4 World • 49th Year, No . 1, January-February 1996 A healthy is a better city Greg Goldstein &llona Kickbusch

Booming Caracas. The world is becoming urbanized at a furious pace; environmental and social issues and their repercussions on health demand a high priority.

he world is being urbanized at a diseases, malnutrition, mental ill­ "A Healthy City is one that is furious pace. Within 15 years, nesses and chronic respiratory dis­ Tbetween 20 and 30 will eases. Unhealthy conditions include continually creating and have populations of over 20 million. poverty, inadequate food and shelter, As national government resources insecure tenure, physical crowding, improving those physical and become more limited and the global poor waste disposal, unsafe working social environments and trend towards political and adminis­ conditions, inadequate local govern­ trative decentralization gathers pace, ment services, overuse of harmful expanding those community city governments are emerging as substances and environmental pollu­ resources which enable people stronger forces. Many of the most tion. Around the world, the cities pressing urban management prob­ attract young people from the coun­ to support each other in lems are associated with rapid urban tryside, lured by freedom from growth, including such environmen­ traditional bonds and ways of life, performing all the functions of tal health issues as water supply, and the promise of increased wealth life and in developing to their housing, pollution and solid-waste and opportunity. Instead, many of management, and the social health them find only a new type of maximum potential." issues of marginalization and vio­ poverty. lence. By 1990, at least 600 million Poor people in cities often have people in the urban areas of develop­ to shoulder total responsibility for ing countries were already living in their basic needs in health, welfare life-threatening and health-threaten­ and employment creation. Of partic­ ing conditions. ular concern to women are issues of People in cities - particularly the social behaviour associated with the poor and the newly arrived- experi­ breakdown of the extended family ence stresses and exposures that and of the two-parent nuclear fam­ result in a wide range of health prob­ ily; more women are working away lems, including communicable from home, and more heads of World Health • 49th Year, No. 1, January- February 1996 s household are single mothers. In the era of the AIDS epidemic, urban life often involves more transient rela­ tionships, especially for migrant workers, with early sexual activity among adolescents, high levels of prostitution, and a reduction in tradi­ tional methods of birth control. With all these problems, environ­ mental considerations in urban plan­ ning and management require far greater attention. The price of neg­ lecting them, apart from the negative health and social impacts, may be to impair urban productivity and restrict future development options, because of unsustainable use or damage to natural resources.

Health through local action Bringing health core and family advice to a poor district of Mexico. The Healthy Cities Programme builds on WHO's definition of health is given to the principle that health local government in two activities as a state of complete physical, can be improved by modifying the that are often new to them: monitor­ mental and social well-being, and has physical environment and the social ing environmental factors and their its roots in the culture and economic determinants of health. impact on health; and putting for­ of many parts of the world; indeed, Although various urban development ward specific health policy recom­ many of the public health innova­ activities (housing, industry, infra­ mendations for relevant departments tions in the past and present have structure, etc.) can cause health such as water and sanitation, indus­ sprung from the local level. In 1985, if they lack health and envi­ try, and education. In the process of WHO proposed a ronmental safeguards, more impor­ consultation with the community scheme to be known as the Healthy tantly they offer health opportunities. and many different agencies and Cities Project. The intention was to They can enhance the health status of groups, an effort is made to develop devise ways of applying the princi­ the population, provided they are a "vision" of the future direction of ples and strategies of accompanied by health promotion the city, and to understand its current through local action in cities and and protection measures. (and past) strengths and qualities. putting them firmly on the agenda of In addressing urban problems, a local government. Healthy Cities project does not seek The value of this programme to to take over the management of such Generating awareness cities has been demonstrated by its functions from the competent author­ unexpectedly rapid expansion to ities and agencies. Rather, it seeks to Drawing up a Municipal Health Plan hundreds of cities and towns, not make health issues understandable serves to generate awareness of only in the industrialized world but and relevant to the work of local health and environmental problems increasingly in the developing world. government and other agencies. It among municipal authorities, non­ In Healthy Cities work, attention supports city health authorities and governmental agencies and commu-

