Kap. 1 schätzt den Effekt sozial gemischten Wohnens auf Resilienz gegenüber epidemischen Schocks. Anhand von Gesundheitsberichten und Berufsdaten aus Stadtverzeichnissen assoziiere ich die Verbreitung der Cholera während der 1866er Epidemie mit einem Maß für soziale Diversität für ca. 12200 Häuser Berlins. Diversere Häuser erleben mit höherer Wahrscheinlichkeit mindestens einen Fall, sind aber auch erfolgreicher bei der Eindämmung weiterer Fälle. Zur kausalem Interpretation nutze ich exogene Variation, die sich aus den geometrischen Eigenschaften der Gebäude ergibt. Ich zeige, dass Exposition gegenüber Außenkontakten und gemeinsamer Zugang zu Leitungswasser in gemischten Mietergemeinschaften die Inzidenzeffekte teilweise erklären. Kap. 2 evaluiert, ob die Cholera als Katalysator für städtische Was¬ser-infrastrukturreformen fungierte. In einer Fallstudie Berlins im 19. Jahrhundert zeige ich, dass die Interpretation der Cholera durch Miasma- und proto-epidemiologische Theorien der prä-bakteriologischen Ära ineffiziente, kontraproduktive Wasserwirtschaftsreformen inspirierten, was die Sterblichkeit für einige Zeit erhöhte. Das gängige Narrativ eines durch epidemische Schocks „erzwungenen“ sanitären Aufbruchs vermittelt ein irreführendes Bild der westlichen Volksgesundheitsgeschichte. Kap. 3 zeigt, dass Leitungswassernetze ohne Kanalisation geringen gesundheitlichen Nutzen stiften. Mittels Wasserspülung schwemmen Individuen Krankheitserreger in Rinnsteine, Grundwasserleiter, Straßen und offene Gewässer. Entlang dieser Abwasserströme lebende Nachbarn werden zusätzlichen Gesundheitsrisiken ausgesetzt, die durch den Anschluss der Abfallverursacher an eine Kanalisation neutralisiert werden. Mittels eines Flussrichtungsmodells schätze ich die Abwasser-Exposition für alle Gebäude Berlins in 1875/1880. In einer Differenz-in-Differenzen-Regression zeige ich, dass die negativen externen Effekte der Leitungswassernutzung dessen direkte Vorteile im Aggregat teilweise aufheben. / Chapter 1 estimates the causal effect of mixed-income housing on resilience to epidemic shocks. Using detailed health reports and occupational data from town directories, I relate cholera incidence to a social diversity measure at the level of Berlin’s roughly 12,200 buildings during the 1866 pandemic. Mixed tenant communities are more likely to experience an initial case, but also more successful in containing further in-house spread. To establish causality, I exploit exogenous variation from building lots’ geometric properties in an instrumental variable approach. I find that increased exposure to outside contacts and shared tap water access partly explain the effects. Chapter 2 evaluates whether cholera functioned as catalysts for the efficient reform of urban water infrastructure. Studying 19th century Berlin, I find that cholera’s conception through miasmatist frameworks and the proto-epidemiological tools of the pre-bacteriological era inspired inefficient and counterproductive approaches to water management and potentially deepened the mortality penalty for a certain time. This suggests that the popular interpretation of a sanitary awakening enforced by epidemic shocks paints a misleading picture of Western public health history. Chapter 3 tests a mechanism explaining why cities yield little health benefits from tap water if they do not simultaneously construct sewers. Individuals use the pressurized water supply to flush pathogens from their local environment, thus feeding additional waste to gutters, groundwater acquirers, streets and open water bodies. Neighbors living along the resulting waste flows bear indirect costs, only neutralized once waste emitters connect to sewers. Using a flow direction model based on Berlin’s elevation profile, I estimate waste flow trajectories and exposure for all buildings in Berlin in 1875/1880. In a difference-in- differences approach, I find that tap water’s negative external effects partly offset its direct benefits.

