The need for healthy city is aggravated by growth and development that is largely unplanned, uncontrolled and chronically under-financed.The distinction between rural and urban areas is usually relatively unproblematic and generally related to degree of development. However, among professionals this distinction has been focused for some time, with efforts being made to develop various criteria to distinguish between urban and rural areas. Clearly defined rules and criteria are important in order to observe urban development and its impacts. In industrial countries the most important criteria for classification of areas have been population density, distance between houses, the structure of the economy and population figures. The need for clearly defined criteria became apparent when one started to develop statistical overviews of urban population density and other demographic characteristics. Initially it was only necessary with a consistent definition for each individual country. As the international focus on problems related to urban areas has increased, comparable global statistics have become necessary. However, much of the current statistical data are difficult to compare.
The delimitation of urban areas is defined differently from country to country and can be complex. The differences are usually due to the variations of settlement types, economic structure, tradition etc. in the respective countries. In some countries the delimitation is based on administrative borders. This may generate problems as the cities may in reality expand or contain large unsettled areas within these borders. There are also large variations with regard to the definition of minimum population density for a settlement to be considered urban. Variations of this criteria are related to how densely populated the country is and how many large cities it contains. In most cases the limits are set between 1500 to 5000 inhabitants. The term village is used for communities characterized by a built-up area and a certain degree of communal rights to the utilization of natural resources.
The global settlement patterns are to an ever increasing degree characterized by urbanisation, defined as those processes which cause an increasing concentration of the population in densely populated areas. This is connected to the increasing specialization of the economic activity in the secondary and tertiary economies. Urbanisation entails certain fundamental changes that are geographical, physical, structural, economical, demographical, cultural and behavioral. In most industrial countries and some developing countries urbanisation has stabilized. However, most developing countries are in the middle of, or at the start of, an urbanisation process. Many developing countries also experience a considerable population growth, resulting in a rapid expansion of many cities in both Asia, Latin America and Africa the last twenty years.
Planning, administration and management, essential to cope with urbanisation, are often little developed or function poorly in many countries. Weak economy and national debt burdens contribute to this. Most cities in developing countries experience common problems like lack of employment opportunities. too little and often inferior housing, inadequate infrastructure and public services, serious environmental problems, poor health, large social inequalities and poverty. In the future there will probably be more urban poor people than rural poor. Urban environmental problems are due to complex cause-effect chains. In order to identify the correct measures it may be necessary to look closer at the connection between cause and effect. However, a fragmented perspective is often the case and leads to projects and programmes focusing individual extremely visible problems while ignoring other problems and the connections between them.
In our rapidly urbanizing world, promoting and protecting the health of people living in cities presents a growing challenge to local and national governments and international organizations. Within 15 years, 20-30 cities will have over 20 million people and most of them in developing countries. More importantly, human-made environments will account for the living space of the majority of the world’s population. By 1990 already, at least 600 million people in the urban areas of developing countries were living under life and health threatening conditions. One quarter of the Third World’s urban population did not have access to an adequate safe water supply and one half did not have an adequate excreta disposal system.
Health problems in cities are aggravated by growth and development that is largely unplanned, uncontrolled and chronically under-financed. Rapid urban growth is overwhelming the capacity of municipal authorities to provide basic environmental services, housing, employment and other minimum prerequisites for a healthy population. This generates severe – in some cases, explosive – health problems, social, financial and political.
People in cities – particularly the poor and newly arrived – experience stresses and exposures that result in ill health, ranging from communicable diseases and malnutrition to mental illnesses and chronic respiratory diseases. As regards urban air pollution, the most recent statistics show that an estimated 600 million people live in cities where sulphur dioxide levels exceed WHO health guidelines and 1 200 million live in cities where particulate matter exceeds WHO health guidelines. Most of these cities are in the developing countries. Unhealthy conditions include poverty, inadequate food and shelter, insecure tenure, physical crowding, poor waste disposal, unsafe working conditions, inadequate local government services, drug abuse and generalized environmental degradation in the urban fringe areas. It is actually one of my deep concerns to have to witness the persistence and increase of urban poverty. The deplorable situation of street children is an alarm signal that action is needed at all levels.
As much as we are concerned about the critical environmental health situation in our cities, there is another side to the coin. That is the health opportunities that are generated through urban development – and they present another challenge to the health sector of similar magnitude. Such health opportunities include:
- introduction of worker training, safe practices and pollution control in industrial developments;
· primary health care and health education associated with house upgrading programmes.
Health development work in cities should be an integral part of a wider urban development effort that involves urban infrastructure, land management, municipal finance, industrial development etc.
Healthy Cities is a programme which is fundamentally about the links between urban living conditions and health and decided to take up the urban challenge as early as 1986. In a Healthy City Project all the city and municipal agencies concerned with energy, food, agriculture, macroeconomic planning, housing, land-use, transportation and other areas, are required to examine the health implications of their policies and programmes and adjust them to better promote health and a healthy environment.
