Towards the Healthy City - Global Built Environment Review
Towards the Healthy City - Global Built Environment Review
Towards the Healthy City - Global Built Environment Review
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Whittingham, N GBER Vol .8 Issue. 2 pp 61 - 87<br />
<strong>Towards</strong> <strong>the</strong> <strong>Healthy</strong> <strong>City</strong>: An<br />
urban planner's reflection on health<br />
and wellbeing.<br />
*Neil Whittingham<br />
Abstract<br />
Health, in a sense, can be considered an intensely personal matter, strongly<br />
governed by behavioural choices and genetics. However, indicators show that at <strong>the</strong><br />
level of <strong>the</strong> community or <strong>the</strong> city, marked disparities exist in morbidity and<br />
mortality throughout <strong>the</strong> world. Clearly, politics, economics and geography also<br />
have a bearing on health outcomes, and not just in environments that are obviously<br />
extremely hazardous. Health problems can in part be due to a failure to reconcile<br />
<strong>the</strong> impact of <strong>the</strong> layout and design of urban form with <strong>the</strong> needs of individuals and<br />
communities for space to achieve a healthy existence. This article seeks a greater<br />
understanding of how <strong>the</strong> planning, design and management of cities have a bearing<br />
on sustainable development and <strong>the</strong> health of <strong>the</strong>ir citizens. It seeks such an<br />
understanding through a consideration of <strong>the</strong> social and environmental determinants<br />
of health and <strong>the</strong> influence that urban policy has upon <strong>the</strong> quality or liveability of<br />
cities. Lessons are sought from development <strong>the</strong>ory and <strong>the</strong> move towards more<br />
collaborative approaches to health, looking particularly at <strong>the</strong> WHO <strong>Healthy</strong> Cities<br />
Project, to identify challenges and recommendations for future policy.<br />
Key words: health, wellbeing, sustainable development, social and<br />
environmental determinants, urban planning, resilience, collaboration, WHO<br />
<strong>Healthy</strong> Cities Project.<br />
*Neil Whittingham<br />
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Introduction<br />
As a chartered urban planner in England that had recently returned to university to<br />
study international development, <strong>the</strong> author of this article offers a reflection on how<br />
concepts that he had recently unear<strong>the</strong>d from development <strong>the</strong>ory can inform<br />
attempts of urban policy to improve health. At <strong>the</strong> outset, it is clearly <strong>the</strong> case that<br />
<strong>the</strong> place any local economy sits within <strong>the</strong> wider global economy has a major<br />
bearing on <strong>the</strong> resources that may be at <strong>the</strong> disposal of any urban polity. During <strong>the</strong><br />
development of <strong>the</strong> global economy, <strong>the</strong> legacy of colonialism has had a huge<br />
bearing on <strong>the</strong> distribution of resources internationally, and this of course has had an<br />
impact on <strong>the</strong> health of <strong>the</strong> populations of <strong>the</strong> world (Gallaher et al., 2009). The<br />
health of <strong>the</strong> population of any particular country became due to a mixture of<br />
centuries of inequitable forces and, at <strong>the</strong> global scale, <strong>the</strong>re remains marked<br />
inequalities to this day, with life expectancies in Zambia and Mozambique, for<br />
example, 39 and 41 years of age, respectively (CIA, 2010).<br />
Such startling and sobering examples, and <strong>the</strong> huge challenge of meeting <strong>the</strong><br />
Millennium Development Goals, however, should not blind folk to glaring health<br />
inequalities closer to home. Within England, historically, <strong>the</strong> impact of overseas<br />
trade and slavery, and <strong>the</strong> significance of high wage levels and readily available coal,<br />
had led to <strong>the</strong> development of <strong>the</strong> economy to such a degree that <strong>the</strong>re became a<br />
widespread capacity to secure a ‘physiological minimum’ diet (Allen, 2009).<br />
Nowadays, <strong>the</strong>re is a general capacity in <strong>the</strong> country to ensure both adequate<br />
nutrition and rapid medical interventions to treat or prevent disease. However, <strong>the</strong>re<br />
remains a great deal of health inequality in England, as shown by <strong>the</strong> Strategic<br />
<strong>Review</strong> of Health Inequalities in England post-2010, undertaken by Professor<br />
Michael Marmot. The report shows that poorer people in English society tend to live<br />
shorter lives. The report estimated that between 1.3 million and 2.5 million extra<br />
years of life could be lived each year in England, if premature deaths could be<br />
prevented (Marmot et al., 2010). Clearly, poor choices have a strong impact on life<br />
expectancies. However, as <strong>the</strong> social epidemiologists Richard Wilkinson and Kate<br />
Pickett argue in <strong>the</strong>ir book Spirit Level, an egalitarian society is a healthier society.<br />
They noted that 10% of <strong>the</strong> population were obese in 1980 in <strong>the</strong> UK, and that figure<br />
is now more than 20%. They consider that despite decades of economic growth, in<br />
<strong>the</strong> light of <strong>the</strong> recent recession and debt crisis, <strong>the</strong> poor diets of many children in <strong>the</strong><br />
UK today may lead to serious health problems in later life, such as diabetes,<br />
cardiovascular disease and cancer, and <strong>the</strong>re could be a decrease in life expectancies<br />
for <strong>the</strong> first time since <strong>the</strong> nineteenth century (Wilkinson and Pickett, 2010).<br />
Renewed fears over food security, with rises in <strong>the</strong> price of groceries in <strong>the</strong> west,<br />
serve as reminders of <strong>the</strong> sensitivity of household budgets to events on an<br />
international scale (Connor, 2010; Thompson and O’Grady, 2010). As such,<br />
questions of health equity and social justice have a persistent relevance at home, as<br />
well as <strong>the</strong> more immediate problems for <strong>the</strong> Horn of Africa, for example. However,<br />
<strong>the</strong>re is not only <strong>the</strong> current travesty of marked inequalities in mortality and<br />
morbidity rates to consider. Forecasted threats to <strong>the</strong> global economy from climate<br />
change, greater competition over crops and fears over water supply, create a need for<br />
a greater urgency to develop local resilience to <strong>the</strong> potential health impacts of such<br />
threats. Many commentators believe that in <strong>the</strong> years to come, <strong>the</strong> threats of climate<br />
change and <strong>the</strong> reaching of peak oil will have a severe impact on our economies and<br />
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consequently on health. With this in mind, it is considered that <strong>the</strong> role of <strong>the</strong> planner<br />
can help in <strong>the</strong> design and implementation of suitable adaptation measures that could<br />
work towards <strong>the</strong> goal of sustainability, whilst, simultaneously, helping overcome<br />
ill-health, vulnerability and health inequalities or, at <strong>the</strong> very least, help in avoiding<br />
an exacerbation of those problems (Stern, 2007; Chamberlin, 2009). As such, a<br />
greater understanding of <strong>the</strong> issues surrounding health and sustainable development<br />
at <strong>the</strong> city level is considered essential, along with an appreciation of how <strong>the</strong> public<br />
can positively influence its circumstances, in order to help enhance health resilience.<br />
It is <strong>the</strong> identification of <strong>the</strong>se relationships and <strong>the</strong> urban policy that strives for a<br />
participatory, sustainable urban development that forms <strong>the</strong> focus of this article.<br />
Perspectives on Health<br />
The fundamental needs for a healthy life, and <strong>the</strong> various models by which <strong>the</strong> varied<br />
and political nature of health has been conceptualised, can act as a starting point for<br />
consideration of what, in <strong>the</strong>ory, urban policy ought to be striving to facilitate. At its<br />
most basic, health depends upon <strong>the</strong> capacity for any individual, family or<br />
community to secure resources of food and water and a safe place to live. To address<br />
health problems that were encountered, a professional biomedical perspective has<br />
traditionally been predominant within England over <strong>the</strong> centuries. However,<br />
differing models of health began to challenge this view. Beyond basic needs, <strong>the</strong> part<br />
that social and emotional matters played in leading a rich and fulfilling life, began to<br />
be more fully acknowledged and so health became to be seen as a more multifaceted<br />
concept. Various authors have tried to encapsulate in words this broad spectrum of<br />
human experience, a famous example being Maslow’s hierarchy of needs, illustrated<br />
in Figure 1.<br />
A socio-ecological perspective, is perhaps more familiar to a planner, in that it<br />
spawned <strong>the</strong> Public Health and planning movements from <strong>the</strong> mid-nineteenth<br />
century, with <strong>the</strong> impact of political factors on a person’s health beginning to be<br />
acknowledged. More recently, within academic literature <strong>the</strong>re has been a turn to a<br />
