Healthy cities and planning

Abstract

The interface between urban planning and human health has had a long history. Public health concerns arising from poor sanitation drove civic design in Roman settlements and major urban planning reforms in industrialised countries in the nineteenth century. In the twentieth and twenty-first centuries, our understanding of how the planning of cities can affect health outcomes has widened to incorporate a greater range of health impacts - obesity, asthma, cardiovascular disease, cancer, to name but a few - and aspects of urban planning such as green space provision, traffic management, urban climate control, air quality management and building standards. We now appreciate that building health into cities is an important role for planning systems, both in the rapidly growing cities of low- to middle-income countries and also in the established cities of high-income countries where there are possibilities of 'retrofitting for health'. In response to this deepening of understanding and recognition, University College London (UCL) and The Lancet joined forces during 2009-11 to convene a Commission with the remit 'to understand the dynamics involved in delivering better health outcomes through built environment interventions in cities across the world'. It sought to develop an analysis that looked at cities across the low-high-income spectrum and focused on how the physical fabric and infrastructure of urban areas can be shaped and reshaped for health. Reviewing the extensive literature on health and cities (for example, Northridge et al., 2003; Sclar et al., 2005; Harpham, 2009; Boyce and Patel, 2010; GNRUHE, 2010 as a few key references) makes it clear that there is a strong degree of consensus on what makes a city healthy: * clean water and good sanitation: a supply of potable water and sanitation infrastructure for sewage treatment and disposal; * clean air: good air quality; * clean land: decontamination of polluted land and facilities for safe waste disposal; * safe homes: housing that provides protection from the weather and a safe indoor environment; * secure neighbourhoods: localities offering security and a sense of community; * car-independence: frequent, affordable and accessible public transport and provision for safe walking and cycling to support mobility and exercise; * green and blue spaces: an infrastructure of greenery and water features for exercise, local climate control, flood prevention and mental well-being; * healthy facilities: an accessible, equitable and functioning system of health care facilities. However, it is equally apparent that many cities across the world do not even meet the basic rights of their citizens with regard to health (Backman, 2008); most fail to fulfil this vision of a healthy city completely. For example, the Healthy Cities movement, which originated in the mid 1980s and has spread across Europe and Northern America and, to a lesser extent, the global South (Ashton, 1986; Hancock, 1993; WHO Regional Office for Europe, 1997; Kenzer, 1999) has found it difficult to achieve outcomes commensurate with its ambitions (Petersen, 1996; Werner and Harpham, 1996; Goumans and Springett, 1997; WHO Regional Office for Europe, 2008; Ritsatakis and Makara, 2009). One criticism made of the Healthy Cities movement is that it lacked a coherent theory of how to deliver change. The Commission therefore devoted considerable time to considering how to conceptualise planning for health in cities. The Commission rejected the widely espoused 'transitions' model which is particularly dominant within the epidemiological literature (e.g. Preston, 1975, Omran, 1983). This looks to economic growth and associated urbanisation and social change as key drivers for better health outcomes. It is closely associated with the arguments for the 'urban advantage', by which it is assumed that people's health will improve as populations move from rural to urban locations. …