Towards the Healthy City - Global Built Environment Review

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Towards the Healthy City: An
urban planner's reflection on health
and wellbeing.
*Neil Whittingham
Abstract
Health, in a sense, can be considered an intensely personal matter, strongly
governed by behavioural choices and genetics. However, indicators show that at the
level of the community or the city, marked disparities exist in morbidity and
mortality throughout the world. Clearly, politics, economics and geography also
have a bearing on health outcomes, and not just in environments that are obviously
extremely hazardous. Health problems can in part be due to a failure to reconcile
the impact of the layout and design of urban form with the needs of individuals and
communities for space to achieve a healthy existence. This article seeks a greater
understanding of how the planning, design and management of cities have a bearing
on sustainable development and the health of their citizens. It seeks such an
understanding through a consideration of the social and environmental determinants
of health and the influence that urban policy has upon the quality or liveability of
cities. Lessons are sought from development theory and the move towards more
collaborative approaches to health, looking particularly at the WHO Healthy Cities
Project, to identify challenges and recommendations for future policy.
Key words: health, wellbeing, sustainable development, social and
environmental determinants, urban planning, resilience, collaboration, WHO
Healthy Cities Project.
*Neil Whittingham
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Introduction
As a chartered urban planner in England that had recently returned to university to
study international development, the author of this article offers a reflection on how
concepts that he had recently unearthed from development theory can inform
attempts of urban policy to improve health. At the outset, it is clearly the case that
the place any local economy sits within the wider global economy has a major
bearing on the resources that may be at the disposal of any urban polity. During the
development of the global economy, the legacy of colonialism has had a huge
bearing on the distribution of resources internationally, and this of course has had an
impact on the health of the populations of the world (Gallaher et al., 2009). The
health of the population of any particular country became due to a mixture of
centuries of inequitable forces and, at the global scale, there remains marked
inequalities to this day, with life expectancies in Zambia and Mozambique, for
example, 39 and 41 years of age, respectively (CIA, 2010).
Such startling and sobering examples, and the huge challenge of meeting the
Millennium Development Goals, however, should not blind folk to glaring health
inequalities closer to home. Within England, historically, the impact of overseas
trade and slavery, and the significance of high wage levels and readily available coal,
had led to the development of the economy to such a degree that there became a
widespread capacity to secure a ‘physiological minimum’ diet (Allen, 2009).
Nowadays, there is a general capacity in the country to ensure both adequate
nutrition and rapid medical interventions to treat or prevent disease. However, there
remains a great deal of health inequality in England, as shown by the Strategic
Review of Health Inequalities in England post-2010, undertaken by Professor
Michael Marmot. The report shows that poorer people in English society tend to live
shorter lives. The report estimated that between 1.3 million and 2.5 million extra
years of life could be lived each year in England, if premature deaths could be
prevented (Marmot et al., 2010). Clearly, poor choices have a strong impact on life
expectancies. However, as the social epidemiologists Richard Wilkinson and Kate
Pickett argue in their book Spirit Level, an egalitarian society is a healthier society.
They noted that 10% of the population were obese in 1980 in the UK, and that figure
is now more than 20%. They consider that despite decades of economic growth, in
the light of the recent recession and debt crisis, the poor diets of many children in the
UK today may lead to serious health problems in later life, such as diabetes,
cardiovascular disease and cancer, and there could be a decrease in life expectancies
for the first time since the nineteenth century (Wilkinson and Pickett, 2010).
Renewed fears over food security, with rises in the price of groceries in the west,
serve as reminders of the sensitivity of household budgets to events on an
international scale (Connor, 2010; Thompson and O’Grady, 2010). As such,
questions of health equity and social justice have a persistent relevance at home, as
well as the more immediate problems for the Horn of Africa, for example. However,
there is not only the current travesty of marked inequalities in mortality and
morbidity rates to consider. Forecasted threats to the global economy from climate
change, greater competition over crops and fears over water supply, create a need for
a greater urgency to develop local resilience to the potential health impacts of such
threats. Many commentators believe that in the years to come, the threats of climate
change and the reaching of peak oil will have a severe impact on our economies and
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consequently on health. With this in mind, it is considered that the role of the planner
can help in the design and implementation of suitable adaptation measures that could
work towards the goal of sustainability, whilst, simultaneously, helping overcome
ill-health, vulnerability and health inequalities or, at the very least, help in avoiding
an exacerbation of those problems (Stern, 2007; Chamberlin, 2009). As such, a
greater understanding of the issues surrounding health and sustainable development
at the city level is considered essential, along with an appreciation of how the public
can positively influence its circumstances, in order to help enhance health resilience.
It is the identification of these relationships and the urban policy that strives for a
participatory, sustainable urban development that forms the focus of this article.
Perspectives on Health
The fundamental needs for a healthy life, and the various models by which the varied
and political nature of health has been conceptualised, can act as a starting point for
consideration of what, in theory, urban policy ought to be striving to facilitate. At its
most basic, health depends upon the capacity for any individual, family or
community to secure resources of food and water and a safe place to live. To address
health problems that were encountered, a professional biomedical perspective has
traditionally been predominant within England over the centuries. However,
differing models of health began to challenge this view. Beyond basic needs, the part
that social and emotional matters played in leading a rich and fulfilling life, began to
be more fully acknowledged and so health became to be seen as a more multifaceted
concept. Various authors have tried to encapsulate in words this broad spectrum of
human experience, a famous example being Maslow’s hierarchy of needs, illustrated
in Figure 1.
A socio-ecological perspective, is perhaps more familiar to a planner, in that it
spawned the Public Health and planning movements from the mid-nineteenth
century, with the impact of political factors on a person’s health beginning to be
acknowledged. More recently, within academic literature there has been a turn to a
‘New Public Health’ within which Antonovsky coined the expression salutogenesis,
to describe a perspective that has as its starting point the identification of the
ingredients of a healthy life for an individual and the ability to cope (Hancock,
1993). Ashton and Seymour (1988) list the determinants of the health of a person as:
i) genetic endowment, ii) environment, iii) nutrition, iv) occupation and v) lifestyle.
