Urban Planning and Public Health in a Rapidly Urbanising World

Illegal-addition-of-storeysThe celebration of the centenary of the RTPI this year, and the centenary of the International Federation for Housing and Planning in 2013 are reminders of the origins of modern urban planning, and in particular of the historic links between planning and public health. A century on, the time is ripe to look at the links between health and place globally. The illnesses and premature mortality which the founding fathers of town planning sought to eradicate by better housing, more open space and access to community facilities still stalk the billion people who live in slums today.
The case for preventative health care is a familiar one. It makes sense to keep people healthy. We also pretty much know how to do this. Diet and exercise figure prominently. What is less frequently discussed is the relation between health and place. Perhaps this is not surprising. A publication last year by the World Economic Forum  remarked “Much of the current debate on the future of health is characterized by short-term and siloed thinking and entrenched positions. A short-term view encourages solutions that deliver immediate results and discourages conversations about more fundamental changes that might only bear fruit in the long term. A lack of cross-stakeholder dialogue constrains the finding of solutions outside the traditional approaches to healthcare.”
Health and urbanisation

The nature of urban living poses some distinctive health challenges. People are crowded together, which means that contagious diseases spread more quickly. Concentration of activities and people makes disposal of wastes and effluents a larger and more difficult task than in the countryside. The sheer scale of vehicle movements in cities also poses greater risks of accidents. In addition, there is evidence that urban living impacts on lifestyles in a negative way in health terms. Not only is urban employment likely to be less physically demanding than its rural equivalent, but access to tobacco, drugs, alcohol and unsafe sex is also greater. Urbanization is also associated with a shift towards calorie-dense diets, characterized by high levels of fat, sugar and salt.

On the other hand, urbanisation is a force that can generate economic growth to fund better health care. In a world that is rapidly urbanising, the way cities develop will have a major impact on global health for the next generations.

The challenge of the slums

Many of the negative ways that urban living impacts upon health are intensified by slum living. Overcrowding is most intense in the slums, clean water and adequate sanitation are often lacking. A WHO/UN Habitat report noted “Pneumonia and diarrhoeal diseases are the leading causes of childhood death globally, and can be a particular problem in urban settings due to crowding, indoor air pollution and poor access to health care in urban slums. For similar reasons, children in urban areas are susceptible to death from malaria and vaccine-preventable illnesses such as measles.” The WHO researchers found that in Africa, Asia and the Americas “children from the poorest urban families are roughly twice as likely to die as children from the richest urban families… In each of the 42 low- and middle-income countries for which data (from 2000 onwards) are available, the poorest urban children are twice as likely as the richest urban children to die before the age of five years.”
Aspirations and obesity

At the same time, there is a growing middle class in rapidly urbanising countries, as I have noted in previous blogs. Their aspirations are towards an urban lifestyle based on car ownership and low density suburban housing. In India there was a 38-fold increase (3 to 115 million) in the number of registered motor vehicles between 1981 and 2009. A report by UN-Habitat records that in India “built-up areas grew faster than the population in nearly all of the largest cities, especially during the 2000–11 period in Greater Mumbai, Bangalore, Pune, Jaipur, and Kolkata.” Similar urban trends can be observed in other parts of the developing world. A further piece of research for the World Bank revealed that while bicycle was the most common mode of travel to work for rural dwellers, for urban residents it was a private car.The researchers found that those who used any mode of active travel to work were significantly less likely to be overweight or obese than those who travelled by private vehicle.
A role for planners
In summary, there are clear linkages between urban living and health at both ends of the wealth spectrum. Slum environments make the poor ill and kill some of their children. Threats of eviction create stress and insecurity for the millions living in informal and hence illegal settlements, not to mention the problems people face when they are actually evicted and their homes are bulldozed. Meanwhile the car-dependent lifestyles of the burgeoning suburbs are creating the problems of obesity and related diseases that have become a familiar feature of health profiles in the developed world.

The pace of urbanisation and the long-lasting nature of urban development mean that the global health maps of the future are being made today. Yet we know how to plan healthy cities. In the centenary since the RTPI was formed the practice of town planning undoubtedly contributed to the significant improvements in public health and life expectancy. The tragedy is that across so much of the developing world the statutory planning systems have failed to adapt to the challenges of rapid urbanisation and too often have become part of the problem rather than the solution. A new urban planning is needed, reconnected to its roots in public health.

  • Judith Eversley

    Such an interesting insight: that we need to manage urban living and health
    *wherever we live*. This was missing from the original Millennium Development
    Goals – health was in there and so was planning in a small way, but not the
    link between them – so there’s an opportunity to put that right in the
    post-2015 Goals.

    • Duncan Brown

      This a very interesting article Cliff and you rightly identify health as one of the big challenges facing the fast growing and urbanising cities of the developing world particularly unplanned slum dwelling settlements. In a UK context I am currently involved in a pilot study assessing the impact of urban planning and health in some of inner East London’s deprived housing estates working with NHS public health colleagues to understand the relationship between place planning and how it may affect public health of local residents. If indeed it can be demonstrated at all amongst other important influencing factors. Perhaps one for RTPI SE event debate in MK.

      • Cliff Hague

        Thanks to Duncan, Judith and Stephen for these comments. I am glad that you found the blog of interest. It was stimulated by an invitation from Hugh Barton (who knows a lot more about planning and public health than I do) to contribute a chapter to a book that he is editng and which will be published (hopefully later this year) by Routledge. So thanks really go to Hugh.

        In Scotland, the Chief Medical Officer, Sir Harry Burns, is forthright in trying to bring health into the mainstream of related policy areas. I am Chair of Built Environment Forum Scotland (www.befs.org.uk) and Sir Harry is going to give our first Annual Lecture which will be in Edinburgh on 25 February and which will look at the health / built environment linkages. I am looking forward to it as he is an excellent speaker and the topic is very important.

        • Hugh Barton

          Thanks for the plug,Cliff! Yes, we are working on a big edited book, provisionally called ‘Planning for health and well-being’ to be published by Routledge at the end of this year. Health was the trigger for town (or spatial) planning in the modern era. It is extra-ordinary that we seem to have forgotten that the fundamental justification for planning (whether of housing, commerce, transport or greenspace, etc) is to create a healthy and convivial habitat for people. The book will plug quite a hole in our knowledge, presenting the latest research and best practice.

  • Stephen Harness

    We are running an event for the RTPI South East on Planning for Health. It’s on 27th February in Milton Keynes (see http://www.rtpi.org.uk for more details), so your blog may be helpful to get the debate going.

  • Sushma Gupta

    Its very interesting article. I really like reading this. And I also found many useful information’s from this post. Thanks for posting.

  • Michael Chang

    Thank you for the article Cliff. Your final point on A Role for Planners is something the TCPA would agree with and that was why we embarked on our Reuniting Health with Planning project in the last couple of years. We will keep banging on about this relationship and provide additional research and support in 2014. Please see http://www.tcpa.org.uk/pages/reuniting-health-with-planning-phase-2-project.html