Mainstreaming health in urban design and planning: advances in theory and practice

Abstract

That urban environments influence health is not a recent discovery, nor is concern for health among urban planners a novel development. Public health practitioners, too, have long advocated for interventions in the urban fabric to address pressing health issues. The origins and evolution of these fields are, indeed, closely interwoven. The ‘sanitary revolution’ of the 19th century recognised the environmental origins of many major urban health threats, and well over a century has elapsed since the birth of the corresponding public health movement focused on improving urban living conditions. Early exploration of the possibilities of urban space for elevating wellbeing included ‘model’ experimental housing projects, as in the industrial company towns of New Lanark and Saltaire (Minnery 2012), and planning theory sowed the seeds not just for research and practice on healthy cities, but also for a deeper examination of the relationship between human and natural systems, for example, through the Garden Cities movement. Today, we have moved far beyond isolated experimental prototypes of healthy urbanism. The WHO Healthy Cities project was founded in 1986, drawing on the principles of Health for All laid out in the 1978 Alma Ata conference, and has achieved many practical successes while expanding to thousands of communities around the world. In parallel, since the 1990s there has been a burgeoning effort to shed light on the interrelated nature of people, health, and the environment at various geographical scales (Lawrence 2021). Indeed, in the modern age, humanity’s impacts on the environment have become so significant that we now know our era as The Anthropocene (Steffen et al. 2007), and we recognize the preservation and flourishing of natural resources as inextricably linked to human health – for example, in the emerging rubric of planetary health. Peer-to-peer city networks, to be sure, increasingly concern themselves with issues of health and environment. Thus, it is now well established that effective urban planning and design can support human and planetary health and that, conversely, poorly designed and managed cities – as often seen in contexts of rapid, unplanned urban growth and limited resources – generate threats to health and environmental burdens. As Lawrence (2004) articulated, health should be seen as ‘a dynamic, holistic and positive concept that should be understood and included in programs, projects and plans about built environments’. Yet, while research, policy, and practice on healthy cities have surged in recent decades, the status of urban health globally remains suboptimal: for example, though city dwellers generally enjoy better health than their rural counterparts, almost 40% have no access to safely managed sanitation services and an estimated 91% of people in urban areas breathe polluted air (WHO 2021). With 68% of the population predicted to live in urban areas by 2050, a failure to incorporate health more decisively into urban planning and management will inevitably lead to growing – and in some cases, locked-in and self-perpetuating – health and environmental burdens. One factor that has limited progress on urban health is underappreciated urban complexity. Cities play host to multifaceted and sometimes paradoxical outcomes. For example, their density can enable more efficient use of resources – an environmental benefit – but they are nonetheless responsible for over 60% of greenhouse gas emissions (WHO 2021). Likewise, they generally offer good access to employment, education, and services like health care and housing (collectively, the key social determinants of health), but also concentrate health risks and hazards such as air and noise pollution and numerous determinants of communicable and noncommunicable diseases, injuries, malnutrition, and mental health issues. These risks and outcomes are, of course, distributed unequally between and within cities. Urban complexity demands systems thinking to understand and advantageously co-create our urban environments. Leveraging synergies across urban planning, design, management, and governance requires dealing with the interactions of cities, their infrastructures, agents, formal governing bodies, and informal processes of development that give rise to complex or unexpected outcomes. Systems thinking can help characterize this complexity and facilitate the implementation of intersectoral policies, enabling practitioners to model and understand interconnected