The following section considers those basic principles underlying the building of healthy cities. It briefly presents the eleven principles that the World Health Organization has repeatedly presented in documentation about the WHO Healthy Cities project to characterise healthy cities (Goldstein, 2000; Tsouros, 1990). Each paragraph explains how these principles can be interpreted to construct healthy cities. The 11 principles of a healthy city are shown in Table 1.
1. The meeting of basic needs (for food, water shelter, income, safety and work) for all the city's people. During the 8000 to 9000 year history of cities, the health of urban populations has been closely related to the management of diverse kinds of natural and human-made hazards which can be a cause of serious injury, illness or premature death. A major task of public authorities is to sustain the supply of basic resources (especially safe water and uncontaminated food), and to ensure the disposal of all kinds of solid and liquid wastes.
Rapid urbanisation during the last century has induced stress on natural ecosystems (Boyden, 1987; McMichael, 1993; Giradet, 1999). This has meant that it is increasingly difficult to guarantee the supply of unpolluted water, uncontami-nated fresh foods, sanitary housing and efficient community services and facilities. For example, the large majority of urban populations in the world are totally dependent on imported foods from far beyond the hinterland of their city. In 2000, only an estimated 15% to 20% of all food in the world was produced in urban areas.
Table 1. Eleven Principles of the WHO Healthy Cities Project
1. The meeting of basic needs (for food, water, shelter, income, safety, and work) for all the city's people
2. A clean, safe physical environment of high quality, including housing quality.
3. An ecosystem that is stable now and sustainable in the long-term.
4. A diverse, vital and innovative economy
5. A strong, mutually supportive and non-exploitive community
6. A high degree of participation and control by the public over the decisions affecting their lives, health, and well-being.
7. The encouragement of connectedness with the past, with the cultural and biological heritage of city-dwellers and with other groups and individuals.
8. Access to a wide variety of experiences and resources with the chance for a wide variety of contact, interaction, and communications.
9. A form that is compatible with and enhances the preceding characteristics.
10. An optimum level of appropriate public health and sick care services accessible to all.
11. High health status (high levels of positive health and low levels of disease).
Source: World Health Organization, in diverse publications; refer to (Goldstein, 2000).
In 2000, the World Health Organization estimated that more than 30% of the world population suffered from one or more of the numerous kinds of malnutrition, and that urban populations were disproportionately at risk. Malnutrition is more common among refugees and displaced populations concerning an estimated 21.5 million people in 1999 (WHO, 2000b). The health implications of malnutrition range from stunted growth during childhood, development of brain damage, risks of other illness and mortality from non-communicable diseases.
An integrated approach to food production and consumption, environmental quality, sustainable resource use and health can be achieved by policies that promote the local production of fresh foods. This innovative approach to urban agriculture can address deficiencies in the nutrition of citizens and reduce the risk of food-borne and non-communicable diseases while simultaneously promoting food security. Food security means that all people continually have "physical and economic access to enough food for an active, healthy life." This concept implies that food production and consumption are sustainable, governed by principles of equity and that "the food is nutritionally adequate and personally and culturally acceptable; and that food is obtained (and consumed) in a matter that upholds basic human dignity." (Pederson, et al., 2000).
2. A clean, safe physical environment of high quality, including housing quality. Urban environments are known to be an important determinant of quality of life and well-being following the results of numerous studies in a range of disciplines cited in other chapters of this Handbook. The multiple components of private and public buildings, infrastructure and services, as well as public outdoor space ought to be considered in terms of their potential and effective contribution to physical, social and mental well-being. It has been common for the World Health Organization to refer to the following eight main components of urban environments.
First, the characteristics of the site, in ensuring safety from "natural" disasters including earthquakes, landslides, flooding and fires; and protection from any potential source of natural radon (World Health Organization, 1997a). Second, the built environment as a shelter for the inhabitants from the extremes of outdoor temperature, as a protector against dust, insects and rodents, and as a provider of security from unwanted persons, and as an insulator against noise (World Health Organization, 1990). Third, effective provision of a safe and continuous supply of water that meets standards for human consumption, and the maintenance of sewage and solid waste disposal (World Health Organization, 1992). Forth, ambient atmospheric conditions in the residential neighbourhood and indoor air quality. Both of these sets of conditions are related to emissions from industrial production in urban areas, as well as transportation, fuels used for domestic cooking and heating, and the local climate and ventilation inside and around buildings (Schwela, 2000). Fifth, occupancy conditions in buildings (notably population density in residential buildings), which can influence the transmission of airborne infections including pneumonia and tuberculosis, and the incidence of injury from domestic accidents (Gray, 2001; Landon, 1996). Sixth, accessibility to community facilities and services (for commerce, education, employment, leisure and primary health care) that are affordable and available to all individuals and groups irrespective of age, socio-economic status, ethnicity or religion (World Health Organization, 2000a). Seventh, food safety, including the provision of uncontaminated fresh foods and water that can be stored with protection against spoilage (World Health Organization, 1997b). Eighth, the control of vectors and hosts of disease outdoors and inside buildings which can propagate in the building structure, the use of non-toxic materials and finishes for building construction, the use and storage of hazardous substances or equipment in the urban environment (World Health Organization, 1990).
