Healthy Cities

Historical Context

Population health and urbanization have been inseparable twins since the dawn of humankind. Cohen, [Page 349]in his 1989 masterpiece of paleo-epidemiology, demonstrates that the shift from nomadic to sedentary and eventually urban lifestyles impacts on occurrence of disease. Still, rural etiology and population pathology differ considerably from urban patterns. Urban organization, on the other hand, allows for different types of interventions, and it is no surprise that the emergence of modern public health can be traced back to urbanization (from public toilets in ancient Rome to sewage systems in industrializing Britain, and from city-state “Health Police” in medieval Germany to surveillance systems in contemporary megacities). In the late 1990s, Porter and Hall even maintained that the shape of twenty first-century cities is dictated by health considerations.

Clearly, they find that modern public health is a direct result of sanitarian programs emerging in mid-nineteenth-century industrializing nations. The Health of Towns movement in Britain (established in 1844) is a direct precursor to Healthy Cities. Modern cities, however, seem to have failed to recognize the most recent shifts in health and disease patterns and their unique potential urban assets to address these.

The etiological shift has moved from predominantly parasitic to microbial infectious and currently chronic diseases; public health interventions have moved from surveillance (such as quarantine) via high-tech pharmaceutical and other clinical interventions to addressing social determinants of health (e.g., inequity and community development). Urban environments are uniquely impacted by such social determinants but are also in a historically unparalleled position to deal with them.

This was recognized as early as 1963 by Duhl and colleagues. In describing what would later become the Healthy Cities movement, they laid down the tenets for analysis and intervention in, for, on, and with social, natural, economic, and built urban environments for the promotion of human and ecosystemic health.

Foundations

The first city to truly adopt these principles became Toronto, more than two decades later (1984). In a serendipitous confluence of global and local developments, the city celebrated emergent emancipatory health promotion approaches by the World Health Organization (WHO) and a decade of innovation in Canadian health policy (the Lalonde Report); its leaders had the ambition to take a radical stance on the health of city dwellers.

The model was quickly taken up by the European Office of WHO, engaging Duhl and Toronto health entrepreneur Hancock to launch an urban health demonstration project. In collaboration with a small group of European cities, they developed 11 qualities a healthy city should attempt to achieve:

• 1.
  a clean, safe physical environment of high quality (including housing quality)
• 2.
  an ecosystem that is stable now and sustainable in the long term
• 3.
  a strong, mutually supportive, and nonexploitive community
• 4.
  a high degree of participation and control by the public over decisions affecting their lives
• 5.
  the meeting of basic needs (food, water, shelter, income, safety and work) for all people
• 6.
  access to a wide variety of experiences and resources, for a wide variety of interaction
• 7.
  a diverse, vital, and innovative city economy
• 8.
  the encouragement of connectedness with the past and heritage of city dwellers and others
• 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)

The original ambition of WHO to run a small-scale demonstration project exemplifying the potential of urban administrations to deal with late twentieth-century health and disease demands was quickly challenged by its enormous popularity. Within the first five years, hundreds of European cities had expressed an interest in joining the project, and cities outside Europe used guidelines to establish their own. This put a demand on WHO at a global level. In Europe, a small group of WHO-designated cities (meeting strict entry requirements into the project) were to be hubs for national, language-, or topic-based networks of Healthy Cities.

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