‘New Public Health’ within which Antonovsky coined <strong>the</strong> expression salutogenesis,<br />
to describe a perspective that has as its starting point <strong>the</strong> identification of <strong>the</strong><br />
ingredients of a healthy life for an individual and <strong>the</strong> ability to cope (Hancock,<br />
1993). Ashton and Seymour (1988) list <strong>the</strong> determinants of <strong>the</strong> health of a person as:<br />
i) genetic endowment, ii) environment, iii) nutrition, iv) occupation and v) lifestyle.<br />
For <strong>the</strong>m, using <strong>the</strong> analogy of life being like a river, a look fur<strong>the</strong>r ‘upstream’ was<br />
seen as necessary for an understanding of <strong>the</strong> causes of ill-health, ra<strong>the</strong>r than solely<br />
dealing with symptoms through <strong>the</strong> medical profession. An ecological model of<br />
health that more holistically acknowledges <strong>the</strong> multifaceted nature of <strong>the</strong><br />
determinants of health is illustrated in Figure 2.<br />
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Figure 1. Maslow’s hierarchy of needs<br />
ESTEEM<br />
SOCIAL<br />
SAFETY<br />
PHYSIOLOGICAL<br />
SELF<br />
REAL-<br />
IZATION<br />
Source: Ashton, J. and Seymour, H. (1988)<br />
64<br />
Freedom<br />
Self –<br />
fulfilment<br />
Respect<br />
Approval<br />
Self respect<br />
Dignity<br />
Acceptance of o<strong>the</strong>rs<br />
Affectionate relationships<br />
Group membership<br />
Protection<br />
Security<br />
<strong>Environment</strong> free from<br />
threat or hazard<br />
Food<br />
Shelter<br />
Freedom from pain<br />
Survival
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Figure 2. The mandala of health: a model of <strong>the</strong> human ecosystem<br />
Sick<br />
Care<br />
system<br />
Personal<br />
Community<br />
Family<br />
behaviour<br />
y<br />
Human<br />
biology<br />
Culture<br />
Community<br />
Lifestyle<br />
Body<br />
Human-made environment<br />
65<br />
Spirit<br />
Biosphere<br />
Mind<br />
Psychosocioeconomic<br />
environment<br />
Physical<br />
environment<br />
Source: Hancock, 1993<br />
Work
Whittingham, N GBER Vol .8 Issue. 2 pp 61 - 87<br />
A positive model of health was famously defined by <strong>the</strong> World Health Organisation<br />
in 1946 as ‘a state of complete physical, mental and social well-being and not merely<br />
<strong>the</strong> absence of disease or infirmity’ (Barry and Yuill, 2008). This definition reaches<br />
much fur<strong>the</strong>r than a purely medical science perspective that seeks to address <strong>the</strong><br />
symptoms of illness, to one that considers quality of life and focuses upon <strong>the</strong><br />
elements that make up a healthy life. The broadening out of perspectives on health to<br />
a fuller acknowledgement of socio-economic and environmental determinants<br />
presents challenges for health research, policy and implementation. There are not<br />
only difficulties in co-ordination of various sectors of <strong>the</strong> economy and civic life that<br />
have a bearing on health outcomes. Human beings are genetically different and<br />
exercise a degree of choice in <strong>the</strong>ir behaviours. People may, of course, have very<br />
differing ideas of what actually constitutes a good quality of life for <strong>the</strong>m as<br />
individuals. Interestingly though, such a perspective on quality of life is increasingly<br />
being recognised at <strong>the</strong> governmental level and has led to <strong>the</strong> development of<br />
economic indicators to quantify happiness, such as that for <strong>the</strong> Himalayan state of<br />
Bhutan, to help show that <strong>the</strong> wealth of <strong>the</strong> population is not solely dependent on<br />
financial or material matters (Centre for Bhutan Studies, 2011).<br />
Mental wellbeing and a sense of happiness, however, are unique to <strong>the</strong> individual<br />
and quite elusive qualities to quantify. Whilst, <strong>the</strong>re are obviously greater risks with<br />
certain behavioural choices, health is clearly related to mental and emotional factors<br />
that are unique to <strong>the</strong> individual concerned. From psychology studies, Linley et al<br />
(2009), based on earlier studies by Carol Ryff, have emphasised that well-being has<br />
two distinct factors: firstly, subjective well-being, based on perceptions of<br />
satisfaction with one’s life; and secondly, psychological well-being, which has been<br />
conceptualised as having six components, namely, a) positive relations with o<strong>the</strong>rs,<br />
b) autonomy, c) environmental mastery, d) self-acceptance, e) purpose in life and f)<br />
personal growth. Clearly, <strong>the</strong> health of city dwellers depends not solely on meeting<br />
basic needs, but also upon <strong>the</strong> successful negotiation of <strong>the</strong> opportunities and<br />
challenges of urban living to satisfy <strong>the</strong>se components. This perspective of<br />
preparedness was expressed well by Dubos, ‘Health is <strong>the</strong> expression of <strong>the</strong> extent to<br />
which <strong>the</strong> individual and social body maintain in readiness <strong>the</strong> resources required to<br />
meet <strong>the</strong> exigencies of <strong>the</strong> future’ (Kelly, M.P., Davies, J.K. and Charlton, B.G.,<br />
1993). Greater identification, <strong>the</strong>n, of <strong>the</strong> linkages between environmental and<br />
spatial policies and health at <strong>the</strong> city region level, can be vital, being seen as ei<strong>the</strong>r<br />
part of <strong>the</strong> quest for sustainable development, and/or with environmental mastery<br />
being seen as a significant component of psychological well-being. Not only mental<br />
health is at stake however; certain urban environments can induce obesity through<br />
<strong>the</strong> need for a car to travel to work and/or take children to school, or <strong>the</strong> lack of<br />
convenient access to fresh foods and open space, for example. Socio-economic and<br />
environmental determinants, <strong>the</strong>n, can be considered to have a significant impact on<br />
both physical and psychological well-being and, whilst <strong>the</strong>re is obviously a great<br />
deal of choice in lifestyle that can have a subsequent impact on health outcomes, a<br />
focus on individual responsibility can be overplayed (WHO, 2010).<br />
The Determinants of Health<br />
The physical attributes of any given urban setting, <strong>the</strong> socio-economic conditions<br />
that prevail at any given time and <strong>the</strong> capacities of any particular community to<br />
thrive are all unique. Ra<strong>the</strong>r than considering that <strong>the</strong>re is a blueprint for planners for<br />
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an ideal healthy city, it would seem more appropriate to strive for <strong>the</strong> achievement of<br />
certain minimum physical and socio-economic standards and to adopt adequate<br />
processes to facilitate <strong>the</strong> shaping of a healthy urban environment. The history of<br />
urban planning evolved from a symbiotic relationship with <strong>the</strong> field of Public Health<br />
and so a renewed appreciation of <strong>the</strong> determinants of health is considered helpful for<br />
understanding <strong>the</strong> attributes of a place that could foster healthy living and, <strong>the</strong>reby,<br />
help inform urban policy to meet <strong>the</strong> challenges facing <strong>the</strong> modern city.<br />
Within <strong>the</strong> academic literature <strong>the</strong>re are many different models through which<br />
research into health can be conducted, and as mentioned above, <strong>the</strong>re has been a<br />
broadening out of perspectives on health to a fuller acknowledgement of <strong>the</strong> impact<br />
of socio-economic and environmental determinants. As well as <strong>the</strong> genetics of any<br />
individual and <strong>the</strong>ir access to health services, health determinants can include <strong>the</strong><br />
physical environment, income and social status, education, gender and social support<br />
networks (WHO, 2010). Even where <strong>the</strong>re is ease of access to health services, <strong>the</strong>re<br />
is <strong>the</strong> question of quality of those services. The term iatrogenesis refers to how<br />
illness can be caused ei<strong>the</strong>r clinically by <strong>the</strong> doctors, hospitals and drug <strong>the</strong>rapies, for<br />
example, or even culturally through an overreliance on <strong>the</strong> consumption of cures and<br />
medicines, instead of taking more personal responsibility for healthy behaviours in<br />
<strong>the</strong> first place (Barry and Yuill, 2008). It appears <strong>the</strong>n that <strong>the</strong>re are many broad<br />
fields of study from development <strong>the</strong>ory and management <strong>the</strong>ory through to<br />
sociology and psychology that can bring insights to bear for a better understanding<br />
of <strong>the</strong> determinants of health, and <strong>the</strong> degree of human control over <strong>the</strong>m.<br />
A useful starting point for considering what actually constitutes a healthy city, are<br />
<strong>the</strong> questions for planners put forward by Kamp et al (2003) which are: What is<br />
environmental quality?; What is <strong>the</strong> effect of my (planning and designing) measures/<br />
interventions on <strong>the</strong> environmental quality and well-being?; Which factors determine<br />
environmental quality?; How big is <strong>the</strong> effect?; Are <strong>the</strong> factors of equal importance<br />
to everyone? Clearly, such questions raise issues that are both physical and social<br />
