THE HEALTH AGENDA
AND CITIES IN THE INDUSTRIAL AGE
We think of the health agenda as a matter of illness that needs to be attended to. But what if we were to think of wellness as something to be nurtured?
Our cities are essentially unhealthy places to live, characterised as they are by heavy traffic, high levels of pollution, noise, violence, social disintegration and isolation. Notwithstanding major changes in the physical environment of our cities that have eliminated, or at least controlled the disease blights of the past, people in towns and cities experience increased rates of non-communicable disease, injuries, and alcohol and substance abuse, with poor people typically exposed to the worst environments.
This has created a huge and escalating drain on healthcare resources in industrialised countries. As cities are now home to more than half of the world’s population (and significantly more in highly urbanised countries such as Australia), the challenge of overcoming the health burden of cities developed and managed along agricultural-age and industrial-age lines is increasingly pressing.
There are ways to tackle these challenges. As designers we have a significant role to play in developing and articulating solutions and helping to implement them. Design for Healthy Cities involves a shift in focus toward the World Health Organisation’s notion that health is a state of complete physical, psychological and social well being; not only the absence of illness. The Ottawa Charter for Health Promotion declared in 1986 that “to reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.”
This involves broadening our focus from hospitals to the communities they serve and the cities that nurture them. It involves moving towards the notion that our cities and their systems serve those who occupy them and not the other way round.
As it happens, the challenge of providing for the health and wellbeing of those who live in cities has another side to it: The challenge of transforming cities so that they can prosper in the face of the urgent demand to reduce the rate at which they generate carbon and the rate at which they use our finite resources.
Just as WHO articulated a holistic view of health, so the World Commission on Environment and Development, otherwise known as the Brundtland Commission articulated the idea of sustainable development as “…development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”
The way we live now runs contrary to the demands of sustainable development in two key areas: the rate at which we generate carbon emissions and the rate at which we are using the earth’s resources.
We know we are generating carbon emissions at a rate unprecedented in human history and that the concentration of carbon in the atmosphere is growing relentlessly. There is general consensus that this is leading to climate disruption. While the politics are difficult, we know that our long term future relies on moderating the rate at which we generate carbon emissions and that our short term future relies on us adapting our cities so they become resilient in the face of our changing climate. The burden of dealing with the consequences of climate disruption fall disproportionately on low income countries, even though they have contributed little to the causes, because many of these countries are at particular risk from such consequences as flooding and spread of disease into new habitats. This introduces a moral dimension to the challenge.
As to our use of resources, the concept of an ecological footprint is useful: It is a measure of human demand on the earth’s ecosystems. It represents the amount of biologically productive land and sea area needed to regenerate the resources a human population consumes and to absorb and render harmless the corresponding waste. With our population projected to peak in the second half of this century at something like 9 billion, it is possible to estimate that our maximum allowable ecological footprint is 1.44 global Ha per person. Industrialised countries in almost all cases are consuming resources substantially in excess of this limit.
One of the benefits of the remarkable development achieved around the world over the course of the 20th century has been the marked improvement in standards of living that has accompanied it. The Human Development Index is one way to measure this. HDI is a comparative measure of wellbeing, especially child welfare, based on life expectancy, literacy, education and standard of living for countries worldwide.
Unfortunately, these welcome improvements in standards of living have been accompanied by less welcome increases in carbon and ecological footprints. One of the challenges of coming decades is to decouple the two so that we can achieve improvements in standards of living without compromising our planet’s resources. This is a particular challenge in countries like China, which are urbanising rapidly. In countries with already high standards of living, reducing ecological footprint without compromising standard of living represents a related challenge.
Cities contribute disproportionately to these problems: While they are home to half the world’s population, cities consume over two-thirds of the world’s energy and account for more than 70 percent of global CO2 emissions. Cities are where we need to focus our attention.
I believe that two things are needed: A target for change and a roadmap to get there.
One way of framing a target is Peter Head’s Ecological Age formulation articulated in his 2008 Brunel lecture.
Ecological Age = [CO2 – 80%] + [1.44 gHa per person] + [increase in Human Development Index HDI]
This links necessary action on reducing our carbon footprint and living within our ecological means with an improvement in quality of life. Even in countries with a high HDI score, such as Australia, quality of life challenges remain pressing and growing, as we note above. The idea that we can effect major change in the way we live while at the same time improving our quality of life is at once challenging and liberating. As Mark Watts observed, our challenge is to “…convert a sprawling, polluted, congested 20th century metropolis into a clean, free-flowing, low carbon city able to survive all that the 21st century will throw at it.” Most of the world’s leading cities have evolved over many decades (London, New York, Paris). A few have been created in a concentrated burst of growth (Sao Paulo), but almost none have been ‘planned’. But that is exactly what is needed now. If the 21st century is to be the ‘Ecological Age’, it will also have to be the age of municipal planning.
Janine Benyus’ brilliant Biomimicry provides an excellent guide not only to why but also to how we might design and retrofit infrastructure for the ecological age. Her approach is to adopt principles that mimic the biological system of which we are part, principles that support a virtuous cycle of benefit: Use waste as a resource, use materials sparingly and do not draw down on resources. Behind these lies an ambition to optimise rather than maximise our systems.
The question is: how do we do this?
The way a city operates is the product and reflection of a complex interaction between its physical form and the social, economic and political drivers that influence it. The pressure to reform cities to meet the challenges provided by current and emerging economic, social and ecological drivers can be viewed in terms of optimising the city as a system that encompasses both its physical and social realms. We need cities to work well and efficiently.
