythrough
innovativeurbanplanningandeducation.Withavisiontochangethecity,thenewlyelected
citygovernmentwonoverthepeopleofMedellnbyreachingouttocommunitiesand
spreadingtheconceptofsocialurbanism.Deviatingfromtheideaofacentralizedcity,the
administrationinvestedinthebuildingoflibraries,parks,schools,andculturalcenters
strategicallyplacedinthemosthistoricallyvolatilepartsofthecity.Emphasisonarchitectural
beautyandinnovationaimedtoincreasecommunityinvestmentandprideinMedellns
transformation.Transportationinfrastructurebymeansofanaerialmetrocablesystem
simultaneouslyprovidedameanstoconnectandintegratedifferentpartsofMedelln,andto
makeurbandevelopmentsaccessibletoadiversepopulation.
ThebuildingofthedevelopmentprojectscalledProyectosUrbanosIntegralesor
IntegralUrbanProjects(PUI)beganin2004innortheasternComuna1,Popular,andComuna
2,SantoDomingo.Theseprojects,largelyreferredtoasPUINororiental,includedvarious
parks,communitycenters,schools,andtheiconiclibrarypark,ParqueBibliotecaSanto

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DomingoSavio,alsoknownasParqueBibliotecaEspana(SpainLibraryPark).PUIsin
Comunas1and2skirtedthemetrocablelinesLandK,whichprovidebidirectionalmobility
overheadthesteepterrainoftheinformalsettlements.
In2006,anewPUIsitewasestablishedinthecentralwestComuna13,SanJavier.A
largenumberofthePUIsinComuna13weredecentralizedfromthemetrocablelineJ,which
reachesonlythenorthernpartofthedistrict.Inadditiontoparks,schools,andthelibrarypark
SanJavierorParqueBibliotecaPresbiteroJosLuisArroyave,anewformofmobilitywas
createdinhillsideescalatorsthattraversethesoutherninformalsettlementsofthecomuna.
PUIsimplementedduringtheFajardoAdministrationinComunas1,2,and13focusedonthe
twoareasoftransportationinfrastructureandsharedcommunityspace.Throughshared
communityspace,plannerstargetedissuesofsocialdiscontinuitywithinlowSESareas,and
throughtransportationinfrastructure,aimedtoaddressissuesofsocialisolationbetween
informalsettlementcommunitiesandmoredevelopedareasofthecity.

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CommunitySpaceandSocialCohesion
SocialurbanisminMedellnduringtheperiodof20042007focusedoninvestmentin
sharedcommunityspaceinthecitysmostunderdevelopedareas.Anintegralpartofthe
planningwastobuildthemostbeautifulbuildingsinthepoorestneighborhoods(Echeverri,
2009).Theemphasisontheaestheticdesignofcommunitycenterswasbornoutofabeliefthat
physicalityofthebuiltenvironmentplaysacriticalroleinincreasingcollectiveownershipand
prideinsharedcommunityspace.Thecitygovernmentimplementedarchitecturalconteststo
sparkcreativecompetitionamongsturbanplannersforthedesignofinnovativecommunity
buildingsandspaces.Objectivesincludedfosteringresidentssenseofconnectiontoone
anotherandinstillingasenseofbelongingtoacommunityofworthandvalue.
Alongwithincreasingcollectivecommunityparticipation,thebuildingofbeautifulnew
landmarksinvulnerableareassoughttoincreasethevisibilityofpreviouslyneglectedareas.
ParqueBibliotecaEspana,oneofthemostwellknownPUIs,isalargelibrarysurroundedby
safegreenspace.Thelibraryparkactsasacommunitycenterforchildrenandfamilies,and
providessharedspaceforcommunityactivity.Nestledwithinahillsideofmakeshifthousing
androads,themodernlibraryparkstandsoutasasymbolofintersectingurbanizationand
poverty.Inadditiontoitsusebycommunitymembers,thelibraryalsoactsasatourist
attraction,makingnortheasterncomunas,forthefirsttime,adestinationforpeopleotherthan
thosewholivethere.Througharchitecturalinnovation,socialurbanistplannersintendedto

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transformComunaNororientalintoaplaceofinternalandexternalsocialvalue,tomakea
seeminglyinvisiblecommunityacenterofactivityandinterest.