and this highlights <strong>the</strong> difficulty in conceptualising <strong>the</strong> multi-faceted nature of health<br />
to aid urban policymakers. Satterthwaite (1999), however, provides a simple<br />
overview that helps in grasping <strong>the</strong> main issues for consideration by civic leaders of<br />
a city, see Table 1. A closer look at <strong>the</strong> five categories shows that <strong>the</strong>y all involve<br />
both science and art, in that <strong>the</strong> goals could involve engineering, biochemistry and<br />
medical science, on <strong>the</strong> one hand, and <strong>the</strong> art of persuasion and political acceptance<br />
of <strong>the</strong> citizenry to shared environmental, health and safety conscious goals, on <strong>the</strong><br />
o<strong>the</strong>r.<br />
Table 1. Five broad categories of environmental action for assessing <strong>the</strong><br />
performance of cities (based on Satterthwaite, D., 1999)<br />
A. Controlling infections and parasitic diseases and <strong>the</strong> health burden <strong>the</strong>y take on<br />
city populations, including reducing city populations’ vulnerability to <strong>the</strong>m.<br />
B. Reducing chemical and physical hazards within <strong>the</strong> home, workplace and wider<br />
society.<br />
C. Achieving a high quality city environment for all city inhabitants – e.g. open<br />
space, and provision for sport and culture.<br />
D. Minimising <strong>the</strong> transfer of environmental costs to <strong>the</strong> inhabitants and<br />
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ecosystems surrounding <strong>the</strong> city.<br />
E. Ensuring progress towards what is referred to its ‘sustainable consumption’, -<br />
i.e. ensuring that <strong>the</strong> goods and services required to meet everyone’s<br />
consumption needs are delivered without undermining <strong>the</strong> environmental<br />
capital of nations, <strong>the</strong> world of future generations.<br />
As well as city planning approaches, Kamp et al (2003) have fur<strong>the</strong>r outlined how<br />
<strong>the</strong>re are a variety of conceptual models through which goals such as <strong>the</strong>se could be<br />
researched, namely: human ecology; quality of life; social indicators; satisfaction<br />
research; and a focus on transactions. The array of perspectives shows that a holistic<br />
approach to <strong>the</strong> health within a city is preferable to one that is reductionist (Dooris,<br />
2005). Given <strong>the</strong> complexity of life in <strong>the</strong> city, an ecological model of health that<br />
attempts to take in a wider variety of influences would seem to be more appropriate<br />
as a guide for policymakers and managers, akin to what is termed a critical holism,<br />
as encouraged by Vincent Tucker (Pieterse, 2010). Figure 3 is a useful holistic<br />
conceptualisation of <strong>the</strong> interrelationships that would go towards <strong>the</strong> make-up of a<br />
sustainable city.<br />
As highlighted in <strong>the</strong> fifth point in Table 1, perspectives on health can be fur<strong>the</strong>r<br />
complicated by <strong>the</strong> threat to wellbeing from poor environmental stewardship, such as<br />
increased vulnerability to <strong>the</strong> impacts of climate change. Differing scenarios have<br />
forecast affects to <strong>the</strong> health and wellbeing of <strong>the</strong> population of a city, such as sea<br />
level rise, melting glaciers and spread of disease and pests, for example, which could<br />
all have a direct bearing on access to fertile land and water, and, indirectly, upon <strong>the</strong><br />
prices of food. This can, of course, exacerbate <strong>the</strong> difficulties of <strong>the</strong> urban poor and<br />
vulnerable to secure a healthy lifestyle or, indeed, <strong>the</strong>ir leaders to secure it for <strong>the</strong>m.<br />
Coupled with this, economies that have relied heavily on fossil fuels are facing a<br />
world where <strong>the</strong> extraction of oil maybe reaching or has reached its peak. Rapidly<br />
rising prices have made <strong>the</strong> search for more sustainable practices of paramount<br />
importance for <strong>the</strong> shoring up of <strong>the</strong> resilience within communities (Chamberlin,<br />
2009).<br />
Also, an appreciation of <strong>the</strong> interrelationships shown in Figure 3 is vital if <strong>the</strong>re is to<br />
be a genuine challenge to <strong>the</strong> new epidemics of obesity, asthma and mental illness<br />
(Jackson, 2002). Freeman (1998), in using <strong>the</strong> models of social support and stress to<br />
appreciate <strong>the</strong> relationship between mental health and <strong>the</strong> environment, argued that<br />
psychiatrists could play more of a role in <strong>the</strong> political process that shapes <strong>the</strong><br />
environment. As well as obvious dangers from pollutants or cold and damp, research<br />
has shown that access to open space and greenery, can not only afford opportunities<br />
for exercise; <strong>the</strong> very sight of it can also enhance a sense of mental wellbeing<br />
(Jackson, 2002). Spatially, marked health inequalities exist both between and within<br />
cities <strong>the</strong>mselves, however, <strong>the</strong> question of equitable access to healthy environments<br />
is far from a straightforward one. It has been shown for Glasgow, for example, that<br />
deprivation is more differentiated, and access to resources, physically and<br />
psychologically, can be also be dependent upon i) <strong>the</strong> quality of <strong>the</strong> resource; ii)<br />
whe<strong>the</strong>r <strong>the</strong> resource is actually health promoting; iii) whe<strong>the</strong>r a resource in a<br />
residential neighbourhood would be used; iv) whe<strong>the</strong>r <strong>the</strong>re may be symbolic<br />
barriers to use; and v) <strong>the</strong> scale and measure of evaluation of deprivation (Macintyre,<br />
MacDonald and Ellaway, 2008).<br />
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Figure 3. Sustainable urbanisation: main components and indicative issues<br />
Health<br />
Care<br />
Source: Adapted from Drakakis-Smith in Pelling (2003)<br />
Shelter<br />
<strong>Environment</strong>al<br />
Infrastructure<br />
Social<br />
SUSTAINABLE<br />
URBAN<br />
DEVELOPMENT<br />
Demographic Political<br />
Ageing Fertility policies<br />
Modern challenges for planning for health<br />
Given that health is such a multi-faceted concept with a wide variety of<br />
determinants, a marked improvement in health and health equity is more likely to be<br />
effected through a variety of interventions. Dooris (2009) highlighted <strong>the</strong> tackling of<br />
health inequalities through promoting inclusion, and a synergy with o<strong>the</strong>r policies<br />
and an approach to modern day issues that has an appreciation of complex systems.<br />
Kjellstrom and Mercado (2008) present a broad range of possible interventions for<br />
health equity, which is shown in Table 2. They consider that urban planning can play<br />
a key role in such interventions.<br />
Table 2. Broad Spectrum of potential interventions for health equity<br />
(Source: Kjellstrom and Mercado, 2008)<br />
1. Build social cohesion and trust at all levels<br />
2. Improve <strong>the</strong> living environment<br />
3. Support healthy housing, neighbourhoods and o<strong>the</strong>r local settings<br />
4. Invest in clean air<br />
5. Promote easy access to higher quality food<br />
6. Create safe and healthy workplaces<br />
7. Adopt comprehensive strategies to reduce urban violence and<br />
substance abuse<br />
69<br />
Employment<br />
Poverty<br />
Economic<br />
Human<br />
Rights<br />
Industrial<br />
policy
Whittingham, N GBER Vol .8 Issue. 2 pp 61 - 87<br />
8. Develop more equitable urban health systems<br />
9. Use innovative financing schemes, e.g. cash transfers<br />
10. Hold urban planners accountable for health<br />
11. Address urban sprawl<br />
Such interventions are relevant across <strong>the</strong> globe. Whilst <strong>the</strong> local impacts from<br />
uncontrolled industry and squalid housing may have been overcome in western<br />
economies, <strong>the</strong> development process has been identified as a predominant cause of<br />
climate change. As such, planning in both developed and developing economies<br />
continues to play a significant role in whe<strong>the</strong>r <strong>the</strong> layout of cities lends itself to<br />
healthy environments for all of its citizens, and in attempting to mitigate and adapt to<br />
<strong>the</strong> threats of climate change. The planning system in <strong>the</strong> west evolved in socioeconomic<br />
circumstances that were changing following years of austerity. Many of<br />
<strong>the</strong> worse problems of <strong>the</strong> urbanisation process had been overcome, though in <strong>the</strong><br />
years that followed WWII, increasing car ownership began to put fur<strong>the</strong>r pressure for<br />
<strong>the</strong> expansion of cities. Within England, for example, a car oriented economy was<br />
made a fait accompli by a series of cutbacks of support for <strong>the</strong> rail network and <strong>the</strong><br />
support for <strong>the</strong> road building lobby from <strong>the</strong> government of Thatcher. In a sense, <strong>the</strong><br />
second half of <strong>the</strong> twentieth century was one in which <strong>the</strong> seeds of a new public<br />
health crisis were sown through <strong>the</strong> creation of environments for city dwellers that<br />
contribute to obesity (obesogenic environments), and also to <strong>the</strong> continued damage<br />
to <strong>the</strong> global environment through economic expansion.<br />