For them, using the analogy of life being like a river, a look further ‘upstream’ was
seen as necessary for an understanding of the causes of ill-health, rather than solely
dealing with symptoms through the medical profession. An ecological model of
health that more holistically acknowledges the multifaceted nature of the
determinants of health is illustrated in Figure 2.
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Figure 1. Maslow’s hierarchy of needs
ESTEEM
SOCIAL
SAFETY
PHYSIOLOGICAL
SELF
REAL-
IZATION
Source: Ashton, J. and Seymour, H. (1988)
64
Freedom
Self –
fulfilment
Respect
Approval
Self respect
Dignity
Acceptance of others
Affectionate relationships
Group membership
Protection
Security
Environment free from
threat or hazard
Food
Shelter
Freedom from pain
Survival

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Figure 2. The mandala of health: a model of the human ecosystem
Sick
Care
system
Personal
Community
Family
behaviour
y
Human
biology
Culture
Community
Lifestyle
Body
Human-made environment
65
Spirit
Biosphere
Mind
Psychosocioeconomic
environment
Physical
environment
Source: Hancock, 1993
Work

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A positive model of health was famously defined by the World Health Organisation
in 1946 as ‘a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity’ (Barry and Yuill, 2008). This definition reaches
much further than a purely medical science perspective that seeks to address the
symptoms of illness, to one that considers quality of life and focuses upon the
elements that make up a healthy life. The broadening out of perspectives on health to
a fuller acknowledgement of socio-economic and environmental determinants
presents challenges for health research, policy and implementation. There are not
only difficulties in co-ordination of various sectors of the economy and civic life that
have a bearing on health outcomes. Human beings are genetically different and
exercise a degree of choice in their behaviours. People may, of course, have very
differing ideas of what actually constitutes a good quality of life for them as
individuals. Interestingly though, such a perspective on quality of life is increasingly
being recognised at the governmental level and has led to the development of
economic indicators to quantify happiness, such as that for the Himalayan state of
Bhutan, to help show that the wealth of the population is not solely dependent on
financial or material matters (Centre for Bhutan Studies, 2011).
Mental wellbeing and a sense of happiness, however, are unique to the individual
and quite elusive qualities to quantify. Whilst, there are obviously greater risks with
certain behavioural choices, health is clearly related to mental and emotional factors
that are unique to the individual concerned. From psychology studies, Linley et al
(2009), based on earlier studies by Carol Ryff, have emphasised that well-being has
two distinct factors: firstly, subjective well-being, based on perceptions of
satisfaction with one’s life; and secondly, psychological well-being, which has been
conceptualised as having six components, namely, a) positive relations with others,
b) autonomy, c) environmental mastery, d) self-acceptance, e) purpose in life and f)
personal growth. Clearly, the health of city dwellers depends not solely on meeting
basic needs, but also upon the successful negotiation of the opportunities and
challenges of urban living to satisfy these components. This perspective of
preparedness was expressed well by Dubos, ‘Health is the expression of the extent to
which the individual and social body maintain in readiness the resources required to
meet the exigencies of the future’ (Kelly, M.P., Davies, J.K. and Charlton, B.G.,
1993). Greater identification, then, of the linkages between environmental and
spatial policies and health at the city region level, can be vital, being seen as either
part of the quest for sustainable development, and/or with environmental mastery
being seen as a significant component of psychological well-being. Not only mental
health is at stake however; certain urban environments can induce obesity through
the need for a car to travel to work and/or take children to school, or the lack of
convenient access to fresh foods and open space, for example. Socio-economic and
environmental determinants, then, can be considered to have a significant impact on
both physical and psychological well-being and, whilst there is obviously a great
deal of choice in lifestyle that can have a subsequent impact on health outcomes, a
focus on individual responsibility can be overplayed (WHO, 2010).
The Determinants of Health
The physical attributes of any given urban setting, the socio-economic conditions
that prevail at any given time and the capacities of any particular community to
thrive are all unique. Rather than considering that there is a blueprint for planners for
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an ideal healthy city, it would seem more appropriate to strive for the achievement of
certain minimum physical and socio-economic standards and to adopt adequate
processes to facilitate the shaping of a healthy urban environment. The history of
urban planning evolved from a symbiotic relationship with the field of Public Health
and so a renewed appreciation of the determinants of health is considered helpful for
understanding the attributes of a place that could foster healthy living and, thereby,
help inform urban policy to meet the challenges facing the modern city.
Within the academic literature there are many different models through which
research into health can be conducted, and as mentioned above, there has been a
broadening out of perspectives on health to a fuller acknowledgement of the impact
of socio-economic and environmental determinants. As well as the genetics of any
individual and their access to health services, health determinants can include the
physical environment, income and social status, education, gender and social support
networks (WHO, 2010). Even where there is ease of access to health services, there
is the question of quality of those services. The term iatrogenesis refers to how
illness can be caused either clinically by the doctors, hospitals and drug therapies, for
example, or even culturally through an overreliance on the consumption of cures and
medicines, instead of taking more personal responsibility for healthy behaviours in
the first place (Barry and Yuill, 2008). It appears then that there are many broad
fields of study from development theory and management theory through to
sociology and psychology that can bring insights to bear for a better understanding
of the determinants of health, and the degree of human control over them.
A useful starting point for considering what actually constitutes a healthy city, are
the questions for planners put forward by Kamp et al (2003) which are: What is
environmental quality?; What is the effect of my (planning and designing) measures/
interventions on the environmental quality and well-being?; Which factors determine
environmental quality?; How big is the effect?; Are the factors of equal importance
to everyone? Clearly, such questions raise issues that are both physical and social
and this highlights the difficulty in conceptualising the multi-faceted nature of health
to aid urban policymakers. Satterthwaite (1999), however, provides a simple
overview that helps in grasping the main issues for consideration by civic leaders of
a city, see Table 1. A closer look at the five categories shows that they all involve
both science and art, in that the goals could involve engineering, biochemistry and
medical science, on the one hand, and the art of persuasion and political acceptance
of the citizenry to shared environmental, health and safety conscious goals, on the
other.