Research in environmental psychology during the 1990s confirms that the relations between urban environments and health are not limited to the above eight components. In addition, the urban environment, especially residential neighborhoods, ought to be considered in terms of its capacity to nurture and sustain social and psychological processes (Gabe and Williams, 1993; Halpern, 1995; Ludermir and Harpham, 1998). For example, the capacity of the resident in her/his home environment to alleviate stress accumulated at school or in the workplace, and whether this capacity is mediated by views of nature or being in natural surroundings such as urban parks. The multiple dimensions of residential environments that circumscribe the resident's capacity to use her/his domestic setting to promote well-being is a subject that has been studied by a limited number of scholars during the last decade (Ekblad, 1993; Halpern, 1995). Studies in several industrialized countries show that more than half of all non-sleep activities of employed people between 18 and 64 years of age occur inside housing units. Children, the aged and housewives spend even more time indoors. Consequently, their prolonged exposure to shortcomings in the indoor residential environment may have a strong impact on their health and well being (World Health Organization, 1990).
3. An ecosystem that is stable now and sustainable in the long term. The construction of new cities or urban neighborhoods should be considered after a careful appraisal of the constituents of the local environment. Explicit land use guidelines and policies should avoid flood plains, seismic faults and dangers from landslides, while preserving wildlife habitat and agricultural fields in the hinterlands (Girardet, 1999). The site chosen for future urban development can be identified by establishing that it will incur the least ecological, economic and social costs. Consequently, new cities and urban neighborhoods can be developed in a way that preserves the ecological infrastructure underlying the human settlement, especially genetic diversity, soil fertility, mineral reserves, and water catchment areas.
Data and statistics show that many informal housing areas are located on sites that are at risk from natural or human-made hazards. For example, on 17th January 1995, an earthquake in the Kobe-Osaka urban region killed over 6000 people, and ten times that number were injured. In 1999, the cyclone that hit Orissa, India caused the destruction of 742,143 housing units (Mitchell, 1999). After an earthquake in Turkey that year about 1 million people were recorded as homeless including 70% of the population of Izmit.
During the period 1990-1999 more than 186 million people lost their homes due to a natural or a human-made disasters. Armed conflict contributed to about 100 million homeless people. Technological disasters were less significant in the 1990s resulting in about 164'200 homeless people following accidental chemical pollution, explosions and fires in or near industrial plants (UNCHS, 2001). What is also notable in these cases of natural disasters is that injury and death are disproportionately high among low-income groups who live on sloping sites prone to landslides, or in residential buildings least able to withstand the tremors (Mitchell, 1999; UNCHS, 1996). During the 20th century, social development and urban policies in many countries were dominated by issues related to economic and population growth, the accumulation and distribution of capital and material goods, as well as managing the interrelations between public and private interests. This means that the health and well-being of current and future generations, as well as the ecological impacts of urbanization have not been a high priority.
4. A diverse, vital and innovative economy. Urbanization is a process that has been considered in relation to the economic growth of national economies and more recently the global economy (Duffy, 1995; Lo and Yeung, 1998). In some countries, cities are locations for about two-thirds of Gross Domestic Product (GDP). The Bangkok Metropolitan Area, for example, accounts for 74% of manufacturing even though it includes only 10% of Thailand's population. Likewise, Manila comprises 15% of the total population of the Philippines but it produces a third of GDP and it includes about two-thirds of all manufacturing plants (Fuchs, etal, 1994).
Economic, health and other social policies share a goal of improving the livelihood of the inhabitants. Nonetheless, not all cities, nor the inhabitants of a specific city, benefit equally. Economic, health and other social policies raise complex questions that do not have simple answers (Lawrence, 1995). The implementation of these kinds of policies may have outcomes that are neither symmetrical, predictable, nor equitable. During the last three decades, those countries in the South that urbanized most rapidly also had the highest levels of economic growth (UNCHS, 1996). Nonetheless, these trends have also led to relatively high levels of urban poverty and limited achievements in improving environmental conditions including a sufficient volume of potable water, and effective site drainage, and sewage and solid waste disposal. These consequences can have direct, negative impacts on health (Lee, 1999). They have been one reason why urbanization has often been interpreted negatively. In recent years, urban development has received a growing amount of attention leading up to and following the United Nations Summit on Human Settlements (HABITAT II) held in Istanbul in 1996.