Within planning <strong>the</strong>ory, <strong>the</strong> ills of <strong>the</strong> modern city are not necessarily perceived as<br />
being due to a slow or inadequate response to <strong>the</strong> socio-economic conditions. If state<br />
planning is geared towards achieving state objectives, as Cherry (1982) points out,<br />
authors from a Marxist perspective see <strong>the</strong>se objectives as often being geared<br />
towards <strong>the</strong> interest of <strong>the</strong> dominant class. In <strong>the</strong> post-WWII neo-liberal economy,<br />
planning can be seen as having reflected <strong>the</strong>se interests through <strong>the</strong> facilitation of <strong>the</strong><br />
development of space to aid in <strong>the</strong> accumulation of capital. As such, this can have a<br />
differential impact on certain sectors of society, through <strong>the</strong> creation of an<br />
inequitable distribution of unhealthy environments, with <strong>the</strong> working class and poor<br />
bearing <strong>the</strong> brunt of risk of ill-health through increased commuting times, dangerous<br />
roads and isolated, segregated suburban environments, for example. So, for some<br />
authors, <strong>the</strong> planning system can be perceived as having had, as a priority, <strong>the</strong><br />
facilitation of <strong>the</strong> demands of capital, through addressing <strong>the</strong> needs of commerce and<br />
<strong>the</strong> retail industry, and shaping <strong>the</strong> urban form to remedy disorganisation and aiding<br />
<strong>the</strong> reproduction of a readily available workforce. It is clear that, in affecting <strong>the</strong> land<br />
development process, planning does not overcome <strong>the</strong> inherent contradiction<br />
between private accumulation and collective action (Hall, 2002). The urban planning<br />
of cities, <strong>the</strong>refore, has a strong bearing on <strong>the</strong> health and wellbeing of its inhabitants<br />
through determining <strong>the</strong> levels of access to resources, be that access to work, ease of<br />
movement and transport options, or access to open space, for example. Many factors<br />
such as <strong>the</strong>se can have a bearing on <strong>the</strong> lifestyle and life of expectancy of any given<br />
individual in an urban setting. An understanding of <strong>the</strong> relationships between health<br />
and environmental circumstances, <strong>the</strong>n, remains of vital importance in developed<br />
economies, as well as, perhaps, less developed or vulnerable ones. The letter of<br />
Professor Kevin Morgan to <strong>the</strong> Planning magazine of 27 August 2010 succinctly<br />
emphasises that <strong>the</strong> planning profession needs to accept responsibility for its part in<br />
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creating obesogenic environments, and he considers that <strong>the</strong>re is an opportunity for<br />
civic planning to play more of a role in addressing public health matters, compared<br />
to a National Health Service that mainly operates by <strong>the</strong> biomedical model of <strong>the</strong><br />
treatment of illness (Morgan, 2010).<br />
Public Health and urban planning appear to have a renewed convergence, within <strong>the</strong><br />
academic <strong>the</strong>ory at least. An example of this can be seen with regard to <strong>the</strong><br />
encouraging of <strong>the</strong> public away from <strong>the</strong> use of cars to increased walking and<br />
cycling. The concerns of planners have generally revolved around congestion,<br />
danger from crashes, and pollution. Fur<strong>the</strong>r to this, a reduction in <strong>the</strong> impact of<br />
traffic is now seen as an approach to <strong>the</strong> mitigation of climate change. These issues<br />
coincide with <strong>the</strong> concerns of public health to overcome illness that is associated<br />
with lack of activity and obesity and associated illnesses (Hoehner et al, 2003). Also,<br />
new scenarios exist because of <strong>the</strong> development of computer networks and <strong>the</strong>se are<br />
resulting in <strong>the</strong> imperatives to be located in a certain place to be loosened (Mitchell,<br />
2000). As such, vastly enhanced communication networks can pose both<br />
opportunities, such as <strong>the</strong> reduction in <strong>the</strong> requirement to travel and easier<br />
dissemination of health advice, and threats, such as excessively sedentary lifestyles,<br />
and solitary lifestyles behind a computer, both in offices and at home. This<br />
convergence of interests points to <strong>the</strong> opportunities for increased synergy between<br />
professions, through multi-level interventions. It would seem that <strong>the</strong> circumstances<br />
are ripe for transition of <strong>the</strong> working practices of public health and planning into<br />
more formal collaborative relationships.<br />
The power to shape <strong>the</strong> city<br />
In recent decades, urban planning has, seemingly, adopted more communicative and<br />
collaborative approaches, as opposed to ‘top-down’, prescriptive ones (Dale, 2004).<br />
It is considered that a clearer appreciation of <strong>the</strong> political space for <strong>the</strong> creation of<br />
healthier environments, that may genuinely be available for individuals and<br />
communities, could be helped through an understanding of concepts from <strong>the</strong><br />
sociology of development. Awareness of terms, such as agency, capabilities and<br />
social capital, and <strong>the</strong> academic consideration of <strong>the</strong> movement towards more<br />
collaborative working and public participation in <strong>the</strong> provision of public services,<br />
can help underpin more informed urban policy.<br />
Agency, capabilities and social capital<br />
The capacity for anyone to meet <strong>the</strong>ir needs in striving for health is not only<br />
dependent upon <strong>the</strong>ir physical capabilities, and selfish drives, but also on <strong>the</strong> state of<br />
<strong>the</strong> wider economy and <strong>the</strong> societal will to cooperate in <strong>the</strong> adequate distribution of<br />
resources. Amartya Sen has usefully encapsulated this relationship by distinguishing<br />
between <strong>the</strong> processes in society and <strong>the</strong> opportunities for <strong>the</strong> individual, and gives<br />
<strong>the</strong> term ‘unfreedom’ to an inadequacy in ei<strong>the</strong>r. For poor people, restricted<br />
circumstances lead to a restricted life (Sen, 1999; Yunus, 2010). Externally<br />
established conditions, be <strong>the</strong>y physical, economic or political, are described within<br />
sociology as structure, and <strong>the</strong> capacity of an individual to control <strong>the</strong>ir<br />
circumstances to lead to a particular health outcome, is seen as agency (Barry and<br />
Yuill, 2008). This interplay between <strong>the</strong> dictates of circumstances and <strong>the</strong> will,<br />
ability and opportunity to change circumstances lies at <strong>the</strong> core of what determines a<br />
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healthy life. The distribution of <strong>the</strong> resources that enable a healthy life is obviously,<br />
contentious and at <strong>the</strong> macro-economic level, within <strong>the</strong> current neoliberal economy<br />
of much of <strong>the</strong> world, <strong>the</strong> structure provides riches for some, that enable a healthy<br />
prosperous life. However, such wealth can be at <strong>the</strong> expense of o<strong>the</strong>rs; a trend that<br />
geographer David Harvey has termed accumulation by dispossession (Harvey,<br />
2005). The agency of any individual to make healthy choices can be strongly<br />
influenced by that structure through <strong>the</strong> degree of access to jobs and/or financial<br />
credit, education, a healthy environment and good quality housing, for example.<br />
The recent financial crisis for neo-liberal western economies has exacerbated <strong>the</strong><br />
difficulties for many to maintain a healthy diet and secure a roof over <strong>the</strong>ir heads. A<br />
recent report from <strong>the</strong> thinktank, <strong>the</strong> Institute of Fiscal Studies shows that <strong>the</strong><br />
austerity measures of <strong>the</strong> current coalition government in <strong>the</strong> UK are hitting <strong>the</strong><br />
poorest in <strong>the</strong> country <strong>the</strong> hardest (Elliott and Dodd, 2010). This economic pressure<br />
can, of course, impact upon <strong>the</strong> capacity to maintain healthy lifestyles, <strong>the</strong>reby<br />
increasing <strong>the</strong> importance for both individuals and communities to be empowered to<br />
enhance <strong>the</strong>ir resilience. For any individual, <strong>the</strong>ir capabilities to develop <strong>the</strong>ir<br />
resilience to environmental threats are dependent upon physical, emotional and<br />
psychological qualities. The capabilities approach was outlined by Sen in his<br />
influential book Development as Freedom in 1999 and fur<strong>the</strong>r work on <strong>the</strong> approach<br />
has been undertaken by Nussbaum. A helpful summary of <strong>the</strong> perspective taken by<br />
Nussbaum can be found in Table 3 (McGillivray, M., 2008). For a person to more<br />
fully and successfully engage with processes that shape <strong>the</strong> quality of <strong>the</strong>ir social,<br />
political and physical environment, it is clear that <strong>the</strong> more capabilities <strong>the</strong>y have as<br />
individuals <strong>the</strong> more enhanced are <strong>the</strong> chances of leading a healthy life.<br />
