What is a ‘healthy city’? The answer lies in the paradigm of the beholder.

by Jinhee Kim

What is health? What is a city? And what is a ‘healthy city’…? Convinced that the essence of a healthy city is in the commitment to the values of health equity and empowerment and in the process to develop healthy public policies, my answer to that last question would at times end up being an enigma to the inquirer. I would sell abstract truisms. ‘That all sounds great, but what exactly is a healthy city?’, they would retort. I may have found a way to resolve this paradox, well, at least for myself.

Urban health is a field of research and practice in which a diverse range of actors from multiple disciplines, sectors and trades are involved. Different professions and sectors address urban health issues based on their conceptual, theoretical, methodological, instrumental and even historically determined positions.

Distinctively different groups would be likely to have different views on:

  • Which urban health issues are more important (a conceptual gaze);
  • What causes these urban health issues (theoretical frameworks);
  • Which data collection or analytical method would best measure and seek information (methodologies);
  • Which solutions effectively resolve the prioritised issues (instrumental dimensions).

Consequently, depending on how these dimensions are defined, the vision of a ‘healthy city’ and the preferred ways to get there would inevitably be different between groups.

In the field of urban planning and health, a popular sub-topic of urban health, there appear to be four dominant approaches, or paradigms, that I label as – the ‘medical-industrial city (MIC)’, the ‘urban health science (UHS), the ‘healthy built environments (HBE)’ and the ‘health social movements (HSM)’ paradigm. Each one of these is characteristically unique in the way the urban health problems or issues are defined, analysed and sought to be resolved.

The ‘medical-industrial city’ paradigm

The ‘medical-industrial city (MIC)’ paradigm is a position on urban health that is driven by the business and industry sector – e.g. healthcare, construction, technology, etc. Researchers, practitioners and policymakers supporting this world view believe that the investment in healthcare infrastructure and technology will bring urban economic growth. Such growth is their dominant preoccupation. Here, the concept of health is often coupled with the images of economic prosperity in the form of liveability and healthy lifestyles. For example, the nexus between urban planning and health in the Greater Sydney’s health and education precinct is similar to the views of this paradigm.

Health and education precincts
(The Greater Sydney Region Plan, A Metropolis of Three Cities, 2015)
The ‘urban health science (UHS)’ paradigm

The ‘urban health science (UHS)’ paradigm is characteristic in its strong emphasis on the application of epidemiological and classic Cartesian analytical methods in understanding the complex causal relationships between the urban environment and its health impacts. This gaze tends to emphasise concepts such as risk behaviour or odds ratios, and as a consequence may look exclusively behaviourist. The types of evidence are critical in informing and evaluating effective interventions and policies. Examples of this paradigm in practice are shown in projects such as the Australian Urban Health Indicators and in initiatives such as the Partnership for Healthy Cities supported by the Bloomberg Foundation. The data makes visible how healthy or liveable cities are, and are used to prescribe high impact and proven interventions that reduce unhealthy outcomes in cities.

Fourteen proven interventions to prevent noncommunicable diseases and injuries (The Partnership for Healthy Cities)
The ‘healthy built environment (HBE)’ paradigm

The ‘healthy built environment (HBE)’ paradigm proposes the (re-)integration of health into the objectives of spatial planning of cities. The healthy built environments view has an explicit focus on transforming the regulations and institutions that constitute the urban and spatial planning system and advocates for the adoption of health as a major integrative goal for urban planning and design. Often, activities following this paradigm produce a set of codes or guidelines to be used as a guide or benchmark in the review of development proposals. The NSW Ministry of Health Healthy Built Environment Checklist is an example that shares features of this position. Here, a clear set of recommendations are given to health professionals to influence planning decisions.

Healthy Built Environment Checklist (NSW Ministry of Health, 2020)

The ‘health social movement (HSM)’ paradigm

The ‘health social movement (HSM)’ paradigm seeks to integrate health considerations into all aspects of urban governance, with an emphasis on operationalising values such as health equity and empowerment. The WHO Healthy Cities movement is an example of city action and research in this paradigm, along with other examples of community-based participatory action. Here, values such as solidarity, equity, sustainability and empowerment guide the identification of urban health issues and the solutions are ideally driven by the empowered community, focusing both inward (in communal action) and outward (in seeking policy and systems change). 

