Building health in our cities
“The most important asset of any city is the health of its people.”
WHO, Health as the pulse of the New Urban Agenda
“If the purpose of urban planning is not for human health, then what is it for?”
Dr Maria Neira, WHO Director, Department of Environment, Climate Change and Health
Four months and counting into lockdown, with reopening delayed and no definitive end in sight, it is hard to imagine a time when health is not at the centre of the news or not a consideration of every policy decision. In May this year, the WHO and UN-HABITAT published a new sourcebook Integrating Health in Urban and Territorial Planning, making the case for putting health at the heart of urban planning. Planned and written before the COVID-19 outbreak became a global pandemic, it makes no specific mention to our current crisis, but underscores the need – that is now undeniable – to think about health and place together and that there is no global population health without health for all communities and people.
The pandemic, with its uneven distribution of COVID-19 infection and death rates, has brought into sharp relief the spatial and social dimensions of health and the prevalence of inequities. Defined as differences in health that are systematic, socially produced, and unfair, health inequities are often a reflection of wider inequities in society (UN-HABITAT and WHO, 2020). Researchers have mapped COVID-19 hospitalization rates and shown geographic disparities to overlap with economic inequities (such as access to health insurance), environmental injustice (such as proximity of traffic and other forms of pollution), and systemic racism (such as the legacy of “redlining” in the U.S.) (Nemeth & Rowan, 2020). Exposure to risk is uneven and a high concentration of risk is where people are already facing deprivations.
We are also witnessing the compounding effects of noncommunicable diseases (NCDs) on the impact of infectious diseases. People with pre-existing conditions are more vulnerable to becoming severely ill with the virus (WHO, 2020). Data from as early as April showed that almost 90% of COVID-19 hospitalizations involved co-morbidities (CDC, 2020). Again, health and place are interlinked as our environments are significant drivers of NCDs. In addition to environmental risk factors (such as air and water pollution), preventable risk factors for NCDs (such as physical inactivity, hypertension, and unhealthy diet) are tied to the environments in which we live, learn, work, and play. The spaces we inhabit not only influence infectious disease vectors and transmission, but they enable or limit people’s ability to live healthier, safer lives. Housing quality, access to safe, open public spaces, walkability to amenities and jobs – these conditions affect people’s ability to observe social distancing and shelter-in-place during this pandemic and they also strongly impact people’s vulnerability to the disease itself.
Every city has its COVID-19 maps. In New York, the Bronx – predominantly Black and Hispanic borough – has the highest rates of coronavirus cases, hospitalizations, and deaths, laying bare the borough’s socio-economic and environmental vulnerabilities. In the South Bronx in particular, median family income is $28,038 vs. $55,191 citywide. Persons per household are higher than the city average. Many residents are essential workers - working in care homes, supermarkets, the public transport system - and unable to work-from-home and relying on public transit to commute. High incidences of chronic conditions consistently place the South Bronx bottom of New York’s health rankings. (Gonzalez, 2020). Its Mott Haven neighbourhood is nicknamed “Asthma Alley” because of the high levels of air pollution and asthma hospitalizations are five times the national average and 21 times the rate of other New York City neighbourhoods (Kilani, 2019). A key polluter is traffic, from four nearby highways and an ever-growing convoy of trucks; the South Bronx is home to several distribution centres – Fedex, Fresh Direct, and Amazon just signing a lease in June (Young, 2020) – providing services that disproportionately benefit residents in wealthier boroughs, demand for which has further increased during the pandemic lockdown.
These are complex, systemic issues with no silver bullet solutions. That said, COVID-19 has revealed the extent to which our urban planning and design processes, at all spatial scales, can influence people’s health for the better:
- Planning and designing more compact, socially inclusive, and better-connected places – these are upstream interventions that have a significant impact on health outcomes at scale (addressing “the causes of the causes” of disease or injury) and, done equitably, have the potential to protect all. One concept that has been gaining traction recently is the “20-minute neighbourhood.” The idea is to give people “the ability to meet most of their daily needs within a 20-minute walk from home, with safe cycling and local transport options” (Plan Melbourne, 2018). More than just about walkability, this model brings together increased neighbourhood densities, more mixed-use development across public transit and active transport (walking and cycling) catchments.
- Bringing health to the discussion helps place people at the centre of the agenda, and not just, for example, economic targets or infrastructure delivery. This is akin to Eric Klinenberg’s work on “social infrastructure,” forcing us to ask, does this physical infrastructure foster a health community?
- Collecting, analysing and disseminating disaggregated, spatial data can unmask inequities, illuminating needs and vulnerabilities. A recent example of this in action is data science company RS21’s Urban Health Vulnerability Index, a mapping tool to help identify urban populations at high risk for COVID-19.
As the authors of Integrating Health in Urban and Territorial Planning point out, public health and urban planning are natural allies; as modern disciplines, they share a common ancestry in the sanitation movements during 19thcentury industrialization. Both have a whole population focus and examine trends and long-term outcomes. And health can be used as a “lens” to merge agendas, promote a systems approach and empower greater collaboration. Plus – and this is my favourite fact from the sourcebook – combining the two disciplines addresses almost all seventeen of the UN Sustainable Development Goals.
The approach of using a topic “lens” to merge agendas is one shared by Fordcastle’s sister network, Aging2.0; in their case, using “ageing” as the lens to focus myriad interests and activities. Their data-driven insight and matchmaking platform, The Collective, is organized around specific Topics – opportunity areas to innovate for a better ageing experience for all – that bring together multiple stakeholders around a shared agenda to build a common set of metrics. We’re now bringing together different perspectives, organisations and examples of innovative places to develop a Topic around “Healthy Habitats”, and we’d be interested in hearing from organisations interested to explore the overlap between places, health and longevity innovation.
The current crisis has served as an extreme stress test, revealing fissures and breaks in our health and urban systems. Our urban environments need to be built and rebuilt for our shared health. Even before the coronavirus pandemic, living in unhealthy environments killed 12.6 million people in 2012 and air pollution killed 7 million people in 2016 (UN-HABITAT and WHO, 2020). NCDs now account for over 70% of global deaths annually (WHO, 2018) and urbanization is a key driver of the NCD epidemic. Today, over half the world’s population lives in cities and this is projected to rise to 70 percent by 2050. Meanwhile an estimated 75 percent of the physical infrastructure that we will inhabit has yet to be built (UN-HABITAT and WHO, 2020). The opportunities to build healthier, more vibrant, and more just communities are vast, and that work will start by recognizing the important link between urban design and population health.