Creating healthy, just and eco-sensitive cities

This issue introduces the first of two special issues of the NSW Public Health Bulletin that examine health and cities. This issue introduces the topic and identifies the challenges for public health workers and their counterparts in urban management (urban, transport and social planners, environmental engineers and auditors, sustainability officers and others) and the land development and infrastructure sectors of industry. The second issue will focus on ways to move forward by describing urban planning and design approaches to enhance population health.

Cities can be great places in which to live. Currently, 90% of the Australian population chooses to live in urban settlements. People are attracted to cities for many reasons, including the availability of employment, education, social and cultural opportunities, and access to shops, food outlets, health care and other services.

The United Nations has estimated that during 2007 the human species will become a predominantly urban species; for the first time in human history more than half of all people will live in cities.¹ Consequently, the governance of cities is increasingly important for human futures. Those responsible should manage our cities in the interests of both human health and the health of the environment.

The way people live in cities affects their health by influencing levels of physical activity, food choices, safety, social connection and participation, and exposure to pollutants. These influences are determinants of common, contemporary health problems such as obesity, diabetes, heart disease, some cancers, depression, injury and asthma. The way people live in cities also affects the health of the environment through loss of biodiversity, changes to ecosystems, carbon dioxide emissions and the production of other pollutants. These environmental changes, in turn, have feedback impacts on human health.

Within cities there is inequity in access to infrastructure and other resources.² This applies to transport (mass transit, in particular), healthy food outlets, other shops, parks, libraries and health and community services, and creates barriers to good health and environmental outcomes in both large cities and smaller urban settlements.

These are the challenges we will explore in two special issues of the Bulletin. While health workers have a discourse on ‘urban health’,³ urbanists have a discourse on ‘sustainable cities’.⁴ Here we seek an integrated perspective on cities, sustainability and health, and present emerging ecological approaches and systems thinking.

Concerns about urban sustainability and population health are not new. For example, the Australian National University established the Hong Kong Human Ecology Program in the early 1970s. This was supported by the United Nations Educational, Cultural and Scientific Organization and was the first attempt to understand the ecology of a city and its human population in a holistic and integrated way.⁵ This program demonstrated that the actions necessary to protect the biosphere correspond substantially with those required to maintain and improve the quality of human life experience.

In the 1980s, the World Health Organization established the Healthy Cities initiative.⁶ The goal of Healthy Cities projects is the integration of health in decision-making in cities, through partnerships between public and private sectors and community participation. Several Australian cities have become Healthy Cities, including Illawarra and Blacktown in New South Wales and Noarlunga in South Australia.

In recent years, there has been a paradigm shift in the way public health workers think about health and the urban environment.⁷ This shift reflects an improved understanding of the importance of environmental determinants of health and has been enabled by new approaches to research.⁸ During 2004, the Year of the Built Environment in Australia, there were many activities and events designed to raise awareness about urban environmental issues. The NSW Government Architect initiated a healthy environments project and published a booklet on the topic.⁹ The booklet contains 11 essays about health and the environment by researchers and practitioners in the field.

The Standing Committee on Environment and Heritage in the Australian House of Representatives reported on the sustainability of cities in 2005. The Committee is now inquiring into a charter and commission for sustainability in Australia. The response to these inquiries has the potential to shape the future of Australian cities. It is important that population health is a central consideration in the response as cities cannot be sustainable unless they are healthy places in which to live.¹⁰

The Australian Academy of Science hosted a Fenner Conference on the topic Urbanism, Environment and Health in Canberra in May 2006. The conference examined ways of living in cities and the consequences for our health and for the environment. It was delivered through a partnership between those interested in population health and urban environments, and included perspectives from research, policy, the private sector and the community. More information, including abstracts and audio recordings, is available on the conference website.¹¹

Following the Fenner Conference, The Sydney Morning Herald published a series of articles on Sick Cities in August 2006, including case studies reviewed by Dr Chris Rissel, director of health promotion with Sydney South West Area Health Service. The Herald maintains a multimedia website on this topic, with the articles and additional audio and video material.¹²

The papers in this issue have been developed from presentations at the 2006 Fenner Conference. McMichael provides a concise history of cities and public health from the industrial era to the present, with a focus on Australia and England. He highlights major urban health penalties and responses to them. He emphasises the importance of ensuring human health is a central consideration in the sustainability discourse, for both policy and practice.

Howe argues for a renewed focus on urban policy in Australia. She is persuasive about the need for effective governance to enable the three levels of government in Australia to work with the community and the private sector to develop healthy and sustainable cities. Kearns, Beaty and Barnett from CSIRO Sustainable Ecosystems present an extended urban metabolism model as a framework for linking urban resource inputs to the spatial patterns and organisational processes of urban consumption. They identify important relationships between urban metabolism and human health.

Capon and Blakely propose a checklist for healthy and sustainable communities. The checklist identifies attributes of urban environments that affect the health of residents and the health of the environment. It is intended to stimulate debate and could be developed as a tool for government and industry.

Box 1^13–17 contains a glossary of the terms used in these two special issues that may be unfamiliar to the usual readership of the Bulletin.

Boyden has proposed a conceptual framework to represent the biophysical and cultural components of systems.¹⁸ This framework can help us to understand the urban system and the impact of changes to variables within the system. The framework has utility as a tool for the planning and evaluation of interventions.

Health impact assessment is another tool for applying public health analysis to the built environment.⁸ The Centre for Health Equity Training, Research and Evaluation at University of New South Wales is currently funded by NSW Health to promote the use of equity-focused health impact assessment as a policy, planning and evaluation tool.¹⁹ An example of one project under this initiative is the health impact assessment of the Sydney Metropolitan Strategy. A brief report of this follows this editorial.

To achieve healthy, equitable and sustainable cities, it will be necessary to strengthen professional relationships between urbanists and public health workers. Partnerships can be fostered through collaborative projects (both research and intervention), joint workforce development and advocacy. There is also a need for further innovation in scientific method. The science supporting sustainability is an emerging science that seeks to understand the interactions between nature and society.²⁰ Only through such work, across and between traditional disciplines, will we develop the knowledge and approaches necessary to address the challenge of health and cities.

More than 15 years ago, Ashton argued for a new approach to environmental health, a shift from sanitarian to ecologist.²¹ NSW public health workers should now embrace this challenge. It is through everyday activities that, as citizens, we all experience the highs and lows of city life. For this reason, we should also encourage vigorous debate in the wider community about this important topic.

Box 1.  Glossary