TransportationInfrastructure
andSocialIntegration
Socialurbanism
developmentplansintegrated
urbanupgradingapproachesby
increasingperceivedvalueof
modernpublicspacesand
concurrentlyestablishing
equitableconnectiveinfrastructure.Theadditionalconnectivitycomponentofsocialurbanism
aimedtoincreasesocialcohesioninMedellnbylinkingthenewlyestablishedurbanamenities
inpreviouslyisolatedareasofthecity.Bothgeographicandsocialsegregationreinforcethe
dividebetweentherichandpoorinMedelln.Manyofthecityscomunasarelocatedonsteep
hills,makingautomobileaccessibilityachallenge.Toovercomethisbarrier,thefirstaerial
metrocablesystem,employingskilifttechnology,wasimplementedasaformofpublic
transport.Themetrocablesystemintendedtodrawoutthecityscentralpopulationstothe
newpublicspacesinformerlyinaccessibleandunsafecomunas,andtoprovideameansof
accessforhighriskpopulationstoopportunitiesinthemorecentralanddevelopedareas.By
increasingpopulationflowbetweentheoutskirtsandcenterofthecity,themetrocable
proposesasolutiontointegratingpopulationsthatpreviouslysharedlittlecontact.Thistwo

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wayaccesssystemworkstodecreasethesenseofphysicalisolationandtobuildasenseof
socialunitywithinallareasofthecity.
TheriseofsocialurbanisminMedellnadditionallypresenteditselfasanopportunity
forcommunityparticipationandcollaboration.Acoreaspectofsocialurbanismwastheability
ofaffectedcommunitiestoparticipateindevelopmentplans.Invitingcommunitymembersto
thedrawingboardaimedtoaddress
concernsofleadershipoversight
andcommunitydiscontentwith
outsiderfixesthataroseduringthe
implementationoftheprecursor
programPRIMED.Planners
recognizedthatrefurbishingand
repurposingexistinglandmightnegativelyaffectcommunitymembersdespiteendgoalsof
overallcommunitybenefit.Publicmeetings,calledTalleresdeImaginariosorImagination
Workshops,aimedtogiveparticipantsasenseofinvestmentandownershipindevelopment
projects,increasingthelikelihoodofacceptanceandpositiveuseofnewpublicspacesafter
establishment.LearningfromtheexperienceofPRIMED,socialurbanismstrategies
incorporatedonthegroundcommunityinvestmentandeducationinareasintendedtobenefit
fromdevelopmentprojects.Similartothephysicalintegrationprovidedbythemetrocable
system,communityparticipationactedasasocialbridgetoconnectandintegratepopulations
thathistoricallyhadlittlesayincityplanning.

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UrbanDevelopmentasPublicHealthIntervention
Urbanplanningcanbeconsideredpublichealthpolicywhendevelopmentplans
addresssocialdeterminantsofhealthandrestructurethebuiltenvironmenttoincrease
communityresourcesandprotectivehealthfactors.Throughapublichealthframework,urban
developmentcanbeusedasatooltoalleviateupstreamcausesofdisease.Thoughnowhere
nearperfect,theplacepreviouslyknownasoneofthemostdangerouscitiesintheworldhas
madestridesinreducingviolenceandimprovingsafetyforcommunitymembersandvisitors.
Datashowsthatratesofviolenceandhomicidehavedecreased,andthatviolenceisnolonger
theleadingcauseofdeathinMedelln(AlcaldadeMedelln,2011).Whatremainsinquestion,
however,istheabilityofurbanupgradinginMedellntomeasurablyimprovehealthoutcomes
inaffectedcomunas.Inasocialcontext,healthininformalsettlementsmaybepositively
affectedforsimilarreasonsthatcrimehasbeenreducedincreasedsocialcohesionand
communityinvestmentinupgradingplans.Policymakersandstakeholdersofchangein
Medellnfacethetaskofadequatelyassessingthedistributionofhealthoutcomesacrossthe
cityscomunasanddrawingconclusionsaboutthecurrentefficacyofurbanplanningasaform
ofpublichealthintervention.