Table 1. Five broad categories of environmental action for assessing the
performance of cities (based on Satterthwaite, D., 1999)
A. Controlling infections and parasitic diseases and the health burden they take on
city populations, including reducing city populations’ vulnerability to them.
B. Reducing chemical and physical hazards within the home, workplace and wider
society.
C. Achieving a high quality city environment for all city inhabitants – e.g. open
space, and provision for sport and culture.
D. Minimising the transfer of environmental costs to the inhabitants and
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ecosystems surrounding the city.
E. Ensuring progress towards what is referred to its ‘sustainable consumption’, -
i.e. ensuring that the goods and services required to meet everyone’s
consumption needs are delivered without undermining the environmental
capital of nations, the world of future generations.
As well as city planning approaches, Kamp et al (2003) have further outlined how
there are a variety of conceptual models through which goals such as these could be
researched, namely: human ecology; quality of life; social indicators; satisfaction
research; and a focus on transactions. The array of perspectives shows that a holistic
approach to the health within a city is preferable to one that is reductionist (Dooris,
2005). Given the complexity of life in the city, an ecological model of health that
attempts to take in a wider variety of influences would seem to be more appropriate
as a guide for policymakers and managers, akin to what is termed a critical holism,
as encouraged by Vincent Tucker (Pieterse, 2010). Figure 3 is a useful holistic
conceptualisation of the interrelationships that would go towards the make-up of a
sustainable city.
As highlighted in the fifth point in Table 1, perspectives on health can be further
complicated by the threat to wellbeing from poor environmental stewardship, such as
increased vulnerability to the impacts of climate change. Differing scenarios have
forecast affects to the health and wellbeing of the population of a city, such as sea
level rise, melting glaciers and spread of disease and pests, for example, which could
all have a direct bearing on access to fertile land and water, and, indirectly, upon the
prices of food. This can, of course, exacerbate the difficulties of the urban poor and
vulnerable to secure a healthy lifestyle or, indeed, their leaders to secure it for them.
Coupled with this, economies that have relied heavily on fossil fuels are facing a
world where the extraction of oil maybe reaching or has reached its peak. Rapidly
rising prices have made the search for more sustainable practices of paramount
importance for the shoring up of the resilience within communities (Chamberlin,
2009).
Also, an appreciation of the interrelationships shown in Figure 3 is vital if there is to
be a genuine challenge to the new epidemics of obesity, asthma and mental illness
(Jackson, 2002). Freeman (1998), in using the models of social support and stress to
appreciate the relationship between mental health and the environment, argued that
psychiatrists could play more of a role in the political process that shapes the
environment. As well as obvious dangers from pollutants or cold and damp, research
has shown that access to open space and greenery, can not only afford opportunities
for exercise; the very sight of it can also enhance a sense of mental wellbeing
(Jackson, 2002). Spatially, marked health inequalities exist both between and within
cities themselves, however, the question of equitable access to healthy environments
is far from a straightforward one. It has been shown for Glasgow, for example, that
deprivation is more differentiated, and access to resources, physically and
psychologically, can be also be dependent upon i) the quality of the resource; ii)
whether the resource is actually health promoting; iii) whether a resource in a
residential neighbourhood would be used; iv) whether there may be symbolic
barriers to use; and v) the scale and measure of evaluation of deprivation (Macintyre,
MacDonald and Ellaway, 2008).
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Figure 3. Sustainable urbanisation: main components and indicative issues
Health
Care
Source: Adapted from Drakakis-Smith in Pelling (2003)
Shelter
Environmental
Infrastructure
Social
SUSTAINABLE
URBAN
DEVELOPMENT
Demographic Political
Ageing Fertility policies
Modern challenges for planning for health
Given that health is such a multi-faceted concept with a wide variety of
determinants, a marked improvement in health and health equity is more likely to be
effected through a variety of interventions. Dooris (2009) highlighted the tackling of
health inequalities through promoting inclusion, and a synergy with other policies
and an approach to modern day issues that has an appreciation of complex systems.
Kjellstrom and Mercado (2008) present a broad range of possible interventions for
health equity, which is shown in Table 2. They consider that urban planning can play
a key role in such interventions.
Table 2. Broad Spectrum of potential interventions for health equity
(Source: Kjellstrom and Mercado, 2008)
1. Build social cohesion and trust at all levels
2. Improve the living environment
3. Support healthy housing, neighbourhoods and other local settings
4. Invest in clean air
5. Promote easy access to higher quality food
6. Create safe and healthy workplaces
7. Adopt comprehensive strategies to reduce urban violence and
substance abuse
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Employment
Poverty
Economic
Human
Rights
Industrial
policy

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8. Develop more equitable urban health systems
9. Use innovative financing schemes, e.g. cash transfers
10. Hold urban planners accountable for health
11. Address urban sprawl
Such interventions are relevant across the globe. Whilst the local impacts from
uncontrolled industry and squalid housing may have been overcome in western
economies, the development process has been identified as a predominant cause of
climate change. As such, planning in both developed and developing economies
continues to play a significant role in whether the layout of cities lends itself to
healthy environments for all of its citizens, and in attempting to mitigate and adapt to
the threats of climate change. The planning system in the west evolved in socioeconomic
circumstances that were changing following years of austerity. Many of
the worse problems of the urbanisation process had been overcome, though in the
years that followed WWII, increasing car ownership began to put further pressure for
the expansion of cities. Within England, for example, a car oriented economy was
made a fait accompli by a series of cutbacks of support for the rail network and the
support for the road building lobby from the government of Thatcher. In a sense, the
second half of the twentieth century was one in which the seeds of a new public
health crisis were sown through the creation of environments for city dwellers that
contribute to obesity (obesogenic environments), and also to the continued damage
to the global environment through economic expansion.