It is important to consider all feasible development options and their environmental, economic, health and other social impacts before any decisions are made (Lawrence, 1995). For example, economic incentives to promote local employment by constructing new factories in a city may be successful in creating jobs, while simultaneously permitting emissions that have negative impacts on the quality of air and local water supplies in that locality and adjoining areas. This example shows that what is positive for the local economy may not be positive for some constituents of the local environment and that there can be negative impacts on the health of the population. It also shows that the capacity of the health sector to deal with the health and well-being of populations is limited and that close collaboration with other sectors would be beneficial.
5. A strong, mutually supportive and non-exploitive community. Equity is a key concept of the WHO Healthy Cities project (Goldstein, 2000; Tsouros and Farrington, 2003). Equity refers to a set of legal principles founded on justice and fair conduct that counteract unjustifiable acts or deeds. It implies fairness in the relationship between an individual and other persons, and between an individual, groups and the state. These relationships include a just distribution of the benefits and services in a society with respect to a universal standard or values such as human rights. For example, no individual or institution should act in a way to damage, compromise or limit the freedom and rights of others. Equity is an important component of the division of capital, as well as access to and distribution of information, resources and services including education, health care and social welfare (Lawrence, 2002).
The distinction between equality and equity is important because equality means equal circumstances, treatment and outcomes for all, whereas equity recognizes social differences and seeks to establish whether these differences are fair and just.
Inequalities of professional status, income, housing and work conditions are reflected in and reinforced by inequalities of health and well-being (Dahlgren and Whitehead, 1992; Townsend, et al., 1992). Although the economic, social and physical characteristics of urban neighborhoods can be correlated with rates of morbidity and mortality, the lifestyle of groups and individuals cannot be ignored (Marmot and Wilkinson, 1999). Residents in deprived urban areas commonly have diets that contain relatively high levels of sugar, starch and fats, because foods high in protein, minerals and vitamins are relatively expensive. Smoking is also more prevalent, especially among women (Wilkinson, 1996). In essence when poverty is interpreted as a compound index of deprivation including lack of income and lack of access to education, employment, housing and social support, it is a significant indicator of urban morbidity and mortality.
6. A high degree of participation and control by the public over the decisions affecting their lives, health and well-being. The WHO Healthy Cities project includes a strong commitment to public participation, which is considered to be a prerequisite for a healthy city (World Health Organization, 2002).
The term participation has a wide range of meanings because it can be interpreted as a means of achieving a goal or objective, and as a dynamic process that is not quantifiable or predictable. In the health sector, Wallerstein and Bernstein (1994) concluded from a literature review that there is no consensus about participation, which can refer to a process, a program, a technique or a methodology. Participation can be interpreted as a broad term that refers to dialogue between policy institutions and civic society in order to formulate goals, projects and the allocation of resources in order to achieve desired outcomes. A wide range of techniques and methods can be used including civic forums, focus groups, citizen's juries, surveys, role playing and gaming. These methods can be applied using aids or tools such as maps, plans, photographs, small- or large-scale simulation models and computed aided design kits (Marans and Stokols, 1993).
In the late 1970s, citizen participation was considered for the first time in relation to primary health care in the Declaration of Primary Health Care at Alma Ata in 1977. Since then, participation has become an established component of definitions of health and as a means of promoting health in communities (Eklund, 1999). Participatory approaches have also been widely applied for housing construction, urban planning, and environmental conservation policies by municipal governments and non-governmental organizations (NGOs) on the understanding that complex issues should not be interpreted in democratic societies by one set of criteria or values (Gibbons, et al, 1994). In 1992, this trend was endorsed by Agenda 21, which advocates citizen participation in decision-making (United Nations, 1992).
An interest in the concept and practice of empowerment has developed since the 1970s in a number of fields of enquiry including social psychology, community studies and urban planning (Chavis and Wandersman, 1990). In the 1990s, empowerment was explicitly linked to citizen control in health education, primacy health care and housing. Today, there is no shared definition of empowerment. Some argue that is not normative because it is only defined in terms of its societal context. Nonetheless, the core of empowerment includes the concepts of authority and power. These enable a process by which individuals and communities assume power and then act effectively in changing their lives and their local environment. In the field of public health, Wallerstein (1992) states, "Empowerment is a multi-level construct that involves people assuming control and mastery over their lives in the context of their social and political environment; they gain sense of control and purposefulness to exert political power as they participate in the democratic life of their community for social change."