It is clear we cannot be prescriptive about how cities should develop, but instead should concentrate on creating a development and governance environment in which resilient and effective solutions can evolve. We believe that the most effective way to achieve this is to adopt a holistic approach to how we think about cities and the way we plan them, develop them, manage them and live in them. In the past, when cities were smaller and simpler and the problems of the city condition were not so acute, cities could be planned and developed effectively enough by addressing elements of the city system separately – so a health department or a transport department or a housing authority could in the twentieth century deliver effectively on its remit. It is clear that in this century such an approach is simply not up to the task.
It is also clear that the linear, centralised infrastructure systems that worked so well for cities in the 20th century – transport, energy, water, waste, food, health – are becoming increasingly stretched and stressed and expensive and are probably no longer the most effective solution for the future as cities continue to expand. Projections for Australia, for instance, show its population approximately doubling in coming decades and we might expect most of that growth to occur in cities. The picture of workers living on the remote urban fringe in houses built on the city’s former market gardens spending ever increasing amounts of their discretionary time travelling on ever more congested roads and railways to jobs in the centre of the city is not an attractive one.
If we think of cities as systems we might think about how best to intervene in those systems. Renowned systems analyst Donella Meadows provides a framework with her classic Twelve Leverage Points to intervene in a System. This framework gives us a means to reflect on those elements we need to focus on to effect change. Meadows notes that we tend to spend an inordinate amount of time focusing on relatively ineffective leverage points and, given the complexity of systems, in many cases push things the wrong way.
Establishment of air quality or water quality standards are examples of intervention in the urban system through manipulation of parameters – item 12 on Meadows’s list. While such measures yield long-term health benefits, their impact is indirect and slow-acting, as they rely on progressive modification to the urban system in response to tightening standards. This demands industry compliance from polluters and establishment of a regime of monitoring and enforcement to support and reinforce the declared standards. This is not to say such standards are not important; simply that they are a weak means of improving the health of cities.
Contrast this with a change of mindset (item 2 on Meadows’s list) reflecting a ‘wellness’ rather than ‘illness’ approach to health, a change from an exclusive focus on care to a mixed one that includes prevention. Such a change in mindset might drive integration of health and urban development policy agendas and attention, for instance, to the drivers of obesity (e.g. creation of more walkable communities, encouragement and facilitation of routine walking and cycling, development of local sources of fresh produce), depression (e.g. attention to social isolation through more comprehensive public transport services) and marital breakdown (e.g. retrieval of discretionary time through attention to land use mix to minimise long commutes). Imagine how effective that could be in reducing the overall demand on struggling health systems, with their ballooning budgets and challenging prospects in the face of projected demographic changes over coming decades. Instead of being regarded as a drain on the public purse, health departments could become the engine room of urban development.
Or contrast the recurring call for more hospital beds (item 10 on Meadows’s list: The size of buffers) with a goal to minimise health department expenditure (item 3). The former may address a specific issue that has emerged in a region but is at best a bandaid solution that does no more than address a symptom of health system malaise. The latter, in contrast, determines overall actions and budgets. If the goal of the health system were amended to focus on optimising health outcomes, a different approach to the health task might well emerge. Driven by a wellness approach to health care, a goal of optimising health outcomes might help drive the inevitable move to community-based care, not simply as a means to limit burgeoning costs but to improve health outcomes.
So, real change in creation of healthy communities demands that we focus on those intervention points that have the power to change the way we think about our cities and the way we manage them. Thinking about the health task in isolation can result in little more than a desperate effort in many jurisdictions of doing more with less, of coping with escalating demands on diminishing budgets. There really is no alternative to adopting an approach that embeds objectives around healthy outcomes in the process of urban design, planning, management and delivery.
Given a number of the health and wellness challenges faced by western societies are the product of current urban form, health professionals have a substantial interest in available means of transforming that urban form.
Specific design interventions can have important impacts on physical and mental health outcomes. For instance, a move away from petrol- and diesel-engined vehicles to walking, cycling and electric vehicles will allow a move back to openable windows and natural ventilation in commercial buildings, with clear and immediate health benefits. Similarly, the benefits to both physical and mental well-being of exposure to the natural environment are well documented. This suggests integration of trees and parkland into the urban fabric not only benefits the physical environment by reducing air pollution and reducing the load on stormwater systems by slowing water runoff, it also has direct health benefits.
A major focus of urban planning and health needs to be on enhancing resilience. Recent natural disasters provide plenty of evidence of the fragility of our city systems and motivation for us to find ways for cities to continue to operate effectively in the face of abnormal conditions as well as normal ones. In our view, development of distributed rather than centralised and linear infrastructure systems – transport, energy, water, waste, food, health – is an important part of the solution to this challenge.
A key way this focus is reflected in health planning is the need to strengthen and support – and, in some cases, create – local communities. Local communities represent the lifeblood of healthy cities and their decline in the second half of the twentieth century in industrial-age cities represents one of the great tragedies of our era. Reinvigoration of local communities (as it happens, an example of Meadows’s item 4: The power to add, change, evolve or self-organise system structure) can provide the foundation on which a wellness-focussed health service is delivered in the ecological age of the 21st century. A city consisting of a network of vibrant local communities filled with empowered citizens will be inherently more resilient than a city with a single central focus surrounded by a sea of community-less commuter suburbs.
Transforming our cities to meet the challenges of the coming decades is vital. So is transforming the way we live in our cities to meet the challenges of delivering on our health agenda. These may be treated as separate and unrelated issues, but to do so invites development of suboptimal outcomes. Better to treat them as the related challenges they are and to work towards best possible outcomes.