PARTB:PolicyRecommendation:AlignmentofUrbanPlanningandPublicHealth
UrbanDevelopmentProjects:CurrentState
AftertheimplementationofinitialPUIs,severaladditionalurbandevelopmentprojects
wereestablishedinComunas5,8,and9undertheadministrationofAlonsoSalazarJaramillo,
MayorofMedellnfrom2008to2011.CurrentMayor,AnbalGaviriahasfocusedlessonthe

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developmentofnewPUIs,insteadinvestingintheareasofeducationandeconomicequity.
SincewordofMedellnscontinuedinnovativeurbanupgradingstrategiestraveledthroughout
theinternationalcommunity,thecityhasreceivedincreasingamountsofmediaattention.In
June2014,Medellnhostedthe7thUNHabitatWorldUrbanForum(WUF7).WUF7presented
theopportunityforglobalurbanplanningexperts,politiciansandstakeholdersofchange,along
withinternationalmediatoexperiencefirsthandthePUIsandtransportationinfrastructure
developedinMedellnsince2004.Thoughmediaanddevelopmentexpertsalikehavepraised
thecitysrecentdevelopment,factorsoflongevityandareasofimpactremainedinquestion.
Academicsandcommunitymembersexpressvaryingresponsetotheconceptofsocial
urbanismandPUIs.Someapplaudsocialurbanismasagoldenstandardforglobalurban
developmentpractice;otherscritiquethemodelforhavingoverestimatedimpactsand
decliningcommunityparticipationbeyondinitialstagesofdevelopment.Betweenthesetwo
views,istheresponsethatsocialurbanismhasincorporatedfundamentalandpreviously
lackingprinciplesofcommunityinclusionandsocialequalityintourbanplanning;yetthere
remainsanimportantmissingcomponentofcomprehensiveimpactassessmentandlongterm
commitmenttocommunityinvolvementandthecontinuationandgrowthofexistingPUIs.The
questionofquantifiableimpactremainslargelyunanswered.Thoughthecitycensusprovides
dataonmortalityratesrelatedtoviolenceandbothchronicandinfectiousdisease,therelacksa
connectiveframeworktoexplorechangesinhealthoutcomesovertheperiodof2004tothe
present,andtheirrelationshiptochangesinurbaninfrastructureandthebuiltenvironment.

ImpactAssessment

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MaintainingsocialurbanisminMedellnrequiresclearandcomprehensiveimpact
assessmenttoevaluateexistingurbanupgradingprojects.Currently,nomunicipalassessment
focusesdirectlyonthePUIsandmetrocableinMedelln.Theonlyexistingdatathataids
policymakersinassessingurbandevelopmentprojectsarethecitycensusandnon
governmentalqualityoflifeassessments.Oneofthenotablenongovernmentalqualityoflife
surveysisaprojectcalledMedellnComoVamos(MCV).Establishedin2006,MCVaimsto
evaluatechangesinqualityoflifefromtheperspectiveofMedellnsresidents.Theprograms
goalsaretopromotemoreeffectiveandtransparentgovernment,betterinformed,responsible,
andparticipatorycitizens,andtocreateinterinstitutionalalliancesthatworktowardsabetter
qualityoflifeinMedelln(MedellnComoVamos,2015).MCVconductsanannualsurveyof
thecitytoassessperceptionsofqualityoflife.MetricsforqualityoflifeinMCVarepoverty
andinequality,health,educationandculture,environment,mobilityandpublicspace,security,
housingandpublicspaces,andcivicengagement.Usingthesemetrics,MCVcomparescitizen
perceptionofeachmetricfromeachyear.
DatafromtheMCVprojectprovideimportantinformationforpolicymakersin
Medelln,butdonotspecificallyaddresstheimpactofPUIsandtransportationinfrastructure.
Asaformofimpactassessment,MCVlackstheexplicitidentificationandmeasurementof
socialdeterminantsofhealth,andtheirrelationshiptoexistingurbandevelopmentprojects.
PartneringpublichealthandcityplanninginMedellnrequiresaframeworktoidentifythe
specificwaysinwhichthebuiltandsocialenvironmentsdeterminehealthoutcomes.To
advocatefordevelopmentplansthataddresssocialdeterminantsofhealth,policymakers
requiretoolstoassessboththequantitativeandqualitativeimpactsofaccumulatedtoxicstress