Healthy Cities Vision (Copenhagen Consensus of Mayors, 2018)

What paradigm is mine?

The reality is, of course, that urban health researchers, practitioners and policymakers embrace different configurations and combinations of these four paradigms. The four paradigms are neither mutually exclusive nor always prominently portrayed in individual urban health research efforts or particular policies. It is also not expected for individual studies or researchers to be designated as a particular paradigm. Instead, the significance of clearly articulating the different paradigmatic approaches lies in supporting researchers, practitioners and policymakers to understand better the diversity and the complexity of urban health issues. More importantly, by acknowledging and understanding other viewpoints, policy actors will be able to identify areas for better transdisciplinary collaboration. Rather than simply disregarding a particular position, actively seeking reciprocally valuable starting points would allow for better engagement.

Perhaps in my previous attempts in responding to the question ‘what is a healthy city?’, I was imposing my paradigmatic position to those who might not be sharing the same view. I should now start by framing my answer as one way of defining a healthy city, and that other paradigms co-exist. Hopefully this will enable me to build more constructive collaborations.

Is local government better?

In the health field there has been a call — since the early 1980s — to make health policy development the responsibility of all sectors, not just the health care system’s. This echoes calls from administrative and political science, first voiced in the 1970s, to integrate or join up policy systems. There is a range of monikers for either, from Healthy Public Policy and Health in All Policy to Whole-of-Government and Integrated Governance. Whatever it is called, it remains what Peters has called ‘the holy grail of public administration’.

Our first feasibility study of such integrated health policy at the level of the nation-state was published in the late 1980s and early 1990s. We found that there are many parameters, intimately associated with the very nature of the nation-state and its governance systems, that do not bode well for the development and sustainable implementation of policy for health (rather than policies for, e.g., pharmaceuticals, health workforce development, practitioner accreditation, numbers of hospital beds, etc.). The emerging practice of Healthy Cities around the world from their official European WHO launch in 1986 turned out to be a ‘natural experiment’ (or rather multiple case study inquiry with an N>10,000) to see whether local contexts would provide different opportunities for evidence-based health policy.

Colloquially there have been convincing arguments that devolved governance to local systems is the ‘natural’ and more efficient thing to do. Benjamin Barber attractively argued (in his not entirely rigorously resourced book If Mayors Ruled the World: Dysfunctional Nations, Rising Cities) that ‘local government collects the garbage’ – and that local politics therefore would be more responsive to community needs and might well be more agile in its (health) policy response.

Based on three decades of Healthy Cities evaluations; a typology that has been developed to challenge the more traditional ‘knowledge translation’ paradigm (into an area of seven interlocking nexus theories); horizontal and vertical policy transfer theories; and an eclectic use of policy network and framing perspectives, this paper argues that although health policy making at the local level is relatively easier, its mobilisation and use of relevant evidence sources is often more convoluted. Rather than dealing with more abstract power and governance issues at the nation-state level, the fact that Council collects the garbage also requires it to shepherd a more conscientious and accountable way of generating, managing and applying the evidence to support responsive policy for health.

Read more in this new discussion paper by Evelyne de Leeuw here


Peak Urban : The glocal disconnect in the Anthropocene

Disruptions are not necessarily cataclysmic events located sharply in time. They reach tipping points. In 1956 M. King Hubbert theorised a phenomenon called ‘peak oil’ (1): the moment maximum extraction of crude oil was reached, and from that moment it would go down-hill with the world. ‘Peak oil’ would cast its doom on Planet Earth some time between 1960 and 2050 (with the majority of predictions somewhere next year).