Background: To be able to counter the increasing shortage of general practitioners (GPs) in many countries, it is crucial to remain up‑to‑date with the decisive reasons why young physicians choose or reject a career in this field. Materials and Methods: Qualitative content analysis was performed using data from a cross‑sectional survey among German medical graduates (n = 659, response rate = 64.2%). Subsequently, descriptive statistics was calculated. Results: The most frequent motives to have opted for a GP career were (n = 74/81): Desire for variety and change (62.2%), interest in a long‑term bio‑psycho‑social treatment of patients (52.7%), desire for independence and self‑determination (44.6%), positively perceived work‑life balance (27.0%), interest in contents of the field (12.2%), and reluctance to work in a hospital (12.2%). The most frequent motives to have dismissed the seriously considered idea of becoming a GP were (n = 207/578): Reluctance to establish a practice or perceived associated risks and impairments (33.8%), stronger preference for another field (19.3%), perception of workload being too heavy or an unfavorable work‑life balance (15.0%), perception of too low or inadequate earning opportunities (14.0%), perception of the GP as a \"distributor station\" with limited diagnostic and therapeutic facilities (11.6%), perception of too limited specialization or limited options for further sub‑specialization (10.6%), rejection of (psycho‑) social aspects and demands in general practice (9.7%), and perceived monotony (9.7%). Conclusion: While some motives appear to be hard to influence, others reveal starting points to counter the GP shortage, in particular, with regard to working conditions, the further academic establishment, and the external presentation of the specialty.

Background Over one million asylum seekers were registered in Germany in 2016, most from Syria and Afghanistan. The Refugee Convention guarantees access to healthcare, however delivery mechanisms remain heterogeneous. There is an urgent need for more data describing the health conditions of asylum seekers to guide best practices for healthcare delivery. In this study, we describe the state of health of asylum seekers presenting to a multi-specialty primary care refugee clinic. Methods Demographic and medical diagnosis data were extracted from the electronic medical records of patients seen at the ambulatory refugee clinic in Dresden, Germany between 15 September 2015 and 31 December 2016. Data were de-identified and analyzed using Stata version 14.0. Results Two-thousand-seven-hundred and fifty-three individual patients were seen in the clinic. Of these, 2232 (81.1%) were insured by the state indicating arrival within the last 3 months. The median age was 25, interquartile range 16–34. Only 786 (28.6%) were female, while 1967 (71.5%) were male. The most frequent diagnoses were respiratory (17.4%), followed by miscellaneous symptoms and otherwise not classified ailments (R series, 14.1%), infection (10.8%), musculoskeletal or connective tissue (9.3%), gastrointestinal (6.8%), injury (5.9%), and mental or behavioral (5.1%) categories. Conclusions This study illustrates the diverse medical conditions that affect the asylum seeker population. Asylum seekers in our study group did not have a high burden of communicable diseases, however several warranted additional screening and treatment, including for tuberculosis and scabies. Respiratory illnesses were more common amongst newly arrived refugees. Trauma-related mental health disorders comprised half of mental health diagnoses.

Background: To be able to counter the increasing shortage of general practitioners (GPs) in many countries, it is crucial to remain up‑to‑date with the decisive reasons why young physicians choose or reject a career in this field. Materials and Methods: Qualitative content analysis was performed using data from a cross‑sectional survey among German medical graduates (n = 659, response rate = 64.2%). Subsequently, descriptive statistics was calculated. Results: The most frequent motives to have opted for a GP career were (n = 74/81): Desire for variety and change (62.2%), interest in a long‑term bio‑psycho‑social treatment of patients (52.7%), desire for independence and self‑determination (44.6%), positively perceived work‑life balance (27.0%), interest in contents of the field (12.2%), and reluctance to work in a hospital (12.2%). The most frequent motives to have dismissed the seriously considered idea of becoming a GP were (n = 207/578): Reluctance to establish a practice or perceived associated risks and impairments (33.8%), stronger preference for another field (19.3%), perception of workload being too heavy or an unfavorable work‑life balance (15.0%), perception of too low or inadequate earning opportunities (14.0%), perception of the GP as a \"distributor station\" with limited diagnostic and therapeutic facilities (11.6%), perception of too limited specialization or limited options for further sub‑specialization (10.6%), rejection of (psycho‑) social aspects and demands in general practice (9.7%), and perceived monotony (9.7%). Conclusion: While some motives appear to be hard to influence, others reveal starting points to counter the GP shortage, in particular, with regard to working conditions, the further academic establishment, and the external presentation of the specialty.

Alcohol use is one of the top five causes of disease and disability in almost all countries in Europe, and in the eastern part of Europe it is the number one cause. In the UK, alcohol is now the leading cause of death in men between the ages of 16–54 years, accounting for over 20% of the total. Europeans above 15 years of age in the EU on average consume alcohol at a level which is twice as high as the world average. Alcohol should therefore be a public health priority, but it is not. This paper puts forward a new approach to reduce alcohol use and harms that would have major public health and social impacts. Our approach comprises individual behaviour and policy elements. It is based on the assumption that heavy drinking is key. It is simple, so it would be easy to introduce, and because it lacks stigmatising issues such as the diagnosis of addiction and dependence, it should not be contentious.