HEALTH FOR ALL SEniNGS THAT SUPPORT HEALTH implies Improved health requires making these • Reduced inequi ti es in health. 11 settings" more supportive of health • Emphasis on prevention of disea ses. • Home, ViTiage, Neighbourhood. • lntersecto ral cooperation includ ing reducing • School. environ mental risks . • Workplace. • Community participation. • Food M arkets . • Emphasis on in health care • City and Distri ct. system s. • Sport and Leisure . • International cooperation . 6 World Health • 49th Year, No. l, Jonuory-Februory 1996 nities, and to mobilize resources to tions, the ministry of health, and and industrial development. deal with the problems. The plan municipal health agencies responsi­ Examples of such links include the should not be considered a "one-off' ble for providing health services, joint Healthy Cities and Sustainable exercise that will generate all the running health centres or managing Cities Programme in Ibadan, Nigeria necessary actions to solve the city's hospitals. Such issues might include (where a city health plan is inte­ health problems once and for all; making maternal and child health grated into the development plan for rather it should be seen as a process services more accessible for under­ the city), and the joint effort on of consultation, data-gathering and served areas, strengthening family Healthy Cities and urban infrastruc­ analysis that continually opens new planning, improving health educa­ ture development now being intro­ channels of communication. The tion, or introducing better, more duced in Bangladesh by WHO and plan may include programmes or appropriate and more readily avail­ the Asian Development Bank. projects for specific settings, such as able drug therapies for common WHO is actively promoting the schools, workplaces, the market­ diseases. Healthy Cities approach worldwide, place and health care locations. Healthy Cities may be a "stand­ not least by organizing intercountry A key issue is how national pro­ alone" project in a given city, or may meetings in all regions, on a regular grammes may influence the project. be the health component of a larger basis, to review the progress of the In some countries, it has been helpful development effort that involves participating cities and to facilitate to establish a "national Healthy such areas as urban infrastructure, the exchange of health and environ- Cities commission" or network. A land management, municipal finance mental technologies as well clear commitment by such as experiences with suc­ a body to local government cessful projects. The pro­ policies that reduce margin­ ject coordinators of alization or the exclusion of participating cities are poor communities from entered into an interna­ social and economic life tional database, and and services can greatly newsletters and technical assist local efforts. reports are regularly circu­ Comprehensive health lated to the interested development approaches in parties. • a Healthy City project include "healthy villages", "health-promoting schools", "health-promot- ing workplaces" and Or Greg Goldstein is Health y Cities "health-promoting hospi- Coordinator in the Urban Un it, tals". In addition, partner- ECONOMIC Division of Operational Support ships aimed at tackling ENVIRONMENT in Environmental Health; and local issues may form Or /Iona Kickbusch, who initiated the WHO Healthy Cities ap­ between women's organi­ SUPPORTIVE ENVIRONMENTS proach, is Director of the Division zations, health-oriented of Health Promotion, Education and Communication, World nongovernmental organiza­ In cities, all aspects of the environment ore inter/inked and impinge on the Health Organization, 12 1 1 tions, the ministry of citizens' health . Geneva 27, Switzerland

CHARAOERISTICS OF AHEALTHY CITY CHALLENGES FOR HEALTHY CITIES • Clean, safe physica l environment. • GENERATE vi sibi li ty at the local level for health • Basic needs met for all people. issues and the health-for-all strategy. • Strong, mutua lly supportive, integrated and non­ • MOVE health high on the social and political exploitative community. agenda, and contribute to the development of • High degree of public participation in local and healthy municipal pol icies. city govern ment. • CREATE inn ovati ve action for health that • Acess to wide variety of experi ences, interaction emphasizes th e interaction between people, and commun ication. environmen t, lifestyles and health . • Promotion and celebration of hi storical and • FACILITATE organizational and institutional cultural heritage. changes that encourage cooperation between various departments and sectors, and that promote commun ity parti cipation.