Relationships with <strong>the</strong> community also form a part of <strong>the</strong> capabilities perspective, so<br />
involvement with community activities is not solely seen as a desired political<br />
objective, it is also an aspect of a healthy life for <strong>the</strong> individual.<br />
Table 3. Nussbaum’s central human functional capabilities<br />
(source: McGillivray, 2008)<br />
Life: being able to live to <strong>the</strong> end of a human life of normal length; not dying<br />
prematurely, or before one’s life is so reduced as to be not worth living<br />
Bodily health: being able to have good health, including reproductive health; to be<br />
adequately nourished; to have adequate shelter<br />
Bodily integrity: being able to move freely from place to place; having one’s bodily<br />
boundaries treated as sovereign as such being able to secure against assault,<br />
including sexual assault, child sexual abuse, and domestic violence; having<br />
opportunities for sexual satisfaction and for choice in matters of reproduction<br />
Senses, imagination, thought: being able to use <strong>the</strong> senses, to imagine, think and<br />
reason – and to do <strong>the</strong>se things in a ‘truly human’ way, a way informed and<br />
cultivated by an adequate education, including, but by no means limited to, literacy<br />
and basic ma<strong>the</strong>matical and scientific training<br />
Emotions: being able to have attachments to things and persons outside ourselves; to<br />
love those who love and care for us, to grieve at <strong>the</strong>ir absence; in general, to love, to<br />
grieve, to experience longing, gratitude, and justified anger<br />
Practical reason: being able to form a conception of <strong>the</strong> good and to engage in<br />
critical reflection about <strong>the</strong> planning of one’ s own life<br />
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Affiliation: being able to live for and towards o<strong>the</strong>rs, to recognise and show concern<br />
for o<strong>the</strong>r human beings, to engage in various forms of social interaction; to be able to<br />
imagine <strong>the</strong> situation of ano<strong>the</strong>r and to have compassion for that situation; to have<br />
<strong>the</strong> capability for both justice and friendship; having <strong>the</strong> social bases of self-respect<br />
and non-humiliation; being able to be treated as a dignified being whose worth is<br />
equal to that of o<strong>the</strong>rs (this entails, at a minimum, protections against discrimination<br />
on <strong>the</strong> basis of race, sex, religion, caste, ethnicity, or national origin)<br />
O<strong>the</strong>r Species: being able to live with concern for and in relation to animals, plants<br />
and <strong>the</strong> world of nature<br />
Play: being able to laugh, to play, to enjoy recreational activities<br />
Control over one’s environment: being able to participate effectively in political<br />
choices that govern one’s life; having <strong>the</strong> right of political participation, protection<br />
of free speech and association; being able to hold property (both land and movable<br />
goods), not just formally but in terms of real opportunity; and having property rights<br />
on an equal basis with o<strong>the</strong>rs; having <strong>the</strong> right to seek employment on an equal basis<br />
with o<strong>the</strong>rs; having <strong>the</strong> freedom from unwarranted search and seizure.<br />
A valid goal for <strong>the</strong> involvement of an individual in political processes is, surely, to<br />
achieve some form of enhancement of circumstances for <strong>the</strong>mselves and <strong>the</strong>ir<br />
community. As such, a key concept in considering <strong>the</strong> worth of urban policy, that<br />
fur<strong>the</strong>r expands from a focus solely on <strong>the</strong> individual, is <strong>the</strong> degree to which social<br />
capital is improved for local communities. As Bridge et al. (2009) point out,<br />
however, social capital is a contested term that can cover both institutional attempts<br />
to involve <strong>the</strong> population and also more ‘organic’ forms of organisation within <strong>the</strong><br />
community. Various definitions of social capital can be found in Table 4.<br />
Table 4. Definitions of social capital (source: Bridge et al, 2009)<br />
1. features of social life – networks, norms and trust – that enable<br />
participants to act toge<strong>the</strong>r more effectively to pursue shared<br />
objectives...Social capital, in short, refers to social connections and <strong>the</strong><br />
attendant norms and trust.<br />
2. Social capital is seen as <strong>the</strong> foundation on which social stability and a<br />
community’s ability to help itself are built; and its absence is thought to<br />
be a key factor in neighbourhood decline.<br />
3. <strong>the</strong> institutions, relationships and norms that shape <strong>the</strong> quality and<br />
quantity of a society’s social interactions.<br />
4. networks toge<strong>the</strong>r with shared norms, values and understandings that<br />
facilitate co-operation within or among groups.<br />
5.The term ‘social capital’ is increasingly used by policy makers as ano<strong>the</strong>r<br />
way of describing ‘community’, but it is important to recognise that a<br />
traditional community is just one of many forms of social capital. Work-<br />
based networks, diffuse friendships and shared or mutually<br />
acknowledged social values can all be seen as forms of social capital.<br />
The Department for International Development considers that to address poverty<br />
and, by implication, tackle poor health, <strong>the</strong>re are five types of capital that are<br />
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considered important for achieving ‘sustainable livelihoods’ . As well as social<br />
capital (which <strong>the</strong>y define as networks of helpful friends, neighbours and associates),<br />
<strong>the</strong>se are: human capital – <strong>the</strong> capacity to make a living through skills, knowledge,<br />
labour and good health; natural capital – <strong>the</strong> resources available; physical capital- <strong>the</strong><br />
infrastructure and goods; and financial capital – money and credit to achieve<br />
objectives (Bridge et al., 2009). A reflection upon <strong>the</strong> concepts of agency, capability<br />
and social capital has hopefully been useful, <strong>the</strong>n, to highlight how <strong>the</strong>re is an<br />
interplay between imposed physical circumstances and political structures and <strong>the</strong><br />
knowledge, skills and will of individuals and <strong>the</strong> community to shape that<br />
environment. It is useful to view urban policy in terms of how <strong>the</strong> capital of <strong>the</strong><br />
disadvantaged is actually served or enhanced.<br />
Collaborative approaches to shaping <strong>the</strong> environment<br />
If control over one’s environment is seen as a significant element of psychological<br />
well-being, active involvement of <strong>the</strong> public in using <strong>the</strong>ir agency to shape urban<br />
policy can contribute to improving both physical and mental health, as well as<br />
working towards <strong>the</strong> goal of sustainability. Urban policy, in acting as an intervention<br />
to steer development, is generally perceived as ei<strong>the</strong>r mitigation against <strong>the</strong> worse<br />
possible environmental impacts of development, an aid to <strong>the</strong> facilitation of financial<br />
capital or a combination of <strong>the</strong> two. Within so-called ‘mixed’ economies, <strong>the</strong>re is a<br />
general perception that <strong>the</strong>re are democratic opportunities to influence <strong>the</strong> design and<br />
layout of cities. For any individual, <strong>the</strong> capacity and knowledge to shape <strong>the</strong>ir<br />
environment in order to enhance <strong>the</strong>ir health is mediated through <strong>the</strong> degree to which<br />
involvement in decision-making is welcomed. It is useful to consider whe<strong>the</strong>r <strong>the</strong><br />
move towards collaborative and participatory working practices for urban policy has<br />
potential to more directly impact upon social capital in a way that is beneficial to <strong>the</strong><br />
poor. The degree to which public involvement in public services is welcomed and<br />
facilitated stems partly from developments from <strong>the</strong> conflict of ideas between <strong>the</strong><br />
capitalist United States and <strong>the</strong> state socialism of <strong>the</strong> Soviet Union. The fall of <strong>the</strong><br />
Berlin Wall was seen by many commentators as <strong>the</strong> end game in an ideological<br />
battle over how resources should be distributed, both intra and internationally.<br />
Famously, Thatcher had referred to capitalism as <strong>the</strong> only game in town and Francis<br />
Fukuyama declared that alternative political ideologies had been defeated and that<br />
liberal democracy was <strong>the</strong> final highpoint of <strong>the</strong> history of human political and<br />
economic systems. However, over <strong>the</strong> last twenty years, within academia and policy<br />
thinktank circles, <strong>the</strong> neo-liberal policies have become under renewed attack as <strong>the</strong>re<br />
have became growing disparities between rich and poor both across <strong>the</strong> globe.<br />
Anthony Giddens became influential to policymakers through his ‘Third Way’ which<br />
posited a more socially responsible form of doing business, an increase in<br />
partnership working and policies geared towards social inclusion to bring about a<br />