The rise and fall of geo-extraction based internal combustion machines fuelling industrialisation is a (admittedly disruptive) blip on the glacial time scale of geological epochs. It is unsettling, therefore, that we humans are the first species in the existence of the planet to be aware of the fact that we are witnessing a shift in epochs – and are entering into one of our own making.

This is the Anthropocene – where humans have started to make a permanent impact, indelible and observable for the remaining existence of the solar system on the strata of sedimentation of Earth. The Anthropocene is the ultimate disruptor of the Earth’s systems. Geologists have debated where in time the starting point of this human caused sedimentation can be placed. The first detonation of thermo-nuclear devices in the 1940s has been proposed (leaving a thin layer of radioactive matter on the Earth’s crust), others are more ‘conservative’ and observe permanent residue of (micro)plastics in seabeds and mountain ranges as the first evidence of an Anthropocene.

I see human settlement as the phenomenon contributing most to the Anthropocene. After a slow start for about 10000 years urbanisation has picked up pace in the mid-1800s, and Earth has been famously declared an urban planet in an urban century by the United Nations soon after the turn of this millennium (2). More than half of the world’s population now lives in cities, and depending on the method of counting this may yet have reached 70%.

We have reached ‘Peak Urban’ – there is no way back. The urban environment is our future habitat and it is shaping peoples’ health potential and threats. It has suddenly become the permanent disruptor. Romantic notions of natural living surrounded by pristine environments and autarkic subsistence must now be relegated to the Holocene. The environments of our entire lives, whether we like it or not, will be constructed by human structure and human agency. No matter whether they are red (built), grey (institutions), green (natural/terrestrial) or blue (natural/aquatic) environments, our surrounds are anthropocenic and -genic.

It is therefore dramatic that we get these environments so often wrong. Wrong for human interaction and growth, wrong for health and wellbeing, wrong for social and ecological sustainability, wrong at virtually any level. If we create our own urban environment, why don’t we make better efforts at getting it all right?

At its simplest, cities have dual purpose: they concentrate things, and they move things. If one of these functions is not hitting the mark, the other will suffer. Cities thus entering into decay have a hard time emerging into health and prosperity again – let alone into sustainability. Scaled up to global connectivity and ‘peak urban’, some cities do have the value and governance systems to concentrate nimbly, whereas others find themselves isolated and on the fringe of viability – but regressing from city-hood is not an option; they simply decline into urban deserts or withdraw from the equitable provision of services, infrastructure and facilities, turning suburbia into Peak Slum and disconnected and mobility-challenged hotbeds of non-communicable disease, disability and unequal opportunity.

The growth of the local, of urbanity, has not kept pace with the global governance systems that have emerged over the last two centuries or so – those of nation-states declaring sovereignty (3). The Anthropocene created an insurmountable governance disconnect between what matters locally and what happens globally – and the other way around. City-dwellers and their representatives feel increasingly disconnected from the global discourse that drives the creation of health, sustainability and prosperity. They will be the have-nots of the Anthropocene. Millennials are filling this space in glocal connectedness through social media and the gig economy but may not contribute to traditional social and community development, leaving urban administrations that cannot keep pace with these new forms of concentration and mobility yet again left to their own – haphazard – devices. New inequities will emerge between the connected and the disconnected.

Is the glocal disconnect view of Peak Urban in this Anthropocene painting too much of a bleak picture? The future of the urban planet and this urban century surely must look better – especially for the health governance opportunities that are created by concentrations of technology and media?

Yes. There is light. Groups of communities and local governments have explicitly chosen to seek a governance role on the global podium. They have connected around values such as health (Healthy Cities), technology (Smart Cities) and other themes (Resilient Cities, Slow Cities, Age-Friendly Cities, Safe Cities). They have joined, facilitated by Habitat III in Quito, in globe-spanning networks like Sustainable Cities, United Cities and ICLEI, and have explicitly embraced multi-professionalism, the value of connected research and development, the power of committed communities and diversity, and open and transparent exchange of experience. Perhaps one of the most compelling characteristics of these glocal networks (4) is that, different from the second half of the 20th century, there is no distinction between the Global North and the Global South anymore. The urbanist Saskia Sassen (5) a few decades ago described a class of ‘Global Cities’ in which it makes no difference whether you are in Copenhagen, Seoul, Kinshasa, Sao Paolo or Chicago to navigate public transport or the food system – it appears that connected glocal cities of the 21st century, indeed of the Anthropocene, are all world cities.

