Urban Health and Healthy CitiesDr Trevor Hancock

Public Health ConsultantBC Ministry of HealthA presentation at ESPN

Rio de Janeiro, Brazil3rd April 2008

Urban healthUrban health has at least two distinct

meanings: the health of the urban settlement

in terms of how well it functions as a community and as an ecosystem, and

the health of the human population that lives within the urban ecosystem It also sometimes refers to urban health

care

Healthy cities Intended to take health

promotion “out to the streets”, into every day life

Health promotion is “the process of enabling people to increase control over and improve their health”

Ottawa Charter, 1986 So healthy cities is about the

process (= “governance”)

Outline1. Urban ecosystem health2. Urban population health

a) Urban health care3. Healthy cities and healthy

urban governance

1. Urban ecosystem health

Key components of the urban ecosystem

The built environment Social, economic, cultural and

political environments Bio-regions and the biosphere Human beings Other biota

Where North Americans live

We are 80% urbanised We spend 90% of our time indoors

And 5% in our cars So the built environment is the ‘natural

habitat’ of North Americans . . . but we live 100% of the time on the

planet, within natural ecosystems So we are still subject to global and

bioregional changes in ecosystem health

Ecosystems "Ecosystems are communities

of interacting organisms and the physical environment in which they live." (World Resources, 2000-2001)

For humans, the predominant form of community in the 21st century is the city we are now 50% urbanised

Cities as urban ecosystems

We are “communities of interacting organisms” and the physical environment in which we live is increasingly the city . . .

So the city is the dominant ecosystem for humans.

The city is a setting The fact that we interact,

that we are social animals, means the city is, in health promotion terms, a setting both a physical place and a

social space

Cities do not exist in isolation

They are part of local bioregions and global

ecosystems regional, national and global

economies ethno-racial and/or national

cultures and systems of values and politics

Bioregion “A territory defined by a

combination of biological, social and geographic criteria, rather than geopolitical considerations; generally, a system of related, interconnected ecosystems.”

Source: Global Biodiversity Assessment

Greater Toronto Bioregion

Human andecosystem health

All development occurs within the context of regional and global ecosystems:

"In every respect, human development and human security are closely linked to the productivity of ecosystems. Our future rests squarely on their continued viability.

(World Resources, 2000-2001)

The social web of life

The web of social relations is just as vital to our health as the web of life

It too must be sustained

Social ecologyStudy of the relationships

between individuals, social groups and their environments.

The mission of social ecology is the interdisciplinary analysis of complex problems of contemporary society which occur in the social and physical environments.

Public health and social ecology

"...most public health challenges . . . are too complex to be understood adequately from single levels of analysis and, instead, require more comprehensive approaches that integrate psychologic, organizational, cultural, community planning, and regulatory perspectives."

(Stokols, 1996, p. 283)

Urban social sustainability

“the continuing ability of a city to function as a long-term viable setting for human interaction, communication and cultural development . . .”

Yiftachel and Hedgcock, 1993

A socially sustainable city is .

. . “marked by vitality, solidarity

and a common sense of place among its residents . . . (and)

by a lack of overt or violent intergroup conflict, conspicuous spatial segregation, or chronic political instability”

Yiftachel and Hedgcock, 1993

Dimensions of urban ecosystem

health Human population health status Urban community social well-

being Quality of the built environment Quality of urban environmental

media Health of the biotic community Urban ecological footprint

Hancock, 2000

1. Human population health

status The health status of the

urban human population in terms of their physical and mental wellbeing, including the distribution of health and wellbeing across the different segments of the community (health equity);

2. Urban community social

well-being The health of the urban

community - its social well-being - including social, economic and cultural conditions, and the distribution of these and other determinants of health (social equity);

3. Quality of the built environment

The quality of the built environment including aspects of housing quality, transportation, sewage and water supply, roads and public transport systems, parks and recreation facilities and other civic amenities

4. Quality of the urban environmental

media The quality of the urban

environmental media in terms of air, water, soil and noise pollution. This is a measure of environmental quality;

5. Health of the biotic community

The health of the biotic community, including aspects of habitat quality and genetic and species diversity;

6. Urban ecological footprint

The impact of the urban ecosystem on the wider natural ecosystems of which it is a part (the urban ecological footprint). This is a measure of environmental sustainability.

Measuring urban health/ the health of

the cityThere are six aspects of "health" that

need to be measured: - the bio-psychological health of individuals

and populations - the social health of the community as a

whole, - the quality of the built environment - the quality of key environmental media - the health and diversity of the biotic

community - the ecological impact or footprint of the

city.