change in <strong>the</strong> relationships between <strong>the</strong> market, <strong>the</strong> state and civil society (Howell<br />
and Pearce, 2001).<br />
In <strong>the</strong>ory, and subsequently in practice, in recent years <strong>the</strong>re has been an increase in<br />
collaboration in <strong>the</strong> provision of public services, between <strong>the</strong> public and private<br />
sectors and civil society. From a Marxist perspective, greater public involvement in<br />
<strong>the</strong> overall context of a neo-liberal economy, through <strong>the</strong> use of voluntary labour and<br />
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<strong>the</strong> creation of a perceived ‘sense of ownership’ of <strong>the</strong> processes that effect civic life,<br />
could be seen as a way of staving off more radical challenges to <strong>the</strong> overall structure.<br />
Also, as Arnstein pointed out in her ladder of participation, governmental<br />
programmes can be seen as tokenistic if <strong>the</strong> public are merely informed of a<br />
proposed development ra<strong>the</strong>r than involved in its design or conception. Also, <strong>the</strong><br />
choices of who gets involved in a collaborative programme or project can be<br />
unrepresentative and it has been argued that <strong>the</strong> actual forms of discourse used in<br />
collaborative projects can fur<strong>the</strong>r <strong>the</strong> maintenance of unequal power relations, if<br />
certain sectors of <strong>the</strong> community are uncomfortable with particular formalities or<br />
styles of communication (Fairclough, 2001; Stern and Green, 2008). If <strong>the</strong><br />
collaborative approaches that are put into place are to be a valid use of <strong>the</strong> agency of<br />
<strong>the</strong> poor, who bear <strong>the</strong> brunt of <strong>the</strong> manifest unhealthy environments, <strong>the</strong> degree to<br />
which <strong>the</strong> processes prove to be beneficial and ‘pro-poor’ is a salient question to<br />
consider. The evolution of collaborative approaches to <strong>the</strong> provision of public<br />
services is, however, generally considered beneficial by both <strong>the</strong> political left and<br />
right. Collaboration can be considered along <strong>the</strong> lines of whe<strong>the</strong>r it is a betterment<br />
administered by outside agencies or empowerment through a degree of community<br />
self-determination (Sullivan and Skelcher, 2002).<br />
<strong>Towards</strong> <strong>the</strong> <strong>Healthy</strong> <strong>City</strong><br />
A development that, in <strong>the</strong>ory at least, has represented a greater opportunity for<br />
collaborative empowerment, is <strong>the</strong> <strong>Healthy</strong> Cities project of <strong>the</strong> World Health<br />
Organisation (WHO). A closer look at this is considered helpful for an appreciation<br />
of <strong>the</strong> challenges faced in working collaboratively to address health and sustainable<br />
development challenges. The WHO <strong>Healthy</strong> Cities Project is a prime example of a<br />
partnership approach, and has become widely accepted for health promotion in <strong>the</strong><br />
urban setting (Norris and Pittman, 2000). As noted above, <strong>the</strong> prevailing paradigm<br />
within public health of a biomedical model of medical treatment, and a ‘victimblaming’<br />
approach to health education, came under mounting criticism in recent<br />
decades. With an increased acknowledgement of <strong>the</strong> social and environmental<br />
determinants of health, <strong>the</strong> work of Thomas McKeown, highlighted <strong>the</strong> importance<br />
of Public Health improvements to <strong>the</strong> nineteenth century city. Following this, and<br />
<strong>the</strong> Lalonde Report of 1974, which forecast <strong>the</strong> importance of <strong>the</strong> promotion of<br />
healthy lifestyles, a consolidated place for community participation in facilitating<br />
healthy lifestyles became accepted, in <strong>the</strong>ory at least, with <strong>the</strong> WHO Alma-Ata<br />
Conference and Declaration on Primary Health Care (Davies and Kelly, 1993). The<br />
conference began a move towards a strategy for ‘Health for All by 2000’, and <strong>the</strong><br />
push for a new public health, which culminated in <strong>the</strong> Ottawa Charter for Health<br />
Promotion of 1986, which encouraged more effective community involvement, and<br />
<strong>the</strong> formal launching of <strong>the</strong> WHO <strong>Healthy</strong> Cities project that year. The <strong>Healthy</strong><br />
Cities moniker is now used throughout <strong>the</strong> world and it has become a global network<br />
for health promotion at <strong>the</strong> city level (Kenzer, 1999).<br />
The European arm of <strong>the</strong> <strong>Healthy</strong> Cities Network has grown from an initial thirty<br />
five cities, for <strong>the</strong> first phase between 1987-1992, to currently over ninety. Through a<br />
series of phases, <strong>the</strong> WHO has guided networks of <strong>the</strong> civic leaders of cities in <strong>the</strong><br />
adoption of policies, multisectorally, that aim to improve health and wellbeing of<br />
<strong>the</strong>ir populations, through a collaborative approach to health promotion. To join <strong>the</strong><br />
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network, a city’s civic leaders prepare a city health profile and a city health<br />
development plan to address core priorities that are renewed every five years. By<br />
1991, participating cities had to have a steering committee of political, business and<br />
civil society representatives and a technical committee. The Phases that have been<br />
established to date can be seen in Table 5 (WHO, 2010c). Hancock (1993) noted that<br />
<strong>the</strong>re are three salient features of <strong>the</strong> <strong>Healthy</strong> Cities project, namely: that health is<br />
considered a positive quality; that an ecological model, that considers <strong>the</strong> many<br />
factors that determine health, is considered preferable; and that a focus is taken on<br />
addressing inequalities in health. Following a WHO Project Office assessment in<br />
1991, and given <strong>the</strong> sense that a process is sought for constant improvement of<br />
citizen’s health, Tsouros and Draper (1993) outlined <strong>the</strong> need for political<br />
commitment and <strong>the</strong> adoption of new working practices, both intersectorally and<br />
with community groups.<br />
Table 5. Phases and overall goals of <strong>the</strong> WHO <strong>Healthy</strong> Cities project<br />
(source WHO, 2010c)<br />
Phase I (1987-1992)<br />
Goal to introduce new ways of working for health in cities<br />
Phase II (1993-1997)<br />
Emphasis on action through healthy public policy and comprehensive city health<br />
planning<br />
Phase III (1998-2002)<br />
Core <strong>the</strong>mes of equity, sustainable development and social development, with a<br />
focus on integrated planning for health development<br />
Phase IV (2003-2008)<br />
Emphasis on equity, sustainable development, participatory and democratic<br />
governance and tackling <strong>the</strong> determinants of health. Also a commitment to working<br />
on healthy ageing, healthy urban planning, health impact assessment and physical<br />
activity and active living<br />
Phase V (2009-2013)<br />
Priority given to health and health equity in all local policies. Core <strong>the</strong>mes are:<br />
caring and supportive environments, healthy living, and healthy urban design. Phase<br />
V is supported by <strong>the</strong> Zagreb Declaration for <strong>Healthy</strong> Cities<br />
The current aims stated by WHO for a <strong>Healthy</strong> <strong>City</strong> can be seen in Table 6. The<br />
<strong>Healthy</strong> Cities project aims have current political backing through <strong>the</strong> commitment<br />
of civic leaders of European cities to <strong>the</strong> Zagreb Declaration of 2008. The<br />
Declaration outlines <strong>the</strong> core principles for a consideration of health in all local<br />
policies, namely: equity; participation and empowerment; working in partnership;<br />
solidarity and friendship; and sustainable development. Fur<strong>the</strong>r to this, <strong>the</strong><br />
Declaration outlines new concerns and challenges. These are summarised as i)<br />
achieving a reduction in inequality, social exclusion and vulnerability, b) reducing<br />
<strong>the</strong> social and economic costs of noncommunicable and chronic diseases, c) tackling<br />
emerging public health threats including climate change, d) achieving a greater<br />
understanding of <strong>the</strong> impacts on health of <strong>the</strong> built environment to help ensure a<br />
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stronger link between policies for health and sustainable development. In keeping<br />
with <strong>the</strong> fourth of <strong>the</strong>se challenges, this article has sought to gain an overview of <strong>the</strong><br />
determinants of health and sought an appreciation of <strong>the</strong> interrelationship of urban<br />
policy with public health.<br />
Challenges for management<br />
In reflecting upon <strong>the</strong> experience of <strong>the</strong> management of <strong>the</strong> <strong>Healthy</strong> Cities project,<br />
points gleaned from <strong>the</strong> academic literature are summarised below in terms of issues<br />
concerned with i) implementation, ii) research and iii) evaluation.<br />
(i) Implementation<br />
The <strong>Healthy</strong> Cities project is essentially a practical movement to enhance public<br />