Networked, distributed glocal urban (health) governance is the only way beyond Peak Urban.

Evelyne de Leeuw

1 Hubbert MK. Nuclear energy and the fossil fuel. In: Drilling and production practice. 1956 Jan 1. American Petroleum Institute.
2 McDonald RI. Global urbanization: can ecologists identify a sustainable way forward? Frontiers in Ecology and the Environment. 2008 Mar;6(2):99-104.
3 de Leeuw, E., B. Townsend, E. Martin, C. M. Jones & C. Clavier Emerging theoretical frameworks for global health governance. Chapter 6 in: Clavier, C. & E. de Leeuw, eds. 2013 Health Promotion and the Policy Process. Oxford University Press, Oxford
4 Castells M. The new public sphere: Global civil society, communication networks, and global governance. The Annals of the American Academy of Political and Social Science. 2008 Mar;616(1):78-93.
5 Sassen S. Global city. Princeton, NJ: Princeton University Press; 1991.

Do we deserve good cities…?

A couple of years ago I went to Buenos Aires to attend the ‘Feria Mundial de Salud y Municipios: Derecho, Ciudadanía y Gestión local integrada para el Desarrollo’ (the World Fair of Local Government and Health: Rights, Citizenship and Integrated Local Management for Development – yes I agree Latinos have a much better way with words than we have). It was a relatively stale talkfest, so one afternoon I skipped class with some Danish community development friends to explore the slums. In Argentina, interestingly, these are called ‘Villas’ – but obviously they don’t even remotely resemble the multi-million dollar abodes you would see in Point Piper.

We ended up passing around and sipping yerba mate with a bunch of heavily tattooed slum dwellers. We chatted about slum life – how it allows communities to live under the radar, but also how that invisibility becomes a problem when you require public services or rights. At one point I suggested that all of those heavies (including their mamas and glorious troupes of kids) lived in the Villa illegally. Oh no, they responded, they were very legal, and (they started pushing my Danish pals and myself up a creaky ladder onto the hot tin roof) this is how we do it: we were looking out over a dusty plain at the edge of the slum. Some of the mate-sipping youths appeared with a couple of slender tree trunks, sheets of corrugated iron and rope. Within minutes they had tied together a shed. They ran back into the Villa and came lugging back two old Pirelli tires, a table and a mattress. The tires went on the roof, the table and mattress under it. “There!” the grandfather next to me on the roof said, “Now we have a legal dwelling.” Apparently something with a roof, a table and a bed cannot be bulldozed.

I had witnessed the most rapid urban sprawl ever.

It’s legal, but is it any good?

I was reminded of this little adventure when I saw the recent debate around population growth and urban planning unfold. Population growth isn’t necessarily bad and can be sustainable – if managed well and with hygienic ideas about purpose and function – spatially, morally, economically and in terms of human development. And urban planning is not just about putting in the hardware, although in the debates on ABC’s Four Corners and Q and A it seemed that the major issues revolved around the kilometers of asphalt, tunnel, and rail.

I have said this before and I will repeat it again. Urban planning, the liveability of our cities, and the sustainability of place is built on that hardware, but they come alive and acquire meaning through the human spirit that is unleashed upon it. In good and bad ways. Let’s take a look at a report of a little while back by Victoria’s Auditor-General on public transport. The singularly most significant message in the report comes from Figure 3B. The caption should have been ‘The shoddy chaos of Melbourne’s transport network’ but of course an esteemed oversight body like the Auditor-General can’t say such things.

