Shaping cities for health: complexity and the planning of urban environments in the 21st century

Abstract

The Healthy Cities movement has been in process for almost 30 years, and the features needed to transform a city into a healthy one are becoming increasingly understood. What is less well understood, however, is how to deliver the potential health benefits and how to ensure that they reach all citizens in urban areas across the world. This task is becoming increasingly important because most of the world’s population already live in cities, and, with high rates of urbanisation, many millions more will soon do so in the coming decades. The Commission met during November, 2009, to June, 2011, to provide an analysis of how health outcomes can be improved through modification of the physical fabric of towns and cities and to discuss the role that urban planning can have in the delivering of health improvements. The Commission began from the premise that cities are complex systems, with urban health outcomes dependent on many interactions and feedback loops, so that prediction within the planning process is fraught with difficulties and unintended consequences are common. Although health outcomes are, on average, better in higher-income than in lower-income countries, urban health outcomes in specific cities cannot be assumed to improve with economic growth and demographic change. The so-called urban advantage—a term that encapsulates the health benefits of living in urban as opposed to rural areas—has to be actively created and maintained through policy interventions. Furthermore, average levels of health hide the effect of socioeconomic inequality within urban areas. Rich and poor people live in very different epidemiological worlds, even within the same city. And such disparity occurs in both high-income and low-income countries.Through case studies of sanitation and wastewater management, urban mobility, building standards and indoor air quality, the urban heat island effect (the difference in average temperatures between city centres and the surrounding countryside), and urbanagriculture, we draw attention to the complexities involved in the achievement of urban health improvement through urban planning policies. Complexity thinking stresses that the development of a plan that anticipates all future change for these issues will not be possible. Instead, incremental attempts to reach a goal need to be tried and tested. Such thinking suggests a new approach to planning for urban health—one with three main components. First, there needs to be an emphasis on the promotion of experimentation through diverse projects and the use of trial and error to increase the understanding of how best to improve urban health outcomes in specifi c contexts. Localised projects can be sensitive to local circumstances and might use the resources of local communities and organisations to eff ectively deliver their goals. Urban planners need to be actively looking for windows of opportunity to promote such projects. Second, this emphasis on learning from projects in turn suggests the need for strengthened assessment. However, a different kind of assessment is needed to that usually used for public health interventions. In line with ideas of social learning, such assessment should be based on dialogue, deliberation, and discussion between key stakeholders rather than a technical exercise done by external experts. It would also call on a wide range of sources of knowledge, combining statistical data with the insights of tacit and experiential knowledge held by practitioners and the lay knowledge and experience of local communities. The aim is to create a community of practice of all stakeholders around the incorporation of health concerns into urban development and regeneration to support hands-on learning. Available measures of assessment might prove useful, but only if they are used to support dialogue between stakeholders. Third, consideration of the value-laden nature of policy interventions and the creation of forums to debate the moral and ethical dimensions of different approaches to urban health and city environments are essential. Indepth consultation, mediation, and deliberation are all processes that can be used to engage stakeholders in detailed and problem-orientated argumentation on potential solutions. They can also support the promotion of the urban health agenda itself, an agenda that often falls victim to powerful vested interests and, as a result, the needs of more vulnerable groups in urban societies are often forgotten. If health equity concerns are to be addressed, inclusion of the full range of community representatives within such deliberation and debate is essential.