![]()
PART I
Perspectives
Overview by Hugh Barton
The purpose of this first group of chapters is to provide a series of varied perspectives on the subject of planning and health, with the object of helping readers to orientate their thinking. The perspectives range from the theory of planning to the need for professional bridge-building, from the central issue of health inequalities to that of climate change, from the history of health and planning in the West to the current plight of unhealthy environments in poorer countries. It becomes evident that, despite planning for health being in general a new field of study, it reaches back in time, and across many of the fundamental social, economic, environmental and political concerns of today. The authors – from England, Australia, the USA, Scotland, Wales and Switzerland – are all leaders in their fields, and internationally respected.
Health and well-being at the heart of planning
Chapter 1 serves as an introduction to the whole book. Hugh Barton sets the context by defining both health and planning broadly, making clear that health policy is not just the concern of doctors, and planning not just of town planners. He explains the ‘time-bomb’ of public health, and the role that spatial planning plays in shaping unhealthy or healthy urban environments. The core of the chapter reviews the way that planners look at themselves: the move from an early focus on health to an increasing concern with means not ends, culminating in the principles of collaborative planning. Barton argues that promoting health and well-being should be reinstated as the prime purpose of planning. He presents a conceptual framework – the Settlement Health Map – as an aid to integrating health, planning and sustainable development.
The history of planning in relation to health
Chapter 2, by Robert Freestone and Andrew Wheeler, traces the history of planning through a public health lens, from the late nineteenth century to the present day. They show that the trajectory of health integration into planning is neither simple nor consistent. While early planners were concerned about basic living conditions – effective sanitation, healthy housing, access to greenspace – there was subsequently fragmentation of responsibility and regulation that made integrated strategies problematic. Public health became oriented around the medical view of health, while planning was caught up in the rush to motorisation. The market re-asserted its position (if it had ever lost it) and the increasing pluralism of built environment decision-making impeded coherent strategies. In the later twentieth century the United Nations and the World Health Organization were at the forefront of moves to re-affirm the centrality of people, and their health, in planning decisions. The authors talk about rebirth of the nexus, and the beginning of the healing of the rift.
Urban inequities, population health and spatial planning
In Chapter 3, Jason Corburn examines the central issue of health inequity, tracing its persistence through the twentieth century. Modern planning often involved the renewal of unhealthy neighbourhoods, yet by late in the century environmental inequality remained. The problem has shifted from communicable to non-communicable disease, and the policies designed to tackle the former are no longer a sufficient basis for healthy planning. There are winners and losers in the political and economic struggles of place making. Corburn advocates an adaptive planning style, working with stakeholders, that recognises cumulative disadvantage and does not wait for absolute proof of causality, but emphasises action in the face of uncertainty.
Rapid urbanisation, health and well-being
Cliff Hague, in Chapter 4, amplifies the equity theme in relation to rapid urbanisation in the developing world. As president of the Commonwealth Association of Planners he has studied the housing and health problems of the poor, especially in slums and informal settlements. The sheer speed of urban growth has outpaced the ability of governments to manage the situation, and planning has sometimes become part of the problem, not the solution – including when planning full motorisation for the rich at the expense of the poor. Hague argues for better targeted regulation, aimed at participatory upgrading of the slums. The chapter provides a welcome corrective to the general emphasis in the book on richer countries – but the solutions proposed have a general relevance.
Healthy cities, healthy planet
Chapter 5, by Herbert Girardet, picks up the theme of urbanisation and relates it to questions of global sustainability. Cities depend for their survival on the exploitation of scarce resources, and tend to pollute both their immediate hinterland and the water and atmosphere of the earth, threatening life and health. The current linear approach to urban metabolism is unsustainable, and needs to be replaced with circular systems. Girardet illustrates a move from what he calls Petropolis to Ecopolis, with the aims of moderating the rate of climate change and regenerating the human habitat. People’s health depends on global health. Technology, he says, is not the problem. Rather it is the short-term, patchwork approach to problems by decision-makers.