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atthecommunitylevel.Quantitativedatasuchasratesofdiseaseandmortality,alongwith
employmentratesandmeasurementsofincomeinequalityhelpsubstantiatequalitativedata
thatfocusonqualityoflife,communityselfperception,andchangesinsocialinequality.
IndevelopingacomprehensiveimpactassessmentofthePUIsandtransportation
infrastructureinMedelln,policymakersmustidentifyspecificareasofinfluence.TheUnited
StatesCenterforDiseaseControlandPreventioncurrentlyoutlinesaplacebasedapproachto
assessingpotentialpublichealthimpactofplans,projects,andpoliciesthatrelatetothebuilt
environmentandcommunitydesign(CDC,2015).ThisevaluationstrategycalledHealth
ImpactAssessment(HIA),isatoolthataidsplannersincreatingdevelopmentpolicythat
considershealthapriority.KeystagesofHIAareidentifyingpotentialimpacts,assessingrisks
andbenefits,makingrecommendations,reportingtodecisionmakers,andmonitoringand
evaluatingtheprojectorpolicyasitcomestofruition.ThoughHIAstrategyistraditionally
usedtoassesspotentialimpactsintheplanningstagesofurbandevelopmentprojects,the
foundationalconceptsoftheHIAmodel,particularlymonitoringandevaluation,canbeusedto
retroactivelygaugetheimpactofexistingprogramsandprojects.Becausetherehasbeenno
specificimpactassessmentpertainingtothemetrocableandPUIsinMedelln,policymakers
aretaskedwiththechallengeofassessingtheprojectsandprogramsthathavebeenineffect
forthepastdecade,alongwithdevelopingcomprehensiveimpactassessmentstrategiesthat
willcloselyfollowanyfuturePUIsfromtheearlystagesofdesignthroughimplementation,
andultimatelytothechangesinuseandperceptionintheyearsaftercompletion.

BarrierstoChange

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CommitmenttolongtermoversightandimpactassessmentofPUIsiseasierproposed
thanaccomplished.Politicaltensionandgovernmentalcorruptionhavehistoricallyprevented
Medellnfromestablishingcontroloverdrugandgangrelatedcrime,andimplementingurban
developmentprojectsthatadequatelyaddressissuesofpoverty,crime,andpoorhealth.Tothis
day,impetusforchangeiscontingentonpoliticalwill,makingdevelopmentplansinextricably
linkedtopoliticalandsocialclimate.Tomaintainsocialurbanismonthemunicipalagenda,
politicianshavethetaskofelevatingissuesofpovertyandsocialinequality.Mayorfrom2004
2007,SergioFajardochampionedmanyoftheprojectsthathavegainedMedellninternational
attentionintheareaofurbanupgrading.Hiscampaignwasbuiltonaplatformaccessibility,
transparency,andcommunityinclusion.Fajardossuccessor,AlonsoSalazarJaramillo,and
currentMayor,AnbalGaviria,havecontinueddevelopmentplansrelatedtothesocial
urbanismmodel.However,itisimportanttonotethatthesuccessandmaintenanceofexisting
PUIsalongwiththedevelopmentofnewprojectsisafragilepromise,sensitivetoshiftsin
politicalpower.Inanattempttodistinguishhispoliticalplatform,Gavirahaschosentofocus
moreenergyintheareaofeducation.Thoughinvestmentineducationisanimportantaspectof
socialchangeinMedelln,thereremainsaneedforlongtermcommitmenttoexisting
developmentprojects,andtheintegrationorcoinvestmentintheareasofeducation,job
trainingandjobcreation,andcommunitybuilding.Withoutcommittedoversightand
communitypartnershiponbehalfofthecitygovernment,developmentprojectsfacetheriskof
bothphysicalandsocialdeteriorationintheyearsfollowingimplementation.
DespitetheendofPabloEscobarsnarcotraffickingreign,theemergenceofsmall
gangshasleadtothepersistenceofviolenceinsomeofMedellnscomunas.Thepositive

