Healthy cities / by John Ashton

Healthy Cities than five children in 1,000 stay in education after the age of 16 com-pared to 20 per cent in the affluent areas of the city. Mortality rates vary by as much as 100 per cent between social groups. by John Asht6n The growing realisation that most of the improvement in health which has occurred in the recent past has come about because of action outside the medical sector- economic development, better nu- trition and education, better hous- ing and a cleaner environment, and the adoption of birth control-has fostered renewed interest in pre- ventive medicine . This interest has spawned the notion of health pro- motion and, in turn, WHO's strategy of Health for all by the year 2000 with its emphasis on reducing inequalities in health, promoting public participation, reorientating medical care and encouraging an intersectoral approach. Now WHO has established a major new initia- tive focusing on Healthy Cities as a way of taking Health for all off the shelves and into the streets of cities throughout the world. B y the year 2000, 75 per cent of Europeans and a majority of the population throughout the world will live in cities. What will these cities be like and what effect will life in cities have on people's health? The process of mass migration from the countryside to the cities- although a recent phenomenon in the southern hemisphere-began 300 years ago in the north of Europe and North America. At that time, the end of feudalism and revolutions in agriculture and later in industry led to hundreds of thou- sands of people seeking to avoid ru- ral poverty and improve the quality of life of their families by moving to the cities. What many of them en- countered in the great industrial cities such as Manchester and Liverpool was slum housing, envi- ronmental squalor and grinding poverty, conditions which are all too familiar in rapidly growing cities throughout the world today. In Liverpool, which took less than 200 years to grow from a fish- ing village of 5,000 people into one of the greatest world ports with a population of one million people, the result for many citizens was disaster. Epidemics were rampant and infant mortality rates of 200 per 1,000 live births prompted govern- ment intervention in support of a public health movement. A Liver- pool general practitioner, William Henry Duncan, was so concerned about the squalor in which his pa- tients were living that he conducted a survey and found that 25 per cent of the population lived in unventi- lated earth-floored cellar dwellings with no sanitation and no safe water supply. It was Duncan's cam- paigning on behalf of the poor that led to his appointment in 1847 as the United Kingdom's first Medical Officer of Health , and the first moves to establish public health de- partments in city councils through- out the world. After 150 ¥ears, much has im- WORLD HEALTH, June 1988 proved but much remains the same. The infectious diseases may have all but disappeared from the towns and cities in the wealthier northern hemisphere, but they have been re- placed by heart disease, strokes, ac- cidents, cancer, suicide and a range of socially related problems such as stress and depression, alcohol and drug abuse. In the southern hemi- sphere and in poor communities everywhere, epidemics of infectious diseases co-exist with the new life- style epidemics. In their efforts to improve the housing and environ- mental conditions many cities have made fundamental mistakes on a large scale ; building large housing estates with no public participation in their planning, compulsorily removing people from their old neighbourhoods, and breaking up long-established networks of com- munity support. Gross inequalities in health exist between richer and poorer areas. In some areas of Liv- erpool, as many as 70 per cent of men are unemployed and fewer The Healthy Cities symbol incorporates the WHO slogan He?lth for all by the year 2000. Defining the healthy city is not an easy task. Certainly a healthy city is more than one which simply has good health services. The idea implies that the city, as a place which allows scope for human pos- sibility and experience, has a cru- cial role to play in determining the health of those living in it. Yet each city is unique and has its own life, its own soul and spirit, even its own personality. A healthy city has been defined ::. . :. . :: ... . . . . . . UK HEALTHY CITIES Conference LIVERPOOL 28- 30 March 1988 9 as one which is continually expand- ing and creating opportunities for people to live life to the full and to support each other. Central to such a definition is the social implication that, in a healthy city, there is some kind of common field of play and that broadly speaking the citizens are striving towards the same goal. Yet conflict and its creative resolu- tion are also part of a healthy city. At its most fundamental a city is unhealthy if it cannot provide its citizens with these basic resources for health: - safe and adequate food - a safe water supply - sanitation - shelter - freedom from poverty. However, it is clear that these alone are insufficient , and that a range of environmental prerequi- sites (economic, physical , social and cultural) are part of what most people expect for themselves and their families if they are to enjoy full health in the city. The sheer awfulness of much