This interpretation indicates that it is necessary to distinguish between empowerment of individuals and groups or communities in relation to health promotion policies and programs.
7. The encouragement of connectedness with the past, with the cultural and biological heritage of city-dwellers and with other groups and individuals. The natural heritage of cities is commonly associated with the biological and ecological components of their site location, such as Cape Town, Rio de Janeiro, San Francisco and Sydney. The cultural heritage of cities is often considered in relation to human-made monuments, public buildings and cultural festivals. However, in addition to these, urban history can be used creatively as a warehouse of knowledge, including the achievements and shortcomings of specific urban development projects, in order to build healthier cities. In terms of shortcomings, it is important to recognise the legacy of urban renewal programs and projects in many cities around the World after the Second World War. From 1945, land-use and housing policies were enacted to address the housing shortage that accumulated during the previous decade. At the same time decisions were taken to demolish the historic quarters of inner cities by vast programs of urban renewal or reconstruction. Today these so called "model housing estates" are the locus of compound architectural, economic, social and technical problems which negatively affect the health and well-being of residents (Lawrence, 1993).
One positive lesson from urban history could be learned from the public health reform movement that began in Britain in the mid-19th century following rapid urban population growth, industrialization, the concentration of poverty in cities, and the propagation of infectious diseases (Rosen, 1993). The public health problems of unsanitary housing, lack of a supply of safe water, ineffective sewage and solid waste disposal were related to health inequalities that were tackled by devolving responsibility and authority to local municipalities in Britain in 1866. The important role of local public administrations should be remembered at the beginning of the 21st century when neo-liberalism seems to have replaced state initiatives in many countries. It is appropriate to stress the need for public health interventions including solid waste disposal, sewage and water services, and affordable health service and medical care. In many countries today, including those in the former Soviet Union, local public administrations lack the human and financial resources to counteract conditions in cities that have negative impacts on health and well-being.
8. Access to a wide variety of experiences and resources with the chance for a wide variety of contact, interaction and communications. It is necessary to reconsider the city as the focal point of creativity and culture; of conviviality and as places for sedentary living. Today, cities are too frequently interpreted as centers for the mobilization of people, goods and services. Consequently land use planning has adopted zoning laws to locate precise kinds of activities in specific urban areas. This approach has led to the demarcation and separation of land for housing, retailing, industry and leisure activities. Proximity and accessibility were two key characteristics of cities that have been challenged by urban sprawl in the 20th century, including the construction of retailing malls on the outskirts of cities, coupled with inefficient public transport. In contrast, the long-standing custom of mixed activities -still found in Manhattan, and some inner quarters of Paris -provides vitality, and social amenity accessible on foot. Traditionally, these mixed activities enabled interaction between different population groups. Cities of the 21st century should not only be important motors for national economic development but also functionally rich, having a sense of security and being people-friendly.
Social development is a key component of the WHO Healthy Cities project which challenges quantified, economic growth at the expense of sustained qualitative development (Tsouros and Farrington, 2003). Consequently a healthy city should foster an ecologically sound and secure local environment, a diverse and equitable local economy, and a reduction in inequalities leading to the social integration of diverse groups.
Individual and community awareness, and responsibility are prerequisites for a strong commitment by policy decision makers and practitioners to the redefinition of goals and values that promote health and well-being in cities (World Health Organization, 1995). Without this commitment, based on a sound knowledge base and shared goals and values, recent requests for more public participation cannot redefine policy formulation and implementation in meaningful ways. Public participation and empowerment alone are not panaceas for current urban and broader environmental problems, but they can serve as vehicles for identifying what local residents consider as key issues concerning the promotion of health and well-being (Eklund, 1993; Wallerstein, 1992). Before individuals and community groups can effectively participate with scientists, professionals and politicians in policy formulation and implementation there are long-standing institutional and social barriers that need to be dismantled as Lawrence (1995) has argued.
9. A form that is compatible with and enhances the preceding characteristics. Urbanization during the 20th century was characterized by a growth in the number, population size, and total surface area of cities on a scale previously unknown, and this trend is expected to continue (Galea and Vlahov, 2004). Urbanization in the last century has transformed the physical, psychological and social dimensions of daily life including housing, transport and other characteristics of metropolitan areas. For example, improved access to medical services is a common characteristic of urban neighborhoods that is rare in rural areas. Urban life has other important health benefits including easy access to job markets, education, cultural and leisure activities (Lawrence, 1999).