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impactoftransportationinfrastructureandsharedcommunityspacesisthreatenedbycontinued
issueofinvisibleterritoriallinesdrawnbylocalgangs,whicharedifficulttoidentifyand
exceptionallydangeroustocross.AsMedellncontinuestoworktowardsasaferandhealthier
city,strategiestodecreasegangviolencemustbeapartofurbandevelopmentpolicy.
InComuna13,communityorganizerandrapartistbythenameJeihhcohasdeveloped
thehiphoporganizationCasaKolacho,whichemploysartisticexpressiontoempoweryouth
andencouragethemtoparticipateinanonviolenttransformationofMedelln.Thismovement
calledrevolucinsinmuertosorrevolutionwithoutdeathsisacallforasocialchangeof
theveryfabricoftheneighborhood,toreinventthecommunityinapeaceful,authentic,multi
dimensional,andparticipatorymanner(Remerlink,2014).Theorganizationcurrentlyprovides
aspacefor180youthtotakepartdirectlyintheprojectbycreatingmusicandparticipatingin
otherartisticprojectsthatspreadthepeacefulmessagetothecommunity.Animportantsymbol
ofauthenticcommunitydriveninitiatives,CasaKolachoexemplifiestheimportanceofNGOs
andsmallerscalecommunitybasedorganizationsinhelpingrealizegoalsofsocialcohesion
andintegration.

Lessonsfromcommunitybasedmodels

Alongwithimportantfindingsfromimpactassessment,lessonsdrawnfromother

communitybaseddevelopmentmodelsiskeytothegrowthofdevelopmentpolicyinMedelln.
ThecityofRichmond,Californiahasmaderecentstridesintheareaofhealthequitythrough
theinitiativeHealthinAllPolicies.HiAPalongwithTheRichmondHealthEquityPartnership
(RHEP)arecommitmentsmadebythecitytoincorporatehealthintolawsandpoliciesthat

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havenottraditionallybeenconsidered
relevanttopublichealthattheinstitutional
level.HiAPaimstoprovidecommunity
basedurbandevelopmentstrategiesusinga
frameworkoftoxicstressorsthatinfluence
thehealthofthecommunity.
Byrecognizingthatpoliciesrelatedtohousingdevelopment,publiceducation,
supermarkets,andpublicspacescreatesystematicsocioeconomicinequalities,thecityof
Richmondiscurrentlyworkingtoincorporateequityintofuturepoliciesineachoftheseareas.
Thecitynowworkscloselywithitscommunitymemberstoreceiveinputonpoliciesand
developmentinitiatives.Communitiesaretaskedwiththeresponsibilityofleadingprojectsto
developsharedpublicspaces.In2007thenonprofitorganizationPogoParkwasfoundedby
investedcommunitymembersandexpertsintheareasofurbanplanning,architectureandchild
development,withthegoaloftransformingparksandcreatingspaceforchildfriendly
communityinteraction.PogoParkcurrentlyhasfourgreenspaceprojectsintheIronTriangle
areaofRichmond,andworkswithcityplannerstomakethedevelopmentofpublicspaces
moreequitableandcommunityinclusive.
ThecityofOakland,Californiahasalsoseenrecentgrowthintheareaofcommunity
basedhealthinitiatives.YouthUprising,amultiservicecommunitytransformationhub,isa
communitycenterthatworkscloselywithCastlemontHighSchooltoprovidehealthservices
alongwithartclasses,educationalsupport,andculturalactivitiesandeventsforOaklands
youth(YouthUprising,2011).Thismodelviewshealthasameasureofbothbiologicand

