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.