Within planning theory, the ills of the modern city are not necessarily perceived as
being due to a slow or inadequate response to the socio-economic conditions. If state
planning is geared towards achieving state objectives, as Cherry (1982) points out,
authors from a Marxist perspective see these objectives as often being geared
towards the interest of the dominant class. In the post-WWII neo-liberal economy,
planning can be seen as having reflected these interests through the facilitation of the
development of space to aid in the accumulation of capital. As such, this can have a
differential impact on certain sectors of society, through the creation of an
inequitable distribution of unhealthy environments, with the working class and poor
bearing the brunt of risk of ill-health through increased commuting times, dangerous
roads and isolated, segregated suburban environments, for example. So, for some
authors, the planning system can be perceived as having had, as a priority, the
facilitation of the demands of capital, through addressing the needs of commerce and
the retail industry, and shaping the urban form to remedy disorganisation and aiding
the reproduction of a readily available workforce. It is clear that, in affecting the land
development process, planning does not overcome the inherent contradiction
between private accumulation and collective action (Hall, 2002). The urban planning
of cities, therefore, has a strong bearing on the health and wellbeing of its inhabitants
through determining the levels of access to resources, be that access to work, ease of
movement and transport options, or access to open space, for example. Many factors
such as these can have a bearing on the lifestyle and life of expectancy of any given
individual in an urban setting. An understanding of the relationships between health
and environmental circumstances, then, remains of vital importance in developed
economies, as well as, perhaps, less developed or vulnerable ones. The letter of
Professor Kevin Morgan to the Planning magazine of 27 August 2010 succinctly
emphasises that the planning profession needs to accept responsibility for its part in
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creating obesogenic environments, and he considers that there is an opportunity for
civic planning to play more of a role in addressing public health matters, compared
to a National Health Service that mainly operates by the biomedical model of the
treatment of illness (Morgan, 2010).
Public Health and urban planning appear to have a renewed convergence, within the
academic theory at least. An example of this can be seen with regard to the
encouraging of the public away from the use of cars to increased walking and
cycling. The concerns of planners have generally revolved around congestion,
danger from crashes, and pollution. Further to this, a reduction in the impact of
traffic is now seen as an approach to the mitigation of climate change. These issues
coincide with the concerns of public health to overcome illness that is associated
with lack of activity and obesity and associated illnesses (Hoehner et al, 2003). Also,
new scenarios exist because of the development of computer networks and these are
resulting in the imperatives to be located in a certain place to be loosened (Mitchell,
2000). As such, vastly enhanced communication networks can pose both
opportunities, such as the reduction in the requirement to travel and easier
dissemination of health advice, and threats, such as excessively sedentary lifestyles,
and solitary lifestyles behind a computer, both in offices and at home. This
convergence of interests points to the opportunities for increased synergy between
professions, through multi-level interventions. It would seem that the circumstances
are ripe for transition of the working practices of public health and planning into
more formal collaborative relationships.
The power to shape the city
In recent decades, urban planning has, seemingly, adopted more communicative and
collaborative approaches, as opposed to ‘top-down’, prescriptive ones (Dale, 2004).
It is considered that a clearer appreciation of the political space for the creation of
healthier environments, that may genuinely be available for individuals and
communities, could be helped through an understanding of concepts from the
sociology of development. Awareness of terms, such as agency, capabilities and
social capital, and the academic consideration of the movement towards more
collaborative working and public participation in the provision of public services,
can help underpin more informed urban policy.
Agency, capabilities and social capital
The capacity for anyone to meet their needs in striving for health is not only
dependent upon their physical capabilities, and selfish drives, but also on the state of
the wider economy and the societal will to cooperate in the adequate distribution of
resources. Amartya Sen has usefully encapsulated this relationship by distinguishing
between the processes in society and the opportunities for the individual, and gives
the term ‘unfreedom’ to an inadequacy in either. For poor people, restricted
circumstances lead to a restricted life (Sen, 1999; Yunus, 2010). Externally
established conditions, be they physical, economic or political, are described within
sociology as structure, and the capacity of an individual to control their
circumstances to lead to a particular health outcome, is seen as agency (Barry and
Yuill, 2008). This interplay between the dictates of circumstances and the will,
ability and opportunity to change circumstances lies at the core of what determines a
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healthy life. The distribution of the resources that enable a healthy life is obviously,
contentious and at the macro-economic level, within the current neoliberal economy
of much of the world, the structure provides riches for some, that enable a healthy
prosperous life. However, such wealth can be at the expense of others; a trend that
geographer David Harvey has termed accumulation by dispossession (Harvey,
2005). The agency of any individual to make healthy choices can be strongly
influenced by that structure through the degree of access to jobs and/or financial
credit, education, a healthy environment and good quality housing, for example.
The recent financial crisis for neo-liberal western economies has exacerbated the
difficulties for many to maintain a healthy diet and secure a roof over their heads. A
recent report from the thinktank, the Institute of Fiscal Studies shows that the
austerity measures of the current coalition government in the UK are hitting the
poorest in the country the hardest (Elliott and Dodd, 2010). This economic pressure
can, of course, impact upon the capacity to maintain healthy lifestyles, thereby
increasing the importance for both individuals and communities to be empowered to
enhance their resilience. For any individual, their capabilities to develop their
resilience to environmental threats are dependent upon physical, emotional and
psychological qualities. The capabilities approach was outlined by Sen in his
influential book Development as Freedom in 1999 and further work on the approach
has been undertaken by Nussbaum. A helpful summary of the perspective taken by
Nussbaum can be found in Table 3 (McGillivray, M., 2008). For a person to more
fully and successfully engage with processes that shape the quality of their social,
political and physical environment, it is clear that the more capabilities they have as
individuals the more enhanced are the chances of leading a healthy life.
