The Healthy Cities approach-- reflections on a framework for improving global health.

The roots of the Healthy Cities concept may be traced back to 1844, when the Health of Towns Association was formed in the United Kingdom to deliberate on Edwin Chadwick’s reports about poor living conditions in towns and cities. The revival of those concerns in the ‘‘new public health’’ era dates from the Healthy Toronto 2000 convention in 1984 and, subsequently, the enthusiasm of the World Health Organization (WHO) Regional Office for Europe to translate its principles into a tangible global programme of action to promote health. WHO defines a Healthy City as ‘‘one that is continually developing those public policies and creating those physical and social environments which enable its people to mutually support each other in carrying out all functions of life and achieving their full potential’’. This philosophy seeks to enhance the holistic well-being of people who live and work in cities, based on four criteria: (a) explicit political commitment at the highest levels to the principles and strategies of a Healthy Cities project; (b) establishment of new organizational structures to manage change; (c) commitment to developing a shared vision for the city, with a healthy plan andwork on specific themes; and (d) investment in formal and informal networking and cooperation. The concept is founded on the moral and political beliefs that inequalities in social conditions (and therefore health) are unjustified and that their reduction should be an overriding public health objective. While the entry point of the Healthy Cities approach is health, its underlying rationale has always been based on a model of good urban governance, which includes broad political commitment, intersectoral planning, citywide partnerships, community participation, and monitoring and evaluation. The Healthy Cities principles draw on various work on the social determinants of health, notably studies initiated by Thomas McKeown. However, its proponents rightly diverged from McKeown’s overemphasis on the ‘‘invisible hand’’ of improved nutrition at the expense of various types of important social interventions, such as improvements in living and working conditions, public education, medical science, democratic governance, public health practices, and human rights. The International Healthy Cities Foundation partners are drawn from leaders in these sectors. The strategy also takes account of the increasing recognition of the complex effects of urbanization on health. Rapidly growing cities in Africa, Asia, and the Americas constitute the majority of the 300 cities with over one million inhabitants. While poor people in urban cities operate under the most life-threatening living and working conditions, their high concentration nevertheless provides opportunities for improving health: economies of proximity greatly reduce unit costs for provision of piped water, sewers, rubbish collection, immunization services, schools and public transport. Recent UnitedNations statistics estimate that, by 2007, more than half of the world’s populationwill live in urban areas. Thus, Healthy Cities may be viewed as a set of public health strategies of potential benefit to more than half the people in the world. Now in its second decade, a number of important achievements have been attributed to this approach. For example, California’s Healthy Cities and Communities programme, which began in 1987, has contributed significantly to improving the state’s health profile through a multitiered strategy that includes technical assistance, funding, promotion, coordination and collaboration, systems reform, programme evaluation, and recognition. However, the effectiveness of Healthy Cities has largely been confined to industrialized countries, for a number of reasons. First, although its proponents acknowledge that conventional public health projects for the prevention or treatment of diseases did not adequately take account of health risks such as poverty, urban violence and terrorism, the predominantly functionalist health promotion framework within which the Healthy Cities approach operates makes it less likely to focus effectively on these underpinnings of ‘‘unhealthy’’ cities. Indeed, a paradox associatedwith the health promotion framework is that it inadvertently aggravates health inequality, because its messages are more likely to be put into practice by affluent communities. Second, the twin crises of capitalist globalization — ecological unsustainability and social class polarization— have had a particularly deleterious effect on the health of citydwellers in developing countries, including poor communities with hitherto exemplary health systems such as Kerala. Powerful economic and political interests in many countries, rich and poor, have displaced a welfare ideology with a neoliberal ideology, making it even more difficult to deal with those activities that make poor city-dwellers unhealthy. Because poverty is more extreme among the urban population in developing countries, the impact of globalization in poor communities is more adverse. As class polarization extends to rich countries, similar trends develop. In today’s Toronto, for example, homelessness is at levels not seen since the 1930s and food bank usage has doubled since 1990, at a time when the Canadian economy continues a strong recovery. Third, rising levels of urban violence and terrorism have mademany cities unhealthy. InBrazil, for example, the benefits