health, and ultimately to embed a perspective towards health in <strong>the</strong> wider context of<br />
everyday living (Werna et al, 1999).The aims for a healthy city are listed in Table 6<br />
Table 6. Aims for a <strong>Healthy</strong> <strong>City</strong> (Source: WHO, 2010b)<br />
1. a clean, safe, physical environment of high quality (including housing<br />
quality);<br />
2. an ecosystem that is stable now and sustainable in <strong>the</strong> long term<br />
3. a strong mutually supportive and non-exploitative community;<br />
4. a high degree of participation in and control by <strong>the</strong> citizens over <strong>the</strong><br />
decisions affecting <strong>the</strong>ir lives, health and well-being;<br />
5. <strong>the</strong> meeting of basic needs (food, water, shelter, income, safety and<br />
work) for all <strong>the</strong> city’s people;<br />
6. access by <strong>the</strong> people to a wide variety of experiences and resources with<br />
<strong>the</strong> chance for a wide variety of contact, interaction and communication;<br />
7. a diverse, vital and innovative economy;<br />
8. connectedness with <strong>the</strong> past with <strong>the</strong> cultural and biological heritage of<br />
city dwellers and with o<strong>the</strong>r groups and individuals;<br />
9. a form that is compatible with an enhances <strong>the</strong> preceding characteristics;<br />
10. an optimum level of appropriate public health and sickness care services,<br />
accessible to all;<br />
11. high health status (high levels of positive health and low levels of<br />
disease.<br />
In terms of implementation, ra<strong>the</strong>r than compartmentalised or ‘silo-thinking’,<br />
common ground can be sought between various professional disciplines to develop<br />
working partnerships that can give birth to sustainable approaches that have a<br />
renewed sense of holism. Tsourus and Draper (1993) conclude that a successful<br />
healthy cities project depends upon <strong>the</strong> size of <strong>the</strong> city and its economy, strategic<br />
thinking for improving <strong>the</strong> involvement of <strong>the</strong> public, political commitment and<br />
accountability and <strong>the</strong> establishment of multi-sectoral committees. However, <strong>the</strong>re<br />
can be a number of barriers and constraints to cooperative and effective new ways of<br />
working. Traditional health authorities and local government bureaucracies can resist<br />
change to <strong>the</strong>ir modus operandi and <strong>the</strong>re can be a failure to find a common<br />
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‘language’ between health services and social services to discuss and evaluate<br />
priorities. Berkeley and Springett, (2006) coin <strong>the</strong> expression ‘bureaucratic<br />
introversion’ to illustrate <strong>the</strong> difficulties in developing new ways of working for<br />
health. It would seem from <strong>the</strong> literature that questions of successful implementation<br />
are of paramount importance, despite over two decades of experience of <strong>the</strong> <strong>Healthy</strong><br />
Cities project (de Leeuw, 2009).<br />
There can be a diversity of approaches to implementing a healthy cities project, and<br />
<strong>the</strong>re can be a variety of approaches within <strong>the</strong> same country (Flynn, 1993).<br />
However, Werna and Harpham (1996) have a checklist of nine general issues that<br />
came to light through a study of <strong>the</strong> implementation of <strong>Healthy</strong> Cities project in<br />
developing countries, <strong>the</strong>se can be found in Table 7.<br />
Table 7. A Checklist for <strong>the</strong> implementation of <strong>Healthy</strong> Cities<br />
project in developing countries<br />
(source: Werna, E. and Harpham, T., 1996)<br />
(i) <strong>the</strong> appropriateness of <strong>the</strong> institutional organisation of <strong>the</strong> local<br />
authorities;<br />
(ii) conceptual understanding about <strong>the</strong> project among <strong>the</strong> existing<br />
institutions (and <strong>the</strong> project’s members);<br />
(iii) existence of legislation that would make <strong>the</strong> activities of <strong>the</strong> project<br />
officially legitimate;<br />
(iv) existence of a public authority with enough power to co-ordinate <strong>the</strong><br />
process of urban development;<br />
(v) co-operation between different layers of government;<br />
(vi) co-ordination/co-operation between <strong>the</strong> ministries which have agencies<br />
operating in <strong>the</strong> city;<br />
(vii) <strong>the</strong> project’s office capacity to stimulate and build co-operation and to<br />
co-ordinate ongoing activities;<br />
(viii) <strong>the</strong> implementation of internationally funded projects in co-ordination<br />
with existing activities;<br />
(ix) <strong>the</strong> degree of community organisation.<br />
The WHO acknowledgement of <strong>the</strong> importance of personal choice and opinion over<br />
what is a healthy and/or enjoyable course of action, opens <strong>the</strong> debate about health<br />
into a sociological perspective. As such, personal interpretation, as well as differing<br />
professional inputs, point to <strong>the</strong> wisdom of a greater degree of collaboration in <strong>the</strong><br />
promotion of healthy lifestyles, ra<strong>the</strong>r than <strong>the</strong> traditional ‘territorial dominance’ of<br />
<strong>the</strong> medical profession and local authority bureaucracies. Collaboration would<br />
appear to be all <strong>the</strong> more necessary, given <strong>the</strong> scientific evidence of global warming.<br />
(ii) Research<br />
In terms of research, from <strong>the</strong> literature, suggested directions include reviews of <strong>the</strong><br />
literature to improve understanding of <strong>the</strong> debate over environmental justice and<br />
quality, a greater appreciation of people’s perceptions of <strong>the</strong> determinants of quality<br />
of life, and <strong>the</strong> development of a ‘toolbox’ to aid decision-making (Kamp et al,<br />
2003). Tsouros and Draper (1993) have pointed to six areas for which fur<strong>the</strong>r<br />
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research is needed: a) to aid in understanding <strong>the</strong> consequences of disadvantage for<br />
greater equity; b) for studies of health down to <strong>the</strong> city and neighbourhood level as a<br />
precondition of political advocacy and action and associated documentation to<br />
illustrate <strong>the</strong> prerequisites of health; c) for <strong>the</strong> development of new concepts and<br />
methodologies for investigation of <strong>the</strong> impact of urban policy on health; d) to<br />
progress organisational <strong>the</strong>ory for improved intersectoral action; e) to improve<br />
community participation; f) to improve strategic planning that combines a clear<br />
sense of direction with flexibility to changing circumstances.<br />
There are many issues regarding <strong>the</strong> political nature of research, such as <strong>the</strong> agenda<br />
of those funding <strong>the</strong> research. Hunt (1993) points out that <strong>the</strong> underprivileged have<br />
rarely had <strong>the</strong> opportunity to influence <strong>the</strong> topic of <strong>the</strong> research, and conservative<br />
minded and career oriented researchers can also play <strong>the</strong>ir part in maintaining health<br />
discrepancies through using <strong>the</strong> study of <strong>the</strong> poorer sectors of society to fur<strong>the</strong>r <strong>the</strong>ir<br />
own careers, and not effectively disseminating <strong>the</strong> results. Whitehead (1993) also<br />
argues that <strong>the</strong> choice of topics for consideration, <strong>the</strong> choice of methods of research<br />
that are used, and issues over dissemination of results are politically salient<br />
considerations. She points out that need for <strong>Healthy</strong> Cities projects to complement<br />
‘professional’ insights with participatory research for a more genuine sense of<br />
community ownership of <strong>the</strong> agenda, and for more effective dissemination of <strong>the</strong><br />
findings of <strong>the</strong> health research in a broad and timely fashion. Promising signs of<br />
innovative approaches to community health research began to immerge in Australia<br />
and Scotland in <strong>the</strong> 1990s (Baum, 1993; McGhee and McEwen, 1993). However, an<br />
appreciation of who has control of <strong>the</strong> nature of <strong>the</strong> discourse of community<br />
initiatives remains a sobering counter to unbridled enthusiasm for <strong>the</strong>ir apparent<br />
equitable aspirations (Petersen, 1996). Also, if social capital is considered an<br />
enhancement to <strong>the</strong> prospects of making healthy choices, it needs to be<br />
acknowledged that <strong>the</strong> context for participation for a member of a community is<br />
often in informal situations, such as baby sitting, shopping for <strong>the</strong> ill or elderly,<br />
lending tools, even friendly conversations that counter a sense of isolation (Larsen<br />
and Manderson, 1996). Also, <strong>the</strong>re is <strong>the</strong> support that may be given within faithbased<br />
communities. Fur<strong>the</strong>r research into research itself <strong>the</strong>n could be helpful if a<br />
more anthropological and journalistic approach is taken to provide illuminating<br />
stories.<br />
(iii)Evaluation<br />
For public policy, studies of <strong>the</strong> degree of success of particular initiatives provides<br />
justification or o<strong>the</strong>rwise for continued financial support and provides lessons for <strong>the</strong><br />