Relationships with the community also form a part of the capabilities perspective, so
involvement with community activities is not solely seen as a desired political
objective, it is also an aspect of a healthy life for the individual.
Table 3. Nussbaum’s central human functional capabilities
(source: McGillivray, 2008)
Life: being able to live to the end of a human life of normal length; not dying
prematurely, or before one’s life is so reduced as to be not worth living
Bodily health: being able to have good health, including reproductive health; to be
adequately nourished; to have adequate shelter
Bodily integrity: being able to move freely from place to place; having one’s bodily
boundaries treated as sovereign as such being able to secure against assault,
including sexual assault, child sexual abuse, and domestic violence; having
opportunities for sexual satisfaction and for choice in matters of reproduction
Senses, imagination, thought: being able to use the senses, to imagine, think and
reason – and to do these things in a ‘truly human’ way, a way informed and
cultivated by an adequate education, including, but by no means limited to, literacy
and basic mathematical and scientific training
Emotions: being able to have attachments to things and persons outside ourselves; to
love those who love and care for us, to grieve at their absence; in general, to love, to
grieve, to experience longing, gratitude, and justified anger
Practical reason: being able to form a conception of the good and to engage in
critical reflection about the planning of one’ s own life
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Affiliation: being able to live for and towards others, to recognise and show concern
for other human beings, to engage in various forms of social interaction; to be able to
imagine the situation of another and to have compassion for that situation; to have
the capability for both justice and friendship; having the social bases of self-respect
and non-humiliation; being able to be treated as a dignified being whose worth is
equal to that of others (this entails, at a minimum, protections against discrimination
on the basis of race, sex, religion, caste, ethnicity, or national origin)
Other Species: being able to live with concern for and in relation to animals, plants
and the world of nature
Play: being able to laugh, to play, to enjoy recreational activities
Control over one’s environment: being able to participate effectively in political
choices that govern one’s life; having the right of political participation, protection
of free speech and association; being able to hold property (both land and movable
goods), not just formally but in terms of real opportunity; and having property rights
on an equal basis with others; having the right to seek employment on an equal basis
with others; having the freedom from unwarranted search and seizure.
A valid goal for the involvement of an individual in political processes is, surely, to
achieve some form of enhancement of circumstances for themselves and their
community. As such, a key concept in considering the worth of urban policy, that
further expands from a focus solely on the individual, is the degree to which social
capital is improved for local communities. As Bridge et al. (2009) point out,
however, social capital is a contested term that can cover both institutional attempts
to involve the population and also more ‘organic’ forms of organisation within the
community. Various definitions of social capital can be found in Table 4.
Table 4. Definitions of social capital (source: Bridge et al, 2009)
1. features of social life – networks, norms and trust – that enable
participants to act together more effectively to pursue shared
objectives...Social capital, in short, refers to social connections and the
attendant norms and trust.
2. Social capital is seen as the foundation on which social stability and a
community’s ability to help itself are built; and its absence is thought to
be a key factor in neighbourhood decline.
3. the institutions, relationships and norms that shape the quality and
quantity of a society’s social interactions.
4. networks together with shared norms, values and understandings that
facilitate co-operation within or among groups.
5.The term ‘social capital’ is increasingly used by policy makers as another
way of describing ‘community’, but it is important to recognise that a
traditional community is just one of many forms of social capital. Work-
based networks, diffuse friendships and shared or mutually
acknowledged social values can all be seen as forms of social capital.
The Department for International Development considers that to address poverty
and, by implication, tackle poor health, there are five types of capital that are
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considered important for achieving ‘sustainable livelihoods’ . As well as social
capital (which they define as networks of helpful friends, neighbours and associates),
these are: human capital – the capacity to make a living through skills, knowledge,
labour and good health; natural capital – the resources available; physical capital- the
infrastructure and goods; and financial capital – money and credit to achieve
objectives (Bridge et al., 2009). A reflection upon the concepts of agency, capability
and social capital has hopefully been useful, then, to highlight how there is an
interplay between imposed physical circumstances and political structures and the
knowledge, skills and will of individuals and the community to shape that
environment. It is useful to view urban policy in terms of how the capital of the
disadvantaged is actually served or enhanced.
Collaborative approaches to shaping the environment
If control over one’s environment is seen as a significant element of psychological
well-being, active involvement of the public in using their agency to shape urban
policy can contribute to improving both physical and mental health, as well as
working towards the goal of sustainability. Urban policy, in acting as an intervention
to steer development, is generally perceived as either mitigation against the worse
possible environmental impacts of development, an aid to the facilitation of financial
capital or a combination of the two. Within so-called ‘mixed’ economies, there is a
general perception that there are democratic opportunities to influence the design and
layout of cities. For any individual, the capacity and knowledge to shape their
environment in order to enhance their health is mediated through the degree to which
involvement in decision-making is welcomed. It is useful to consider whether the
move towards collaborative and participatory working practices for urban policy has
potential to more directly impact upon social capital in a way that is beneficial to the
poor. The degree to which public involvement in public services is welcomed and
facilitated stems partly from developments from the conflict of ideas between the
capitalist United States and the state socialism of the Soviet Union. The fall of the
Berlin Wall was seen by many commentators as the end game in an ideological
battle over how resources should be distributed, both intra and internationally.
Famously, Thatcher had referred to capitalism as the only game in town and Francis
Fukuyama declared that alternative political ideologies had been defeated and that
liberal democracy was the final highpoint of the history of human political and
economic systems. However, over the last twenty years, within academia and policy
thinktank circles, the neo-liberal policies have become under renewed attack as there
have became growing disparities between rich and poor both across the globe.
Anthony Giddens became influential to policymakers through his ‘Third Way’ which
posited a more socially responsible form of doing business, an increase in
partnership working and policies geared towards social inclusion to bring about a
change in the relationships between the market, the state and civil society (Howell
and Pearce, 2001).