There are many types of human settlement layouts, including linear and nodal, compact and dispersed. The concentration of many kinds of human activities, the built environment and the resident population have many ecological and economic advantages compared with a more dispersed form of human settlement. In essence, a compact form of human settlement uses less arable land, which is a precious nonrenewable resource for the sustenance of all ecosystems (Wackernagel and Rees, 1996). In addition, compact human settlement has a lower unit cost for most kinds of infrastructure and services such as roads, drainage, piped water and sanitation.
One of the most significant changes in the layout and growth of cities during the 20th century was the trend for the development of dispersed suburbs, rather than compact neighborhoods. For example, the resident population of New York has increased by only 5% in the last 25 years, whereas the surface area of its built environment has increased by 61% (Girardet, 1999). This kind of urban and suburban sprawl has many negative impacts, including the increased loss of fertile agricultural lands, the destruction of forests, and irreversible damage to wetlands and coastal ecosystems. The dispersed form of urban development has larger ecological, economic and social costs than the compact city and some of these costs can have negative impacts on health and well-being (Barton and Tsourou, 2000). Therefore, trends that have dominated urban development during the 20th century should be regulated more strictly by land-use controls in order to make urban living less dependent on the ecological resource base. Architects and urban planners can promote ecological efficiency in existing urban neighborhoods by not accepting to design new out of town shopping malls or housing estates that are not accessible using public transport (Dubé, 2000; Kenworthy, 2000). These kinds of peripheral developments on the outskirts of cities converts productive agricultural land and forests into new suburban sprawl that destroys both the ecological and the social fabric of human settlements. They also frequently create dependence on automobiles, thus isolating those who do not drive motor cars, notably children, the handicapped, the aged, and the poor.
10. An optimum level of appropriate public health and sick care services accessible to all. National and local governments, sometimes with the private sector, are responsible for the institutions, organizations and resources that are devoted to promote, sustain or restore health. A health system has important functions including the provision of services and the human, monetary and physical resources that make the delivery of these services possible (World Health Organization, 2000a). These resources can include any contribution whether in informal personal health care, or public or private professional health and medical services. The primary purpose of all services is to improve health by preventive or curative measures. A health system should not only strive to attain the highest average level of the health status of the population, but also simultaneously strive to reduce the differences between the health of individuals and groups. Health care systems have the important responsibility to ensure that people are treated equitably, in an affordable manner and in accordance with human rights.
Today, national governments have less influence on housing, urban planning and the local urban economy than they did two decades ago, when the majority of decisions about urban development were made at the national level. Decentralization (or devolution) has been common in the 1990s, applying the principle of subsidiarity that was endorsed by the United Nations Conference on Environment and Development in Rio de Janeiro in 1992. Decentralization can only be effective if the new roles and responsibilities of local authorities and municipal services are financially supported by the transfer of appropriate resources from the national to the local level (Green, 1998).
Poor municipal management has not relieved the inadequacy of the quantity or quality of water supplied to populations in urban areas. For example, the joint WHO/UNICEF monitoring program estimates that in Asia and the Pacific region less than 65% have water supplied and less than 40% of all households in urban agglomerations have a sewage connection (WHO/UNICEF, 2000). These deficiencies can be compounded by poor environmental management such as the conversion of water catchment areas, deforestation in the hinterlands around cities, pollution from industrial production and land-fill dumps for the disposal of solid wastes. According to available information 85% of India's urban population has access to drinking water but only 20% of the available drinking water meets health and safety standards.
11. High health status (high levels of positive health and low levels of disease). One hundred years ago, about 80% of the World's population lived in rural areas, whereas in the year 2001 about a half of the global population live in cities. At the beginning of the 21st century, urban health can be characterized by relatively high levels of tuberculosis, respiratory and cardiovascular diseases, cancers, adult obesity, and malnutrition, tobacco smoking, mental ill health, alcohol consumption and drug abuse, sexually transmitted diseases (including AIDS), as well as fear of crime, homicides, violence and accidental injury and deaths (Galea and Vlahov, 2004). It is noteworthy that in the 1990s mental ill health was integrated into the etiology of urban health, and that the promotion of both physical and mental health were accepted as a complementary goal for national and local policy makers and professionals (ParryJones and Quelquoz, 1991).
Unfortunately, during the 1990s, a number of negative trends related to the provision of basic infrastructure and services have been recorded by UNCHS Habitat and other organizations. In particular, per capita investment in basic urban services is declining for a number of reasons including urban population growth, especially on the outskirts of cities; in addition, lack of security of tenure offers little incentive for residents to invest in services themselves (UNCHS, 2001). These recent trends in investments in basic infrastructure and services need to be highlighted and challenged by all those who promote public health because they present a major obstacle to the building of healthier cities.
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