Determinants Health In All Policies

Cities, urban design, sustainability, health: some reflections on Health City Design International 2017

Guest blog by @peterroderick15

Cities, urban design, sustainability, health: some reflections on Health City Design International 2017

Infographic – The Art of City Making. ©Peter Roderick 2016

The following blog is a rather rambling reflection on some of the current thinking on cities and health, occasioned by a really fascinating conference at the RCP in London (Health City Design International 2017). I managed to obtain a free ticket to this on the back of having a poster with some colleagues in the exhibition hall. Never say that public health registrars aren’t resourceful – indeed masterful – when it comes to procuring a free lunch or two.

The way we organise urban living is a huge public health issue, with more than 50% the world’s population (projected 66% by 2050) living in cities. Cities create health and ecological gain for the planet in some respects – for instance it’s well known that the average carbon footprint of a Londoner is a third less the UK average – but also act as sites of health and ecological damage: for instance higher levels of inequality and extreme poverty, and poor air quality.

The literature on cities is centuries old, from Hausmann’s Parisian revolution to Mies Van der Rohe and the Bauhaus, the muscular ‘run-a-motorway-through-Manhattan’ urbanism of Robert Moses, the activist-led, urban village counter movement of Jane Jacobs/Ken Greenberg and the paean to the urban that is Edward Glaeser’s more recent ‘Triumph of the City’. If we want to move into this space (and I think we should), public health people will need to read some of this stuff, as well as operating in all kinds of territory which may seem at first both exciting and unfamiliar: urban density, land allocation, infrastructure, green corridors, sprawl containment, urban air/heat flow, road layout, skyscraper site lines, noise and light pollution, Breaam building standards … the list goes on. I’m definitely still at the start of learning about this kind of stuff.

This RCP conference started with speakers from the Lancet-Rockefeller commission on planetary health and the NHS Sustainable Development Unit outlining the planetary and health challenges which innovative city design is looking to solve.

Some nuggets:

• The goal of the 2016 Paris climate accords – to restrict global temperature rise to a 2o C threshold – is now unlikely to be met, and experts are planning for more like an overall 2.7o-3o degree rise at peak. If this is not the statistic that frightens you most this month, it should be.

• This is not all about carbon and global warming – we are overshooting planetary boundaries on around 6 different levels, and some of the effects on aspects of human living are very little publicised:

o Crop yield estimates for a 3o degree warmer world are highly depleted

o Losing all pollinators e.g. bees would lead to estimated 1.42 deaths per year (from malnutrition, communicable disease, eating fewer vegetables

o 80% of the world’s fisheries are overexploited

o Climate change is linked to global conflict – apparently the drought in Syria between 2006 and 2011 fanned the flames of the subsequent bloodbath by driving about 1.5m people into cities. It’s not that climate change is going to kill us – it’s that climate change is going to make us kill each other.

o Evidence is emerging that some newly discovered zoonotic infections are the result of land use changes

On some of this it’s possible to act now through individual behaviour change – for instance, shifting to a diet in line with the NHS ‘Eatwell’ guidelines would reduce greenhouse gas emissions of an average person’s food consumption by 12%, land use by 20% and water use by 6% (moving to a wholly vegetarian diet the figures are a whopping 31%, 51% and 37% respectively). In other areas, the solutions are much more complex: systems-level. The tools i.e. the technology might already be out there, but we need successful social movements to implement them. This was highlighted by David Pencheon (NHS SDU), who used the analogy of education stages:

understanding climate change = school children stuff

creating snazzy technological ideas to tackle climate change = university stuff

creating social movements to solve climate change (peacefully) = Nobel prize-winning stuff.

So what can cities do in all this, as the future primary location of human living?

The rest of the conference gave some clues, and here were the highlights for me:

Support a huge upgrade in public transport and active travel so that every drop of oil possible remains in the ground and every drop of physical activity is squeezed out of city space – these are two sides of the same coin. Air pollution is the big ‘in’ within policy circles at the moment so ruthlessly push this agenda (and frame it better e.g. the ‘40,000 deaths’ statistic is better phrased as ‘average loss of 8 months of life’). Also need to link the obesity crisis to carbon dioxide: one speaker got us all to grab our fatty tissue above our hips, and then remarked ‘that is almost certainly caused by fossil fuel’.