2. Urban population health

City health and citizen health

The ‘health’ of a city is determined by the broad socio-ecological influences.The health of its citizens is determined by the ‘health’ of the city and by

other factors human biology and heredity personal behaviour income health and other services

1. Human population health

status The health status of the

urban human population in terms of their physical and mental wellbeing, including the distribution of health and wellbeing across the different segments of the community (health equity);

Urban health care? Not the same as “urban health” The provision of health care to

urban populations Challenges (in Canadian cities)

include Ethno-racial diversity Homeless population Mobility (home v work, etc)

3. Healthy cities and healthy

urban governance

Healthy cities Intended to take health

promotion “out to the streets”, into every day life

Health promotion is “the process of enabling people to increase control over and improve their health”

Ottawa Charter, 1986 So healthy cities is about the

process (= “governance”)

Apply the Ottawa Charter

Build healthy public policy Create environments

supportive of health Strengthen community action Develop personal skills Re-orient health care services

Governance “management of the course of

events in a social system” (Burris, Drahos and Shearing, 2005)

“the sum of the many ways individuals and institutions, public and private, plan and manage the common affairs of the city”

(UN Habitat, 2002)

Implications for governance

1. Governance is more than government

it involves all the stakeholders in the city

2. ‘Private policy’ matters the policies of the private sector

that have public effect, e.g. Lending policies and urban form Portion size and obesity

3. Governance requires involving both community organisations and individual citizens.

4. The governance of cities is concerned with the “common affairs of the city”.

Common concerns/issues Common vision Common approaches/solutions

The purpose of governance

The central purpose of governance – and government – is (or should be) sustainable and equitable human development Improving the health of the urban

population is one part of that broader agenda

New forms of governance

Focusing on sustainable and equitable human development requires new forms of governance for

corporations societies cities

New corporate governance

The Natural Step ISO 14001 Sustainable business

Corporate social responsibility World Economic Forum Dow Jones Sustainability Index

Ethical investment Workplace democracy

Healthy Private Policy

Policy of the private sector that has public effect, e.g., fatty foods and portion size urban development housing design working conditions car design

New societal governance

Integrated planning link the three sectors

Human development impact analysis Intersectoral governance

public, private and NGO sectors work together

Steering, not rowing Democratic reform

e.g. BC referendum

New city governance

As for society, but also Participatory democracy

e.g. budget process in Porto Alegre, Brasil

Empowering services Community development

working from the bottom up Bioregional government?

How we usually operate

Socialcapital

Humancapital Natural

capital

Economic capital

How we ought to operate

Socialcapital

Humancapital

Natural capital

Economic capital

3a. Intersectoral action for health

Originally one of the key elements of “Health for All” (1978)

Three aspects Inter-department/inter-ministry/inter-agency

Across different departments within government (“whole of government”)

or within Universities, business corporations, large NGOs Cross or intersectoral action

Across different sectors (public, private, NGO/community, academic etc)

Vertical integration From local to regional to state to national to

international/global

Intersectoral Action for Local Development Inter-department/Inter-

ministry/ Inter-agency

Government NGO andCommunity

Academics Privatesector

Local

Regional

State

National

International

“Whole of Government”

Intersectoral Action for Local Development Cross or Intersectoral

Action

Government NGO andCommunity

Academics Private sector

Local

Regional

State

National

International

Intersectoral Action for Local Development

Vertical integration

Government NGO andCommunity

Academics Privatesector

Local

Regional

State

National

International

Partnerships are key

Which means finding common cause is key What is in it for ‘them’? Why would they help you? How can you help them?

Local government partners

Planning department

Engineering dept Police Education Transportation Others?

Interested in designing better communities protecting humans and the

environment creating safer communities improving human potential moving people and goods

efficiently and safely

Private sector partners

Lots of capacity – people, money, skills and competencies, facilities etc

But - caveat partner! Who makes money out of creating illness,

or profits from illness? Whose ‘bottom line’ improves when

population health improves? Who are the ‘producers of health’,

who could help?

Caveat partner!Don’t partner with those who

make money from selling ill health

the tobacco industry and others lose or don’t make money if the health of the population improves

the ‘medical-industrial complex’? profit in ways that harm health

Whose bottom line improves?

So whose bottom line improves when the public’s health improves?

health and life insurance companies tourism and recreation industries sport and fitness industries others?And all businesses when the health and

productivity of their employees improves

How is health produced?

peace food shelter education income

a stable ecosystem

sustainable resources

social justice and equity

The main determinants of health are

Ottawa Charter for Health WHO, 1986

So who are the producers of

health?Those who Build peaceful relations, locally and

globally Grow our food Build our homes and communities Educate children and adults Create safe communities Protect our environment and

resources Create good jobs and generate income