Can Cities Damage Your Health?
In Hong Kong, despite the significant reductions in child mortality achieved over the past 30 years, higher rates are spatially concentrated in particular parts of the New Territories. Analysis from LSE Cities explored in detail on pp. 36–9, shows that in these areas, for example, child mortality is between 17 and 35 deaths per 1,000 live births, compared to an average of four for Hong Kong as a whole. The spatial variation in health performance closely mirrors the distribution of deprivation in Hong Kong: Hong Kong’s 20 per cent most deprived areas have child mortality rates 3 times the Hong Kong average. Such patterns are also found in other health indicators in Hong Kong. As Paul Yip explains in ‘Disconnection in a highly connected city’, suicide rates in Hong Kong’s newly developed satellite towns in the north and northwestern districts are 16 to 25 per cent higher than in Hong Kong on average. Yet such areas provide far from the worse living conditions in Hong Kong. The Society for Community Organization bring life to the statistic that some 80,000 people in Hong Kong live in woefully inadequate conditions, such as ‘cage homes’, cubicles and rooftop constructions, through a series of portraits of residents. If, as Yip concludes, ‘a city is only as strong as its weakest link’, Hong Kong’s health inequalities deserve further attention.
Can we be healthy and happy in cities?
Well-being is a much broader term than health. It encompasses a wide range of issues and can be defined and measured in a variety of different ways, depending on the particular theory of well-being understood.28 Well-being can incorporate both objective needs, such as decent housing and income (often collectively termed, ‘quality of life’ or ‘standard of living’), and subjective feelings of happiness and life satisfaction. One definition captures the meaning of well-being particularly well: ‘it connotes being well psychologically, physically, and socioeconomically, and, we should add, culturally: it is all these things working together’.29 The WHO definition of health, which has now stood for over 60 years, actually encompasses well-being: ‘a state of complete, physical, mental and social well-being and not merely the absence of disease or infirmity’.30 This definition implies that to be healthy is not only to be free of disease but also the ability to make a living, to live in decent conditions, to have access to basic services, to engage in social relationships and to feel able to affect one’s own circumstances.
Do planning and design matter?
The importance of the physical environment to health in cities has been known for more than 100 years. Indeed, public health and urban planning share a common history in the escalating health problems that arose in many European and US cities in the nineteenth century as they rapidly industrialised and grew. At that time, disease was understood to be caused by ‘miasma’ and, following John Snow’s work on a cholera outbreak in Soho, London, in 1854, by ‘contagious entities’, a pre-cursor to modern germ theory. The miasma theory held that diseases such as cholera and typhoid were caused by a foul-smelling bad vapour or mist (miasma). Infections were not passed between people, but were rather caused by exposure to unhealthy environmental conditions that gave off bad air. In England, this theory informed Edwin Chadwick’s sanitation reforms, which aimed to separate households from the disease-causing ‘bad air’ understood to be given off by sewage through the construction of drainage systems.34 It also led to more comprehensive city rebuilding, motivated by a desire to separate both the activities and populations thought to cause disease and thus reduce the risk of contact with bad air and hence infection. Haussmann’s plan for Paris is a prime example.
Health also provided a strong motivation for some of the most influential architecture and planning movements of the twentieth century. Ebenezer Howard’s vision of a ‘garden city’, for example, aimed to marry the best of town and country in a connected cluster of ‘slumless and smokeless cities’. Le Corbusier was motivated by many of the same issues: how to create better living conditions in cities. His vision for a healthy city was, of course, very different, in which cities were razed and built anew, with high-rise towers providing decent housing, amenities and services for the working classes, between which people moved freely in their cars along wide and extensive motorways, and where they could enjoy parks and gardens.
The most common NCDs (heart disease, cancer, type 2 diabetes and respiratory disease) now account for 60 per cent of global deaths each year, driven by the profound lifestyle changes that have accompanied economic and social change.46 In light of the importance of physical activity in reducing the risk of these diseases, substantial efforts have been made to identify the potential of the built environment to encourage or inhibit physical activity. Much of the evidence hinges on whether urban sprawl – in and of itself – leads to greater private car use.47 However, the issue is more subtle than that, leading to the idea of an area needing to have a variety of characteristics in order to be a ‘walkable neighbourhood’: high density, mix of land uses, fine-grained street networks and human-scaled streets.48 While good evidence exists to support the idea that residents of ‘walkable neighbourhoods’ walk more than residents of less ‘walkable neighbourhoods’ (at least twice as many, according to a review of 11 North American studies,49 for example), the lack of longitudinal studies mean that it is not clear to what extent this reflects the choices of residents to live in a neighbourhood that meets their walking preferences.
Shaping cities for health: what next?
As urban health research, policy and practice shifts its geographies towards a broader range of urban contexts, new methodologies and approaches will be required. Here we offer a few suggestions for potential directions of travel.
‘Design-conscious’ methodologies might provide more insight into the precise ways in which the built environment may be influencing health and well-being in a particular setting. Urban design and planning – from the macro-scale of sprawl versus compact development, and private car use versus sustainable transport, to the micro-scale of public space design, access to daylight, trees and recreational spaces – all matter to the way we feel about living in cities. Design-conscious urban health research would be alert to the details that are important in determining, for example, the extent to which an urban park is used by families, whether a health care facility is used by the urban poor, or a rehousing scheme allows for residents to adapt their homes in a safe way, avoiding the temptation to blur them through over-simplistic references to ‘the built environment’.