What the figure says is that all the hardware is in place. There are trains. There are buses. There are rails. There are roads. But what isn’t there is inspiration, commitment, pride and courage. Buses don’t connect to trains and trains don’t connect to buses. There is no seamless public transport experience. Who wants to wait at a wet draughty bus stop (it is Melbourne, after all) for a vehicle that may or may not come in half an hour? Worse – the same report shows that there is a direct relation between public transport chaos and socio-economic disadvantage: if you are poor, you are made to wait.

If you live towards the edge of suburbia you may be forced to own a car – at great expense. Because we also found that public transport inefficiencies are coupled with lacking bicycle infrastructure.

Let’s be very clear: this is supposedly one of the most liveable cities in the world. Professor Billie Giles-Corti has researched it, so it must be true. And indeed, Australia is home to a virtual raft of eminent urban planning and urban health experts, so surely we get it right, don’t we?

Well we don’t. Just because it’s legal, it ain’t necessarily right. Just like that shack on the outskirts of a Buenos Aires Villa.

What makes cities and urban growth ‘tick’?

There has been a suggestion that the liberal (larrikin?) spirit of the Australian outback has prevented a strong value based politic of urban planning in this country. Indeed, in most welfare state typologies we find this great sunburnt country of ours grouped in with the other total free market friend we have – the United States. State interference is the enemy of individual liberty, everyone should be able to do what they want, and if they want to commute every day for four hours, never see their wives and children during waking hours and suffer disproportionately from obesity, diabetes and other non-communicable disease, so be it, it is a free world.

But we know it is not a free world, and we shouldn’t suffer from shoddiness, corruption, the total absence of human dignity and a general spirit of ‘homo homini lupus’ (‘Man is wolf to man’). We have transcended that, not just in our arts and culture, but in the ideas we have about a good world.

A good world is a green and sustainable world for us and those we love, for the next generation and for our guests (thank you so much, Aboriginal Australians, you are not just the symbolic Traditional Owners and Custodians of this land, you are truly our hosts and we all should take a couple of pages out of your Dreaming). It is a world of solidarity and caring, where needed through our public institutions. It is a world of beauty and surprise that we can navigate easily and with wonder – the infrastructure for population growth and urban planning we need shall be an inspired infrastructure that takes into account long term ecological balance. To do that we need to accept that we are (part of) nature, we are not just here to mine and exploit it. Especially in the fragile ecosystem that Australia is it seems to me that far too few people realise this and act on it. In a citizenship pledge for new Australians we should include a commitment to the sustainability of this ancient and delicate land.

But we do not seem to take pride in our land and our being here. Let me conclude with another very colloquial story. I live in Sydney and I do not own or drive a car here. Every morning I walk through Bigge Park in Liverpool to my office. Liverpool Council has made a tremendous effort to rejuvenate this bit of green space. Only a few weeks back tradesmen (nope, did not spot a woman…) installed new benches. This is what they looked like this morning:


On ABC’s Q&A Jane Fitzgerald (Executive Director of the New South Wales Division of the Property Council of Australia) said “we have a choice” – and suggested (or insinuated?) that the same people who deliver such shoddy-to-the-extreme workmanship (or the people who have destroyed it) would care about the world we live in. I’m not sure they would; and I’m not sure our community peers, family elders, intellectuals, politicians, and even infrastructure developers and commercial exploiters are the folk endowed with that ‘choice’, role models we aspire to, if we want to create that world we care for.

In countries where I have lived before I arrived in Australia there is profound concern and ready action for the red (built), grey (infrastructure), blue (water) and green (nature) environment. Often there are long term plans with often a 30 year horizon to invest billions in a comprehensive sustainable future. They are inspired by vision and values. Sometimes these visions are bold and on a grand scale – an entire country’s mobility might be at stake. And often those visions and values can start small: if we are currently developing new residential districts it would only require the tiniest bit of imagination and persuasion to adapt the infrastructure to new, healthy, sustainable and future proof standards. With a fraction of guts every streetlight can become an electric car charger. With the thinnest shred of vision the vast concrete slabs that are our streetscapes are torn out and become permeable surfaces that allow green to thrive and reduce heat islands. With only a sprinkling of values we can care.