of city life in Europe in the last centu- 10 ry inspired many thinkers to consi- der what a Utopian city might con- sist of, and it is no coincidence that town planning had its origins in public health ; nor that in some countries there often are or have been very close links between na- tional ministries of health , housing, environment and culture. One of the problems of developed cities is the extent to which these functions have become compartmentalised as part of an elaborate bureaucratic structure, with vertical programmes and very little integration to bring about a common effect. Back in the 1870s, an ideal healthy city would have included clean air, public transport, small lo- cal hospitals , community homes for the elderly and mentally ill , no sales of tobacco or alcohol, and the adoption of occupational health measures. Ideas such as this influ- enced the town planner Ebenezer Howard, who developed the first " garden city" suburbs in the United Kingdom in the 1890s as a technical solution to city slums. But it seems that the failure to view technical solutions to human problems through the eyes of those most affected has directly contrib- uted to the large-scale planning di- sasters which have afflicted cities throughout the world. Paternalism has no place in Health for all, or in a healthy city. The Healthy Cities project was set up in 1986 by WHO'S European regional office in Copenhagen to support the development of new public health initiatives, initially in the great townships of Europe. It was particularly influenced by the recent experience of local initia- tives in Toronto and Liverpool. The intention was that , by bringing together a network of European towns and cities to work on the de- velopment of health promotion ini- tiatives , not only would cities learn from each other but they would play an important part in dissemi- nating ideas and triggering a New Public Health movement. So great has been the interest in the project that , instead of four or five cities working together, a group of 20 has had to be established , working WORLD HEALTH, June 1988 Only three hours to go before midnight. Cartoon by lend Dallas, Budapest. Left : " Each city has its own life, even its own personality." Rush hour on the Metro in the Soviet city of Kiev. Right: By 1990, Bombay's teeming streets will pack in 10 million inhabitants. The Healthy Cities project encourages cities to learn from each other and eventually develop a New Public Health Movement. Photos L. Sirman © directly with Copenhagen. As many as 100 others are now involved in national networks, using WHO's Health for all strategy as the basis for drawing up public policies for health in their cities. Canada and Australia have set up their own projects , New Zealand is in the pro- cess of doing so , and there is inter- est in the project in South America , China and the British Common- wealth . A network of French- speaking cities has been established which goes beyond Europe , and a Hispanic-speaking group seems likely. The Healthy Cities project is in- tended to last for five years , by which time the aim is that practical models of health promotion at the city level will be commonplace. The role of WHO is as a catalyst in the process of setting a new agenda for health, raising public consciousness towards new Public Health issues and setting up models of good prac- tice. The project contains seven main elements : 1. The establishment of an inter- sectoral committee for the city W ORLD HEALTH, June 1988 which brings together the key decision-makers from the differ- ent agencies and bureaucracies to take a strategic view of health in the city. 2. A parallel technical group to carry out a community diagnosis which is wide-ranging and has a particular focus on inequalities in health within the city. 3. The creation of a great debate within the city about the nature of current health problems- what can and needs to be done about them. 4. The formulation of city plans for health which are action-based and intersectoral in nature . 5. The development of models of good practice representing the different entry-point priorities of the different cities. These may range from major environmental action to support for better indi- vidual lifestyles or the formation of self-help groups, and will illustrate the principles of health promotion , particularly public participation. 6. Monitoring and research into the effectiveness of models of good practice on health in cities ; this will involve higher educa- tional institutions in meaningful collaboration with their host communities. 7. Mutual support, cultural ex- change, collaboration and learn- ing between cities. In the short time that the project has been in existence, there have been a number of important meet- ings and conferences including one in Goteborg, Sweden, on strategies and one in Barcelona, Spain , to help identify suitable indicators of urban health. Several countries have now held national Healthy City conferences. The project has generated a range of resource ma- terials , including background pa- pers , a resource pack, city health plans , books and a major collabora- tive series broadcast on European television. Schoolchildren are par- ticipating in exchange programmes between the cities. Healthy Cities has already ceased to be a project and is well on its way to becoming a movement. • 11