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socialfunction.Byintegratingsharedcommunityspaceandhealthservices,YouthUprising
allowsfortheintersectionofcommunitybuildingandpublichealth,andservesthe
multidimensionalgoalofholisticwellbeing.Principlesofviolencereductionandcommunity
valuecreateasafespaceforthepositiveinteractionofyouthwhoareatriskforgangrelated
andinterpersonalviolence.Themodeladditionallyaddressesstrongindicationsthat
educationalattainmentisapredictorofSES(Winklebyet.al,1992).Thespecificfocuson
urbanyouthandpartnershipwiththeneighboringpublichighschooladdsaneducational
componentthatindirectlyworkstodecreasesocioeconomicinequities.ThoughMedellnfaces
challengesoflowSESpopulationsandhighsocialandhealthrelatedinequities,thecity
presentsanopportunityforsimilarcommunitybasedhealthcentersthatincorporate
foundationalprinciplesofmodelslikeYouthUprising.

TheFutureofSocialUrbanisminMedelln
CriticsofthehypesurroundingsocialurbanisminMedellnhavearguedthatPUIsand
transportationinfrastructurehavenotsignificantlyimprovedsocialinequality,andthat
decreasesinviolencemaybeattributedtoconfoundingfactorssuchasinformalagreements
withexistingcitygangsandparamilitarygroups.Somehavealsoarguedthatalthough
accessibilityacrossareasofthecityhasincreased,thischangemaynotequatetoincreasesor
improvementsinjobopportunitiesformembersofpreviouslyisolatedcomunas.Information
fromthecitycensusandnongovernmentalqualityoflifeassessmentsdemonstratethat
specificimpactsoftransportationinfrastructureandPUIsremainunidentified.Thefutureof

Asari 23
socialurbanismisdependentnotonlyonmakingexplicittheintendedoutcomesof
development,butalsocloselyevaluatingunforeseenimpacts.
ByincreasingsocialmobilityandfiscalopportunityforlowSESpopulations,city
plannerscanincorporatehealthpolicyintonewandexistingurbanplanningpolicies.
Traditionalpublichealthpolicyintheworldspoorestareasfocusesprimarilyonacutecare
andaccesstotreatment.However,approachestoalleviatingpoorhealthinimpoverishedurban
areascannolongerignoretherealitythataccesstoproximalresourcesdoesnotuniversally
equatetoimprovedhealthoutcomes.Asacutecareeffortscontinuetoaddresstheproximal
determinantsofhealthsuchasaccesstohealthcareandsanitation,adualcommitmentto
eliminatingrootcausesofchronicdiseaseiscritical.
Addressingupstreamdeterminantsofhealth,orfoundationalcausesofhealth
disparities,isrootedintheelevationofthesocialandbuiltenvironmentasapublichealth
issue.Throughincreasedvisibility,accessibilityandcommunitybuilding,thesocialurbanism
modelcanbeenviewedasastrategytoaddressthesocialdeterminantsofhealthinMedellns
lowSEScomunas.CurrentresearchonurbandevelopmentinMedellnprimarilyfocuseson
violencereduction;however,theadoptionofatoxicstressframeworkmayhelptointegratethe
areasofresearchonbothviolenceandsocialinequalityasissuesofpublichealth.Immediate
solutionstoaddressinghealthininformalsettlementsareanimportantpartofacollectiveand
comprehensiveapproach.Ultimately,publichealtheffortsshouldfocusonloweringcurrent
andacutehealthrisks,whilesimultaneouslyimplementingpreventativemeasuresthataddress
socialinequitiesattherootofhealthdisparities.Communityinclusion,empowerment,safety,
educationalandeconomicopportunity,andphysicalriskmitigationareallkeyaspectsofany

Asari 24
futuredevelopmentplansinthecityofMedelln.Sustainingtheseprinciplesofthesocial
urbanismmodelbroadensthedefinitionofhealthtoencompassboththebiologicandthe
social,considersimpactsofthebuiltenvironment,andcreatesroomforinterdisciplinary
alliancebetweenthefieldsofpublichealthandurbanplanning.

AdditionalMapsandPhotos

Asari 25

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Asari 27

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