In theory, and subsequently in practice, in recent years there has been an increase in
collaboration in the provision of public services, between the public and private
sectors and civil society. From a Marxist perspective, greater public involvement in
the overall context of a neo-liberal economy, through the use of voluntary labour and
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the creation of a perceived ‘sense of ownership’ of the processes that effect civic life,
could be seen as a way of staving off more radical challenges to the overall structure.
Also, as Arnstein pointed out in her ladder of participation, governmental
programmes can be seen as tokenistic if the public are merely informed of a
proposed development rather than involved in its design or conception. Also, the
choices of who gets involved in a collaborative programme or project can be
unrepresentative and it has been argued that the actual forms of discourse used in
collaborative projects can further the maintenance of unequal power relations, if
certain sectors of the community are uncomfortable with particular formalities or
styles of communication (Fairclough, 2001; Stern and Green, 2008). If the
collaborative approaches that are put into place are to be a valid use of the agency of
the poor, who bear the brunt of the manifest unhealthy environments, the degree to
which the processes prove to be beneficial and ‘pro-poor’ is a salient question to
consider. The evolution of collaborative approaches to the provision of public
services is, however, generally considered beneficial by both the political left and
right. Collaboration can be considered along the lines of whether it is a betterment
administered by outside agencies or empowerment through a degree of community
self-determination (Sullivan and Skelcher, 2002).
Towards the Healthy City
A development that, in theory at least, has represented a greater opportunity for
collaborative empowerment, is the Healthy Cities project of the World Health
Organisation (WHO). A closer look at this is considered helpful for an appreciation
of the challenges faced in working collaboratively to address health and sustainable
development challenges. The WHO Healthy Cities Project is a prime example of a
partnership approach, and has become widely accepted for health promotion in the
urban setting (Norris and Pittman, 2000). As noted above, the prevailing paradigm
within public health of a biomedical model of medical treatment, and a ‘victimblaming’
approach to health education, came under mounting criticism in recent
decades. With an increased acknowledgement of the social and environmental
determinants of health, the work of Thomas McKeown, highlighted the importance
of Public Health improvements to the nineteenth century city. Following this, and
the Lalonde Report of 1974, which forecast the importance of the promotion of
healthy lifestyles, a consolidated place for community participation in facilitating
healthy lifestyles became accepted, in theory at least, with the WHO Alma-Ata
Conference and Declaration on Primary Health Care (Davies and Kelly, 1993). The
conference began a move towards a strategy for ‘Health for All by 2000’, and the
push for a new public health, which culminated in the Ottawa Charter for Health
Promotion of 1986, which encouraged more effective community involvement, and
the formal launching of the WHO Healthy Cities project that year. The Healthy
Cities moniker is now used throughout the world and it has become a global network
for health promotion at the city level (Kenzer, 1999).
The European arm of the Healthy Cities Network has grown from an initial thirty
five cities, for the first phase between 1987-1992, to currently over ninety. Through a
series of phases, the WHO has guided networks of the civic leaders of cities in the
adoption of policies, multisectorally, that aim to improve health and wellbeing of
their populations, through a collaborative approach to health promotion. To join the
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network, a city’s civic leaders prepare a city health profile and a city health
development plan to address core priorities that are renewed every five years. By
1991, participating cities had to have a steering committee of political, business and
civil society representatives and a technical committee. The Phases that have been
established to date can be seen in Table 5 (WHO, 2010c). Hancock (1993) noted that
there are three salient features of the Healthy Cities project, namely: that health is
considered a positive quality; that an ecological model, that considers the many
factors that determine health, is considered preferable; and that a focus is taken on
addressing inequalities in health. Following a WHO Project Office assessment in
1991, and given the sense that a process is sought for constant improvement of
citizen’s health, Tsouros and Draper (1993) outlined the need for political
commitment and the adoption of new working practices, both intersectorally and
with community groups.
Table 5. Phases and overall goals of the WHO Healthy Cities project
(source WHO, 2010c)
Phase I (1987-1992)
Goal to introduce new ways of working for health in cities
Phase II (1993-1997)
Emphasis on action through healthy public policy and comprehensive city health
planning
Phase III (1998-2002)
Core themes of equity, sustainable development and social development, with a
focus on integrated planning for health development
Phase IV (2003-2008)
Emphasis on equity, sustainable development, participatory and democratic
governance and tackling the determinants of health. Also a commitment to working
on healthy ageing, healthy urban planning, health impact assessment and physical
activity and active living
Phase V (2009-2013)
Priority given to health and health equity in all local policies. Core themes are:
caring and supportive environments, healthy living, and healthy urban design. Phase
V is supported by the Zagreb Declaration for Healthy Cities
The current aims stated by WHO for a Healthy City can be seen in Table 6. The
Healthy Cities project aims have current political backing through the commitment
of civic leaders of European cities to the Zagreb Declaration of 2008. The
Declaration outlines the core principles for a consideration of health in all local
policies, namely: equity; participation and empowerment; working in partnership;
solidarity and friendship; and sustainable development. Further to this, the
Declaration outlines new concerns and challenges. These are summarised as i)
achieving a reduction in inequality, social exclusion and vulnerability, b) reducing
the social and economic costs of noncommunicable and chronic diseases, c) tackling
emerging public health threats including climate change, d) achieving a greater
understanding of the impacts on health of the built environment to help ensure a
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stronger link between policies for health and sustainable development. In keeping
with the fourth of these challenges, this article has sought to gain an overview of the
determinants of health and sought an appreciation of the interrelationship of urban
policy with public health.
Challenges for management
In reflecting upon the experience of the management of the Healthy Cities project,
points gleaned from the academic literature are summarised below in terms of issues
concerned with i) implementation, ii) research and iii) evaluation.
