Urban Health and Healthy Cities Dr Trevor Hancock Public Health Consultant BC Ministry of Health A presentation at ESPN Rio de Janeiro, Brazil 3 rd April 2008

Urban health Urban 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”)

Outline 1.Urban ecosystem health 2.Urban population health a)Urban health care 3.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, ) 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 and ecosystem 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, )

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 ecology Study 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 city There 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 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 Social capital Human capital Natural capital Economic capital

How we ought to operate Social capital Human capital 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 GovernmentNGO and Community AcademicsPrivate sector Local Regional State National International “Whole of Government”

Intersectoral Action for Local Development Cross or Intersectoral Action GovernmentNGO and Community AcademicsPrivate sector Local Regional State National International

Intersectoral Action for Local Development Vertical integration GovernmentNGO and Community AcademicsPrivate sector 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

Urban Ecosystem Management... As if Health Mattered What is our purpose/end point How do we measure it? How is it to be achieved? The health sector's role Strengthen community action Healthy public policy Private sector partnerships Governance Building community capital for the 21st century Research issues Hancock, 2000