Meanwhile there are numerous urban initiatives under way, many of them carried by local groups, nongovernmental organizations, community associations, citizens’ groups etc. Thus the Healthy Cities idea has gone well beyond administrative city boundaries; it has in fact inspired many people and given new vigour to citizens’ solidarity, to democratization and to community spirit and responsibility.
The term “Healthy Cities” has become popular and many municipalities around the world are using it to publicize health and environment protection projects they undertake. There are currently in the order of 800 cities (approximately 600 in Europe) involved with the “Healthy Cities” approach. In a number of countries, primarily in Europe but also in Asia, Africa and Latin America the participating cities are linked through national networks approach based upon a participating spirit. In this sense, the Healthy Cities idea will have impacts on social development well beyond the solving of urban environmental health problems. In 1991, the subject of the WHO Technical Discussions was urban health which provided a valuable boost to urban health activities.
WHO’s role in the Healthy Cities movement is to match technical competence and expertise with innovative and workable approaches. The continuous expansion of networks of Healthy Cities demonstrates the viability of this approach while the twinning of North-South and South-South cities has proved a useful strategy to promote the exchange of expertise between continents. It has also enabled the launching of joint programmes to help find solutions to common problems. WHO can further accelerate the development of “Healthy Cities” programmes in various regions by providing publicity and promotion for today’s achievements through mechanisms such as “World Health Day” devoted to Healthy Cities in 1996.
The implementation of Healthy Cities Projects in metropolitan areas around the world has emerged as an effective means for improving urban health and the urban environment, particularly for low-income dwellers. The designation of a Healthy City signifies that new initiatives are being undertaken or planned, which through a new coalition of government and community organizations address priority urban health and environment problems. To date the development of Healthy City Projects or activities has taken different paths in different regions. In Europe, where the Healthy City approach was first developed and promoted by the WHO Regional Office for Europe, a structured Healthy City Programme is in place, whereas in other regions the Healthy City approach is yet to be organized, strengthened and structured to provide for a more lasting and systematic development.
The WHO initiated discussion on the promotion and development of the Healthy Cities approach as a major interregional programme on urban health and environment for the years to come. Its particular strength is its ability to address the major policy orientations of the WHO’s General Programme of Work, namely: integrating health and human development in public policies, ensuring equitable access to health services, promoting and protecting health, preventing and controlling specific health problems. The approach is an important component of the WHO global strategy for health and environment that was endorsed by the World Health Assembly in May 1993.
While the Programme may focus on the priority health and environment issues, it will also address other urban health problems, in accord with regional priorities. To this end it may be a truly “inter-programme” activity of the WHO, that will enhance the coordinated programme delivery of many health programmes at the city and local level.
Important benefits of strengthened WHO Regional Healthy City programmes might include:
- greater effectiveness for WHO programmes in the key city health arena;
- a stronger linkage between WHO and the many existing Healthy City initiatives that aim at improving urban living conditions in all regions;
- a more effective approach to the WHO objective of integrating health and human development in public policies and thereby contributing to sustainable development;
- development of the WHO’s capacities in supporting local and city level public health policies and programmes.
An interregional programme for Healthy Cities might have the overall developmental objective to improve urban health and environment through regionally constituted and operated networks of Healthy Cities. It would seek to develop and maintain a strong inter-programme base in HQ and Regional Offices to promote the active participation of all relevant programmes in HCP. And it would facilitate the coordination of HCP activities in individual cities with other environmental and health related programme activities.
Possible strategies and activities
- Maintain a regionally-oriented flexible approach, so that HCP could be developed differently in different Regions and on a different time schedule.
- Establish WHO Collaborating Centres to provide support to the Programme.
- Continue to develop and disseminate guideline material relying increasingly on successful case study examples of existing Healthy City projects.
- Mobilize extra-budgetary support for programmes as a whole and for regional networks and individual city projects.
- Promote the expansion and strengthening of the Programme through exchange of information, technical support through networking and city “twinning” arrangements, conferences, newsletters, etc.
- To develop a global monitoring system for Healthy Cities, that includes a database on individual city projects.
- To undertake strategic research on Healthy City Projects, for example to develop a methodology for costing the implementation of a project in a given city and to develop methodologies for assessment of the impact of a project on the operation of local government in participating cities.
- To use prominent health-related events, such as “World Health Day”, for health promotion activities in all participating cities.
- To prepare an interregional conference on Healthy Cities, to promote and develop the above objectives on a worldwide basis.
- To use the event of HABITATII in June 1996 to promote health in housing and Healthy Cities.
- To establish and maintain close coordination with international local government associations and with urban programmes of other international agencies, an important objective being the establishment of cooperation with UN Development Programmes at the country level.
- To provide advisory services and other support to individual Healthy City projects, relying on the particular strength of the WHO in its ability to provide in-depth technical support from its comprehensive range of programmes covering virtually all health and environment aspects.
- To foster linkages between WHO’s environmental health activities on the “brown agenda” (for pollution control, water and sanitation etc.) and the Healthy Cities Programme at the individual city level and in the networks.