(i) Implementation
The Healthy Cities project is essentially a practical movement to enhance public
health, and ultimately to embed a perspective towards health in the wider context of
everyday living (Werna et al, 1999).The aims for a healthy city are listed in Table 6
Table 6. Aims for a Healthy City (Source: WHO, 2010b)
1. a clean, safe, physical environment of high quality (including housing
quality);
2. an ecosystem that is stable now and sustainable in the long term
3. a strong mutually supportive and non-exploitative community;
4. a high degree of participation in and control by the citizens over the
decisions affecting their lives, health and well-being;
5. the meeting of basic needs (food, water, shelter, income, safety and
work) for all the city’s people;
6. access by the people to a wide variety of experiences and resources with
the chance for a wide variety of contact, interaction and communication;
7. a diverse, vital and innovative economy;
8. connectedness with the past with the cultural and biological heritage of
city dwellers and with other groups and individuals;
9. a form that is compatible with an enhances the preceding characteristics;
10. an optimum level of appropriate public health and sickness care services,
accessible to all;
11. high health status (high levels of positive health and low levels of
disease.
In terms of implementation, rather than compartmentalised or ‘silo-thinking’,
common ground can be sought between various professional disciplines to develop
working partnerships that can give birth to sustainable approaches that have a
renewed sense of holism. Tsourus and Draper (1993) conclude that a successful
healthy cities project depends upon the size of the city and its economy, strategic
thinking for improving the involvement of the public, political commitment and
accountability and the establishment of multi-sectoral committees. However, there
can be a number of barriers and constraints to cooperative and effective new ways of
working. Traditional health authorities and local government bureaucracies can resist
change to their modus operandi and there can be a failure to find a common
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‘language’ between health services and social services to discuss and evaluate
priorities. Berkeley and Springett, (2006) coin the expression ‘bureaucratic
introversion’ to illustrate the difficulties in developing new ways of working for
health. It would seem from the literature that questions of successful implementation
are of paramount importance, despite over two decades of experience of the Healthy
Cities project (de Leeuw, 2009).
There can be a diversity of approaches to implementing a healthy cities project, and
there can be a variety of approaches within the same country (Flynn, 1993).
However, Werna and Harpham (1996) have a checklist of nine general issues that
came to light through a study of the implementation of Healthy Cities project in
developing countries, these can be found in Table 7.
Table 7. A Checklist for the implementation of Healthy Cities
project in developing countries
(source: Werna, E. and Harpham, T., 1996)
(i) the appropriateness of the institutional organisation of the local
authorities;
(ii) conceptual understanding about the project among the existing
institutions (and the project’s members);
(iii) existence of legislation that would make the activities of the project
officially legitimate;
(iv) existence of a public authority with enough power to co-ordinate the
process of urban development;
(v) co-operation between different layers of government;
(vi) co-ordination/co-operation between the ministries which have agencies
operating in the city;
(vii) the project’s office capacity to stimulate and build co-operation and to
co-ordinate ongoing activities;
(viii) the implementation of internationally funded projects in co-ordination
with existing activities;
(ix) the degree of community organisation.
The WHO acknowledgement of the importance of personal choice and opinion over
what is a healthy and/or enjoyable course of action, opens the debate about health
into a sociological perspective. As such, personal interpretation, as well as differing
professional inputs, point to the wisdom of a greater degree of collaboration in the
promotion of healthy lifestyles, rather than the traditional ‘territorial dominance’ of
the medical profession and local authority bureaucracies. Collaboration would
appear to be all the more necessary, given the scientific evidence of global warming.
(ii) Research
In terms of research, from the literature, suggested directions include reviews of the
literature to improve understanding of the debate over environmental justice and
quality, a greater appreciation of people’s perceptions of the determinants of quality
of life, and the development of a ‘toolbox’ to aid decision-making (Kamp et al,
2003). Tsouros and Draper (1993) have pointed to six areas for which further
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research is needed: a) to aid in understanding the consequences of disadvantage for
greater equity; b) for studies of health down to the city and neighbourhood level as a
precondition of political advocacy and action and associated documentation to
illustrate the prerequisites of health; c) for the development of new concepts and
methodologies for investigation of the impact of urban policy on health; d) to
progress organisational theory for improved intersectoral action; e) to improve
community participation; f) to improve strategic planning that combines a clear
sense of direction with flexibility to changing circumstances.
There are many issues regarding the political nature of research, such as the agenda
of those funding the research. Hunt (1993) points out that the underprivileged have
rarely had the opportunity to influence the topic of the research, and conservative
minded and career oriented researchers can also play their part in maintaining health
discrepancies through using the study of the poorer sectors of society to further their
own careers, and not effectively disseminating the results. Whitehead (1993) also
argues that the choice of topics for consideration, the choice of methods of research
that are used, and issues over dissemination of results are politically salient
considerations. She points out that need for Healthy Cities projects to complement
‘professional’ insights with participatory research for a more genuine sense of
community ownership of the agenda, and for more effective dissemination of the
findings of the health research in a broad and timely fashion. Promising signs of
innovative approaches to community health research began to immerge in Australia
and Scotland in the 1990s (Baum, 1993; McGhee and McEwen, 1993). However, an
appreciation of who has control of the nature of the discourse of community
initiatives remains a sobering counter to unbridled enthusiasm for their apparent
equitable aspirations (Petersen, 1996). Also, if social capital is considered an
enhancement to the prospects of making healthy choices, it needs to be
acknowledged that the context for participation for a member of a community is
often in informal situations, such as baby sitting, shopping for the ill or elderly,
lending tools, even friendly conversations that counter a sense of isolation (Larsen
and Manderson, 1996). Also, there is the support that may be given within faithbased
communities. Further research into research itself then could be helpful if a
more anthropological and journalistic approach is taken to provide illuminating
stories.