The majority of the world’s population lives in urban areas, and more and more people are migrating to urban areas. However, the health hazards of urban life affect the population as well. They often suffer from non-communicable diseases, cardiovascular diseases, cancer and psychosocial problems. To address the increasing concerns about urban health, the WHO developed health promotion initiatives, known as the Healthy Cities programmes in 1986, which aim to place health high on the agendas of decision-makers and to promote comprehensive local strategies for health promotion and sustainable development. It successfully engages local governments in health development from thousands of cities worldwide in both developed and developing countries, including China. In 1994, China started to develop Healthy City pilot projects in the name of Healthy Cities with the suggestion of the WHO. However, the Chinese government started related activities about the environment and health long before WHO introduced the concept of Healthy Cities. The Patriotic Health Campaign was launched in 1952; despite it being a social movement that was not exclusively oriented to urban areas, it paved the way for Healthy Cities programmes in China. Since 1984, the National Government developed more than 40 policies and National Hygienic Cities to improve the urban environment and support Healthy Cities-related activities. However, the implementation of national policies depends on local level actions where collaboration across sectors is problematic, especially since different ministries tend to work separately according to their own prioritized programme. Shanghai is the first mega-city in China to initiate the action for Healthy City development. It was successful in raising high standards for the health status of the population and improving the urban environment in a quantitative way. However, institutional change, especially intersectoral collaboration remains a big challenge for the implementation. Therefore, it would be interesting to know how the local actors develop the Healthy City programme in the specific context of China. However, there is a lack of empirical studies on the Healthy City programme, and few studies focus on intersectoral relationships in Healthy City development; some researches only include limited actors, and some fail to identify the local institutional settings and connect with the international context. On this background, it looks into the policy making processes of making different programmes at different stages as well as the respective modes of policy implementation. This research aims to unfold how local actors develop the Healthy City programme in Shanghai. Two propositions are guiding the analysis: first, whereas policies in China are mainly developed on a national level where everyday challenges of individual local level entities do not play a decisive role, Healthy City policies are implemented on the local level (of cities or city districts) where municipal specificities and local conditions heavily influence the action potentials and actions of authorities and other stakeholders. Second, whereas Healthy City-oriented policies are comprehensive in nature, their implementation is rather fragmented and sectoral. The study applies an approach that is influenced by the discussion about actor-centered institutionalism. The interpretive lens of actor-centered institutionalism is taken to identify the main actors, analyse how they interact with each other, and the underlying institutional settings that are crucial to interpreting policy making and policy implementation. The study will also find out whether the actor-centered institutionalism approach is fully applicable under the conditions of China, or whether certain modifications are to be made. The research follows a qualitative approach, collecting data from multiple sources such as documents, including historic documents in archives, and interviews, combining a variety of research methods including stakeholder analysis, discourse analysis and network analysis. Shanghai is used as a case study as it has the longest experience with the implementation of Healthy City programmes in China, and was also the first to issue a Healthy City Action Plan in 2003. It established the first municipal committee for health promotion in 2005. Whereas the older programmes are analysed based on documents, the latest Healthy City programme is scrutinised by employing document analysis and interviews of different stakeholders in order to get an in-depth understanding of the policy making and implementation processes. This thesis aspires to contribute to the empirical knowledge of the development of public policies, the understanding of actors and actor constellations in Healthy City programmes with reference to specific institutional settings in China, and examining the compatibility and limitations of this interpretive lens in the Chinese context. Moreover, policy recommendations related to practice in Shanghai are provided as further motivation and commitment to Healthy City development in China.