Invest in clever use of green space – horizontal, vertical, diagonal, planted, vegetables, water features, whatever – as the evidence on positive mental and physical health effects is now very strong (though some caveats e.g. allergenic effects, trees trapping air pollution)

Make your city a test bed for low carbon technology – modelling shows that every 7% global increase in investment in lower carbon technology could save 3m lives

Don’t forget the buildings – we spend 90% of our time indoors – there are new types of standards emerging (e.g. Well Building) which combine livability, environmental impact, reducing building sickness syndrome etc The cost of a building over a typical lifecycle – looking at rent, maintenance, and salary and benefits of those who use the building – is 90% sunk into the salary and benefits of workers so need to invest in spaces which work for people

In terms of urban design, I came to the conclusion retrofit and renewal is the name of the game. While I enjoyed the NHS Healthy New Towns session, and think it’s quite innovative of NHS England to work with new-build communities to make them as healthy and sustainable as possible,  in reality we are building fewer houses per year than at any time since the second world war (this graph from James Meeks is illuminating), and coming up with imaginative ways to shape and reimagine existing communities (transport, walking routes, green space etc) is going to positively affect more lives

Use local healthcare systems as anchors – a lot is being said on ‘anchor institutions’ at the moment – the logic being the best thing the NHS can do to build healthy cities and combat climate change is radically look at its employment and purchasing arrangements. But also – and I’d missed this point – look at how it can set a very visible societal example, in the way doctors stopping smoking in the 60s really changed the epidemiological needle. Examples of this for climate change might be ambulances not idling, rooftop turbines on the top of clinics, doctors taking environmentally conscious decisions (e.g. selling their cars, vegetarianism), eco hospital design (see the fabulous drawings for Alderhey in the Park in Liverpool)

Make the economic case: we have a huge productivity problem in the UK (far worse than comparable OECD countries) and it has stalled even further since 2007 – we also have higher rates of MSK/mental health problems which are the key workplace health and wellbeing issues and cost us upwards of 100bn a year

Pay close attention to who lives where – cities are diverse mixes of classes, ethnicities, cultural memory, immigration history, vested interests – and development which doesn’t consider this will be a long term failure. A good example of this is the Mike Nightingale Trust work in Hout Bay in the context of city design in post apartheid South Africa. Lots of implications here in terms of gentrification…

City resilience needs much more prominence – there was some great stuff from Wigan DPH Kate Ardern on moving focus within EPPR work from extreme shocks to long term stressors – looking forward to seeing if the Rockefeller 100 resilient cities programme has any effect

Watch the smart cities agenda– people will increasingly interact with a city through the data they generate from wearables, social media use, geolocation, and this will give us unparalleled insight (for caveats see below)

Some concluding thoughts:

Are cities the answer for everything? It’s a trivial point, but one poster was a very earnest description of a project named ‘tranquil city’, aiming to map urban spots within London with relatively low levels of noise and air pollution as ‘oases of tranquillity’. It simply left me feeling that what they were really looking for is simply ‘the countryside’.

• It might have just been the paradigm I’m in but the conference could have done with some more evidence based medicine-style common sense thinking – I noted that although it was an urban design and health conference there were many more architects and design firms there than doctors/health people. Didn’t seem a lot of academic basis for some of the policy interventions proposed and some seemed a bit blind to the possibility of some unintended consequences – for example, a session on wearables and data generated for personalised medicine where people were getting excited over lots of whizzy tech but there is quite a lot of worry (eg recent BMJ article) that the use of data like this creates overmedicalisation, supply led demand, fails screening criteria like Wilson and Junger etc – and do we really need more illness in the system when services struggle to meet current levels?

There was disappointingly little discussion of the structural, macroeconomic models underlying cities. This leads on to what I felt was the big elephant in the room, which was that, crudely put, some of us were buying and some of us were selling: many of the speakers, exhibitors and posters were showcasing recent architectural/urban design projects, tech solutions, digital products etc and the sense was that some of the innovations were very positively spun in order to achieve commercial gain. Now on one level I don’t object to this at all – solutions to our catastrophic global urban problems will need every effort from every sector, public, private, third, and the ‘state’ certainly doesn’t hold all of the cards – it is just that it’s difficult to clearly discuss the economic determinates of health – for instance the way neoliberal economics is underpinned on GDP growth unsupportable within planetary constraints – whilst being sold a product. At one point someone wisely said that modern capitalism has lifted ½ billion people out of poverty, but is now increasingly like an outdated model – it would have nice to have explored how cities can contribute to redefining it.

• As one exception to this, however, it was fantastic to hear from Lord Andrew Mawson, of Bromley-by-Bow fame, on the economics of poverty and health. He places huge emphasis on entrepreneurship, the value of starting your own company, tackling community poverty through economic growth etc and was excoriating on the way the state can hold back these things (apparently he once said to a council strategy officer ‘your bag of reports, papers regulations, etc is producing poverty in this community’) so this was no mere anticapitalist rant. The sheer sense of ‘this can be done’, plus the power of his story (which started in a church with a congregation of 12 and now has 4 integrated health centres, 66 spin out businesses, 9000 houses, and a regenerated community surrounding it) was very powerful. The conference was almost worth it just for this!

n.b. for those interested our poster on air quality in West Yorkshire can be found here (you have to sign in but its free!)

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