(iii)Evaluation
For public policy, studies of the degree of success of particular initiatives provides
justification or otherwise for continued financial support and provides lessons for the
tailoring of future projects. In terms of evaluation, the health impacts of policy are
due to a large number of interconnected factors. This of course presents difficulty in
identifying which inputs are actually beneficial, either in isolation or through
mutually reinforcing with other factors or inputs. Not only is complexity of
interrelationships between social and environmental determinants an issue: any
benefits of health related policy are likely to be difficult to identify as they are only
likely to manifest themselves, or become apparent, over the long term. Takano and
Nakamura (2001), in their analysis of Healthy Cities projects, used nine heath
determinant indices, namely: healthcare resources, preventive health activities,
environmental quality, housing, urban clutter, local economy, employment, income
and education. Given the more holistic nature of the Healthy Cities approach, further
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work is required to develop methods of evaluating its success or otherwise, in any
particular city, so that lessons can be shared and mistakes avoided (De Leeuw and
Skovgaard, 2005). It would seem that rather than a reductionist approach, it would be
more helpful to develop a holistic approach to evaluating the success or otherwise of
policies in promoting health. Hancock (1993) pointed out that given the intersectoral
working required in a city that adopts the goals of the Healthy Cities project, there is
a lack of agreement on the measures to be used to evaluate the success. He
considered that each city may have to develop its own set of indicators that are
salutogenically oriented. Werna and Harpham (1995) highlight this consideration
between local indicators that can bring out local peculiarities and international
indicators that aid comparison and can be of use in settings where the community
may not be prepared for involvement. They also consider that the nature of Healthy
Cities projects is such that process indicators for evaluation have increased relevance
compared to impact evaluations, however both can be used together to create a
greater understanding of the effectiveness of a project.
The shift from an analysis of illness to one of health and coping with stress requires
sophisticated methods for evaluation. Also, changes to policy, through the
facilitation of community based initiatives, presents unique difficulties for evaluation
as for any individual, there can be differing perceptions of what actually constitutes a
successful policy (Kline, 2000). Smithies and Adams have pointed out a number of
issues that are faced in the evaluation of community based research and these can be
seen in Table 8. Inventive approaches to research began to emerge in the 1990s
(Baum, 1993; O’Neill, 1993; McGhee and McEwen, 1993). However, as Kenzer
(1999) points out in her useful literature review, there are is no set blueprint for
evaluation.
Table 8. Difficulties for evaluation of community based strategies, such as
Healthy Cities
(source: Smithies, J. And Adams, L., 1993)
(i) various actors and interests sometimes opposing each other may be
involved
(ii) the work is developmental and outcomes are unpredictable
(iii) change takes place constantly
(iv) process is integral and needs evaluation as much as any outcomes
(v) evaluation methods should mirror the principles of the approach itself
The five points outlined in Table 8, could be addressed by what Curtice (1993) terms
as ‘fourth generation evaluation’ whereby there is feedback between the providers
and researchers of health related information at every stage of a project, including
the definitions of success. There is clearly scope for improvement in the evaluation
in this pluralistic area (Kline, 2000; Gahin, Veleva and Hart, 2003). Further work
could be undertaken to develop theory-based evaluation (TBE) methods that give
greater recognition of stakeholder participation and a more explicit
acknowledgement of the processes and assumptions involved (Dooris,2005).
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Conclusion
This article has been an exploration of the issues surrounding health and sustainable
development. Health impacts are increasingly being seen as a perspective that should
be taken in all aspects of life. Developing country cities have huge challenges ahead
to secure water supply and adequate sanitation and the provision of adequate housing
in safe locations (Kjellstrom and Mercado, 2008). However, as Marmot et al (2010)
have shown, health inequalities on a large scale can also exist in a supposedly,
developed country. The Marmot review outlines six key policy objectives to act as a
framework for assessing performance in enhancing health and overcoming health
inequalities. These are presented in Table 9.
Table 9. Framework of policy objectives for assessing performance in
enhancing health and overcoming health inequalities
(Source: Marmot et al, 2010)
A – Give every child the best start in life
B - Enable all children, young people and adults to maximise their
capabilities and have control in their lives
C – Create fair employment and good work for all
D- Ensure healthy standard of living for all
E - Create and develop healthy and sustainable places and communities
F - Strengthen the role and impact of ill health prevention
With the appropriate political will, inequalities in access to different resources could
be tackled and health inequalities overcome. However, such inequalities are due to a
variety of determinants and overcoming them requires approaches on a number of
fronts. Coupled with this, the threats of climate change have led to increased political
pressure for economies to be tailored to address such challenges, whilst also
promoting health and wellbeing. Shiva (2009) argues for the need to avoid climate
chaos through a threefold paradigm shift: from a reductionist to a holistic worldview
based on interconnections; from a mechanistic, industrial paradigm to an ecological
one; and from a consumerist definition of being human to one that recognises us as
conservers of the earth’s finite resources and cocreators of wealth with nature. With
such a perspective, it is considered that participatory measures taken to respond to
the twin threats of climate change and peak oil could also represent an opportunity to
enhance the health and wellbeing of the poor and vulnerable and reduce health
inequalities in the shorter and longer terms. Upon reflection, the Healthy Cities
project represents an opportunity to find such common solutions to difficult
syndemic problems, especially if a focus is shifted, in a new form of praxis, from the
study of vulnerabilty to the study of healthy resilience and how people adapt and
thrive (Dooris, 2009; Harpham, 2009). There are however many difficulties to
overcome for effective implementation of health promotion initiatives. A holistic,
participatory perspective, if further translated to healthy cities research could help to
further transcend the dominance of the academic, scientific research paradigm,
provide a greater degree of accountability for the researchers and more effectively
link action, research and evaluation (Smithies and Adams,1993). It is considered that
with further multi-sectoral amendments to practice, further research over holistic
approaches to health and its determinants, and further developments in community
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based health evaluation, the WHO Healthy Cities project provides a suitable vehicle
for planners and, indeed, global society to organise itself to cope better and to learn
lessons to live both more sustainably and more healthily. The main challenge is for
better and more comprehensive implementation (Kenzer,1999). In the words of John
Ashton, in calling for a championing of a community based approach to health, ‘A
new vision for cities and city regions as part of a global community was part of
Healthy Cities’ thinking in 1988; it could be the driver for change we so desperately
need’ (Ashton, J.R., 2009).
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