Background: The alcohol-attributable burden of disease is high among socially disadvantaged individuals. Interventional efforts intending to have a public health impact should also address the reduction of social inequalities due to alcohol. Objective: The aim was to test the moderating role of educational background on the efficacy of a computer-based brief intervention addressing the full spectrum of alcohol use. Methods: We recruited 1646 adults from the general population aged 18 to 64 years (920 women, 55.9%; mean age 31 years; 574 with less than 12 years of school education, 34.9%) who reported alcohol use in the past year. The participants were randomly assigned a brief alcohol intervention or to assessment only (participation rate, 66.9%, 1646/2463 eligible persons). Recruitment took place in a municipal registry office in one German city. All participants filled out a self-administered, tablet-based survey during the recruitment process and were assessed 3, 6, and 12 months later by study assistants via computer-assisted telephone interviews. The intervention consisted of 3 computer-generated and individualized feedback letters that were sent via mail at baseline, month 3, and month 6. The intervention was based on the transtheoretical model of behavior change and expert system software that generated the feedback letters automatically according to previously defined decision rules. The outcome was self-reported change in number of alcoholic drinks per week over 12 months. The moderator was school education according to highest general educational degree (less than 12 years of education vs 12 years or more). Covariates were sex, age, employment, smoking, and alcohol-related risk level. Results: Latent growth modeling revealed that the intervention effect after 12 months was moderated by educational background (incidence rate ratio 1.38, 95% CI 1.08-1.76). Individuals with less than 12 years of school education increased their weekly alcohol use to a lesser extent when they received the intervention compared to assessment only (incidence rate ratio 1.30, 95% CI 1.05-1.62; Bayes factor 3.82). No difference was found between groups (incidence rate ratio 0.95, 95% CI 0.84-1.07; Bayes factor 0.30) among those with 12 or more years of school education. Conclusions: The efficacy of an individualized brief alcohol intervention was moderated by the participants’ educational background. Alcohol users with less than 12 years of school education benefited, whereas those with 12 or more years did not. People with lower levels of education might be more receptive to the behavior change mechanisms used by brief alcohol interventions. The intervention approach may support the reduction of health inequalities in the population at large if individuals with low or medium education can be reached.

This thesis analyses individual and societal relations to human excrement by looking at historical and contemporary examples of symbolics and management systems of human shit and piss. It furthermore connects urban culture to a particular type of perception of the meaning of human waste. End-of-pipe, large scale sewerage solutions for densely populated areas and cities are analysed for their historical origins and contemporary ramifications, and contrasted with examples of classical, mediaeval, early modern and contemporary times in different regions of Europe and India. The cases were presented in a non-chronological order to avoid simple narratives of progress. The focus is on questions of agricultural recycling of excrement and the relevance of human waste for public health issues. Analytical tools during the cross-temporal and cross-cultural case comparison are the categorisations of human excrement as e.g. waste, threat or resource, the technique of dualism-deterritorialisation and occasionally the Entanglement approach. Main results are that the large-scale introduction of sewerage systems in European cities around the world coincides with urbanisation and industrialisation, that pre-industrial dense settlement faced essentially the same excrement management challenges as modern cities do and that the stability of certain management systems has been severely influenced by factors such as power structures, paradigms of purity and piety as well as economic developments. The future relevance of this topic is seen in the predicted rise of urban regions worldwide, but especially in the developing world, a development which is expected to complicate human excrement management issues considerably.

Background Over one million asylum seekers were registered in Germany in 2016, most from Syria and Afghanistan. The Refugee Convention guarantees access to healthcare, however delivery mechanisms remain heterogeneous. There is an urgent need for more data describing the health conditions of asylum seekers to guide best practices for healthcare delivery. In this study, we describe the state of health of asylum seekers presenting to a multi-specialty primary care refugee clinic. Methods Demographic and medical diagnosis data were extracted from the electronic medical records of patients seen at the ambulatory refugee clinic in Dresden, Germany between 15 September 2015 and 31 December 2016. Data were de-identified and analyzed using Stata version 14.0. Results Two-thousand-seven-hundred and fifty-three individual patients were seen in the clinic. Of these, 2232 (81.1%) were insured by the state indicating arrival within the last 3 months. The median age was 25, interquartile range 16–34. Only 786 (28.6%) were female, while 1967 (71.5%) were male. The most frequent diagnoses were respiratory (17.4%), followed by miscellaneous symptoms and otherwise not classified ailments (R series, 14.1%), infection (10.8%), musculoskeletal or connective tissue (9.3%), gastrointestinal (6.8%), injury (5.9%), and mental or behavioral (5.1%) categories. Conclusions This study illustrates the diverse medical conditions that affect the asylum seeker population. Asylum seekers in our study group did not have a high burden of communicable diseases, however several warranted additional screening and treatment, including for tuberculosis and scabies. Respiratory illnesses were more common amongst newly arrived refugees. Trauma-related mental health disorders comprised half of mental health diagnoses.