tailoring of future projects. In terms of evaluation, <strong>the</strong> health impacts of policy are<br />
due to a large number of interconnected factors. This of course presents difficulty in<br />
identifying which inputs are actually beneficial, ei<strong>the</strong>r in isolation or through<br />
mutually reinforcing with o<strong>the</strong>r factors or inputs. Not only is complexity of<br />
interrelationships between social and environmental determinants an issue: any<br />
benefits of health related policy are likely to be difficult to identify as <strong>the</strong>y are only<br />
likely to manifest <strong>the</strong>mselves, or become apparent, over <strong>the</strong> long term. Takano and<br />
Nakamura (2001), in <strong>the</strong>ir analysis of <strong>Healthy</strong> Cities projects, used nine heath<br />
determinant indices, namely: healthcare resources, preventive health activities,<br />
environmental quality, housing, urban clutter, local economy, employment, income<br />
and education. Given <strong>the</strong> more holistic nature of <strong>the</strong> <strong>Healthy</strong> Cities approach, fur<strong>the</strong>r<br />
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work is required to develop methods of evaluating its success or o<strong>the</strong>rwise, in any<br />
particular city, so that lessons can be shared and mistakes avoided (De Leeuw and<br />
Skovgaard, 2005). It would seem that ra<strong>the</strong>r than a reductionist approach, it would be<br />
more helpful to develop a holistic approach to evaluating <strong>the</strong> success or o<strong>the</strong>rwise of<br />
policies in promoting health. Hancock (1993) pointed out that given <strong>the</strong> intersectoral<br />
working required in a city that adopts <strong>the</strong> goals of <strong>the</strong> <strong>Healthy</strong> Cities project, <strong>the</strong>re is<br />
a lack of agreement on <strong>the</strong> measures to be used to evaluate <strong>the</strong> success. He<br />
considered that each city may have to develop its own set of indicators that are<br />
salutogenically oriented. Werna and Harpham (1995) highlight this consideration<br />
between local indicators that can bring out local peculiarities and international<br />
indicators that aid comparison and can be of use in settings where <strong>the</strong> community<br />
may not be prepared for involvement. They also consider that <strong>the</strong> nature of <strong>Healthy</strong><br />
Cities projects is such that process indicators for evaluation have increased relevance<br />
compared to impact evaluations, however both can be used toge<strong>the</strong>r to create a<br />
greater understanding of <strong>the</strong> effectiveness of a project.<br />
The shift from an analysis of illness to one of health and coping with stress requires<br />
sophisticated methods for evaluation. Also, changes to policy, through <strong>the</strong><br />
facilitation of community based initiatives, presents unique difficulties for evaluation<br />
as for any individual, <strong>the</strong>re can be differing perceptions of what actually constitutes a<br />
successful policy (Kline, 2000). Smithies and Adams have pointed out a number of<br />
issues that are faced in <strong>the</strong> evaluation of community based research and <strong>the</strong>se can be<br />
seen in Table 8. Inventive approaches to research began to emerge in <strong>the</strong> 1990s<br />
(Baum, 1993; O’Neill, 1993; McGhee and McEwen, 1993). However, as Kenzer<br />
(1999) points out in her useful literature review, <strong>the</strong>re are is no set blueprint for<br />
evaluation.<br />
Table 8. Difficulties for evaluation of community based strategies, such as<br />
<strong>Healthy</strong> Cities<br />
(source: Smithies, J. And Adams, L., 1993)<br />
(i) various actors and interests sometimes opposing each o<strong>the</strong>r may be<br />
involved<br />
(ii) <strong>the</strong> work is developmental and outcomes are unpredictable<br />
(iii) change takes place constantly<br />
(iv) process is integral and needs evaluation as much as any outcomes<br />
(v) evaluation methods should mirror <strong>the</strong> principles of <strong>the</strong> approach itself<br />
The five points outlined in Table 8, could be addressed by what Curtice (1993) terms<br />
as ‘fourth generation evaluation’ whereby <strong>the</strong>re is feedback between <strong>the</strong> providers<br />
and researchers of health related information at every stage of a project, including<br />
<strong>the</strong> definitions of success. There is clearly scope for improvement in <strong>the</strong> evaluation<br />
in this pluralistic area (Kline, 2000; Gahin, Veleva and Hart, 2003). Fur<strong>the</strong>r work<br />
could be undertaken to develop <strong>the</strong>ory-based evaluation (TBE) methods that give<br />
greater recognition of stakeholder participation and a more explicit<br />
acknowledgement of <strong>the</strong> processes and assumptions involved (Dooris,2005).<br />
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Conclusion<br />
This article has been an exploration of <strong>the</strong> issues surrounding health and sustainable<br />
development. Health impacts are increasingly being seen as a perspective that should<br />
be taken in all aspects of life. Developing country cities have huge challenges ahead<br />
to secure water supply and adequate sanitation and <strong>the</strong> provision of adequate housing<br />
in safe locations (Kjellstrom and Mercado, 2008). However, as Marmot et al (2010)<br />
have shown, health inequalities on a large scale can also exist in a supposedly,<br />
developed country. The Marmot review outlines six key policy objectives to act as a<br />
framework for assessing performance in enhancing health and overcoming health<br />
inequalities. These are presented in Table 9.<br />
Table 9. Framework of policy objectives for assessing performance in<br />
enhancing health and overcoming health inequalities<br />
(Source: Marmot et al, 2010)<br />
A – Give every child <strong>the</strong> best start in life<br />
B - Enable all children, young people and adults to maximise <strong>the</strong>ir<br />
capabilities and have control in <strong>the</strong>ir lives<br />
C – Create fair employment and good work for all<br />
D- Ensure healthy standard of living for all<br />
E - Create and develop healthy and sustainable places and communities<br />
F - Streng<strong>the</strong>n <strong>the</strong> role and impact of ill health prevention<br />
With <strong>the</strong> appropriate political will, inequalities in access to different resources could<br />
be tackled and health inequalities overcome. However, such inequalities are due to a<br />
variety of determinants and overcoming <strong>the</strong>m requires approaches on a number of<br />
fronts. Coupled with this, <strong>the</strong> threats of climate change have led to increased political<br />
pressure for economies to be tailored to address such challenges, whilst also<br />
promoting health and wellbeing. Shiva (2009) argues for <strong>the</strong> need to avoid climate<br />
chaos through a threefold paradigm shift: from a reductionist to a holistic worldview<br />
based on interconnections; from a mechanistic, industrial paradigm to an ecological<br />
one; and from a consumerist definition of being human to one that recognises us as<br />
conservers of <strong>the</strong> earth’s finite resources and cocreators of wealth with nature. With<br />
such a perspective, it is considered that participatory measures taken to respond to<br />
<strong>the</strong> twin threats of climate change and peak oil could also represent an opportunity to<br />
enhance <strong>the</strong> health and wellbeing of <strong>the</strong> poor and vulnerable and reduce health<br />
inequalities in <strong>the</strong> shorter and longer terms. Upon reflection, <strong>the</strong> <strong>Healthy</strong> Cities<br />
project represents an opportunity to find such common solutions to difficult<br />
syndemic problems, especially if a focus is shifted, in a new form of praxis, from <strong>the</strong><br />
study of vulnerabilty to <strong>the</strong> study of healthy resilience and how people adapt and<br />
thrive (Dooris, 2009; Harpham, 2009). There are however many difficulties to<br />
overcome for effective implementation of health promotion initiatives. A holistic,<br />
participatory perspective, if fur<strong>the</strong>r translated to healthy cities research could help to<br />
fur<strong>the</strong>r transcend <strong>the</strong> dominance of <strong>the</strong> academic, scientific research paradigm,<br />
provide a greater degree of accountability for <strong>the</strong> researchers and more effectively<br />
link action, research and evaluation (Smithies and Adams,1993). It is considered that<br />
with fur<strong>the</strong>r multi-sectoral amendments to practice, fur<strong>the</strong>r research over holistic<br />
approaches to health and its determinants, and fur<strong>the</strong>r developments in community<br />
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based health evaluation, <strong>the</strong> WHO <strong>Healthy</strong> Cities project provides a suitable vehicle<br />
for planners and, indeed, global society to organise itself to cope better and to learn<br />
lessons to live both more sustainably and more healthily. The main challenge is for<br />
better and more comprehensive implementation (Kenzer,1999). In <strong>the</strong> words of John<br />
Ashton, in calling for a championing of a community based approach to health, ‘A<br />
new vision for cities and city regions as part of a global community was part of<br />
<strong>Healthy</strong> Cities’ thinking in 1988; it could be <strong>the</strong> driver for change we so desperately<br />
need’ (Ashton, J.R., 2009).<br />
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