Elsevier

The Lancet

Volume 379, Issue 9831, 2–8 June 2012, Pages 2079-2108
The Lancet

The Lancet Commissions
Shaping cities for health: complexity and the planning of urban environments in the 21st century

https://doi.org/10.1016/S0140-6736(12)60435-8Get rights and content

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Executive summary

The Healthy Cities movement has been in process for almost 30 years, and the features needed to transform a city into a healthy one are becoming increasingly understood. What is less well understood, however, is how to deliver the potential health benefits and how to ensure that they reach all citizens in urban areas across the world. This task is becoming increasingly important because most of the world's population already live in cities, and, with high rates of urbanisation, many millions

The health advantages of cities

Health is determined by many factors outside the biomedical domain,7, 8 even with the restricted definition of health as the absence of disease. This point is reinforced when the definition is expanded to the WHO vision of health as a “state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity”,9 the idea of health as the ability to adapt and to self manage,10 and Amartya Sen's idea of justice entailing the ability to live a life one has reason

The Healthy Cities movement

The Healthy Cities movement originated in Toronto, Canada, in 1984, with the Beyond Health Care conference, building on the work of Leonard Duhl and Trevor Hancock.82 2 years later, the Ottawa Charter on Health Promotion was adopted, and WHO held the first Healthy Cities symposium in Lisbon, Portugal, to launch the European Healthy Cities Project.83 The European project proved popular from the outset.84, 85 It has been divided into a series of 5-year phases.86 Phase one focused on new

Healthy cities as complex systems

As Hancock and Duhl103 make clear, cities are “the example par excellence of complex systems: emergent, far from equilibrium, requiring enormous energies to maintain themselves, displaying patterns of inequality and saturated flow systems that use capacity in what appear to be barely sustainable but paradoxically resilient networks”. Along with several other researchers, the Commission is therefore proposing a complex systems approach to the analysis and promotion of healthy cities;111, 112, 113

Background

In high-income countries, any household can expect to have potable water supplied regularly to internal bathrooms and kitchens, a flushing toilet, and storm drainage to prevent flooding. In low-income and middle-income countries, this set of standards is often seen in only the wealthiest neighbourhoods and in well managed and comparatively wealthy municipalities. Water and sanitation services, however, are consistently and notoriously absent in badly managed cities and in the poorest parts of

Background

Building design provides an excellent example of the potential co-benefits of urban health and other social and economic policy goals, such as development goals and climate protection through reduction in greenhouse gas emissions. A WHO report154 draws attention to the fact that although costs are incurred in the reduction of carbon in buildings and in household use of energy, the potential benefits for health are substantial, particularly for low-income households. However, this issue also

Background

Another area in which the complexity involved in the addressing of urban health issues can be seen is in the links between transportation and households' mobility patterns. Much daily human physical activity in cities takes place outside enclosed private spaces, areas influenced by urban planning and management. Such policies can contribute to many policy goals: carbon reduction and economic development, but also health through reduced pollution, greater safety measures, and—the focus

Background

Changing urban form is implicated in a range of feedback loops with potentially adverse consequences for urban residents. For example, urban forms disturb the local climate, which can affect health through modified temperatures—especially in extreme weather conditions. The latest UN Habitat Global Report212 on Human Settlements states that “Evidence is mounting that climate change presents unique challenges for urban areas and their growing populations. These impacts are a result of the

Background

The future of urban and rural areas is closely linked through food supply. Rapid urbanisation of peri-urban arable land is likely to lead to an overall drop in agricultural production of 20–40%, depending on the assumed severity and length of global natural disasters.232 Simultaneously, food export restrictions by food-producing nations233 and constrained access to sustainable energy and water might further inhibit an affordable food supply. In urban areas, malnutrition, undernutrition, and

The promotion of urban health in conditions of complexity

The scope for unintended consequences arising from the interconnected and emergent properties of urban systems is substantial. Academic policy and planning is only slowly coming to terms with the implications of complexity—such thinking calls into question many widely held assumptions about research and policy processes. It challenges the ideas of stability, linearity, and regularity that drive evidence-based policy, emphasising the limitations on the ability to predict, plan, and control the

Recommendations

The Commission recommends that improved urban health outcomes will need a concerted effort to create and maintain the so-called urban advantage through reshaping city environments. Furthermore, such urban planning needs to take account of the inequalities between cities across the world and within individual cities when devising policy. Urban planning efforts should be based on a complexity approach that recognises multidirectional causality, feedback loops, and unintended consequences. Such an

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