Towards the Healthy City - Global Built Environment Review

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Whittingham, N GBER Vol .8 Issue. 2 pp 61 - 87 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 62
Whittingham, N GBER Vol .8 Issue. 2 pp 61 - 87 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. 63
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