Bridging the divide between knowledge and practice
In the final chapter, Roderick Lawrence takes up the governance issues raised by Corburn, Hague and Girardet. He explores the difficulties of bridging two divides: that between professionals, politicians and the public; and that between different disciplines and professions. The prevailing approach of public and private decision-makers is to recognise direct impacts of their decisions (especially if monetised), but sideline the indirect and complex longer-term impacts. The persistence of the construction of urban environments that compromise health is illustrative of this. Business as usual needs to be replaced by interdisciplinary and transdisciplinary processes that apply a human ecology perspective, working with stakeholders through open and critical inquiry.
![]()
1
PLANNING FOR HEALTH AND WELL-BEING
The time for action
Hugh Barton
Introduction: scope and purpose
Planning and public health are siblings, born of the same concerns. The history of town planning, from the era of Hippocrates and Hippodamus in classical Greece to the present, is full of examples of towns designed with the well-being and health of residents a primary concern.1 Modern planning emerged in the late nineteenth century largely in reaction to the unsanitary, overcrowded and inhumane conditions of industrial cities. It was recognised then, and it is increasingly recognised now, that there is an umbilical link between environmental conditions and human health. This link is not only a matter of the direct physical impacts – for example of foul air or contaminated water – but also of indirect social and behavioural effects, on the exercise we take, the people we meet, on equity of access to essential services and to nature.
Yet the environment we have been creating around us compromises health and well-being in many ways. Fundamental issues of housing, sewage treatment and water supply – the concerns of nineteenth-century policy-makers – still prevail in the slums of many great cities in poor and middle income countries. Air pollution is a recognised health problem in most major cities, rich and poor. High car ownership and road construction in many city regions has led to the progressive dispersal of key functions and of population, increasing carbon emissions, undermining the practicality of daily walking and cycling to get to facilities, contributing to the obesity epidemic. Health inequalities, largely due to income, education and status differentials, have been reinforced by spatial inequities (CSDH 2008; WHO 2013).
The concepts of both ‘health’ and ‘planning’ can be interpreted narrowly or broadly. In common parlance ‘health planning’ means the provision of health services – hospitals, clinics and doctors’ surgeries. In-as-much as prevention is pursued, public health programmes focus on infectious diseases, addiction (tobacco, alcohol, drugs) and poor nutrition rather than healthy environments. The emphasis is on the provision of services for people who are ill with acute or chronic conditions, while sidelining the many societal factors that are tending to make them ill. The holistic definition of health formulated by the World Health Organization (WHO) when it was founded in 1946, in the period of determined idealism that followed the Second World War, offers a radical alternative perspective:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political belief, economic or social condition.
(WHO 1948)
This definition makes it clear that health policy is not only a matter for health care professionals, but for the many powers and professions that affect the social, economic and environmental determinants of health. In that context planners, designers and developers have responsibility for promoting healthy settlements.
Planning also needs defining in an inclusive way. It is not simply the bureaucratic process of land use control. We use the term ‘spatial planning’ to indicate a broad concern with all aspects of the human habitat and human settlements that impinge on physical space. The aims of spatial planning are social, economic, ecological and aesthetic. The means are the planning, design, construction and management of the environment. As such it is not the preserve of one profession, the town planner or urbaniste, but embraces the roles of urban designers, architects, landscape architects, transport engineers, land surveyors, economic development officers and other sectoral planners. All these professionals are of course duty bound to satisfy their clients’ demands, be they elected representatives, commercial firms or charitable organisations. But they also have a professional responsibility to the users of the environment they plan and design. The responsibility to users should logically include responsibility for the health impact of their actions.
The rest of this chapter, and the book as a whole, take the broad understanding of health and of spatial planning as given. The chapter first summarises the scope of the relationship between health and the physical environment, highlighting current and emerging crises, and then the level of influence that planning exerts on that environment. It then reviews the evolving theories that have interpreted the role and purpose of planning, arguing for a revived ethical stance that prioritises people’s health and well-being. This leads to the presentation of a framework for thinking about healthy spatial planning that integrates the social determinants of health with an ecological understanding of human settlements. This framework, known as the Settlement Health Map (Barton and Grant 2006), provides the conceptual underpinning for the book.
The time-bomb of public health
On a cursory examination, worldwide trends in health and well-being are positive. Life expectancy is increasing in poor, medium and high income countries. Child mortality has fallen dramatically. These trends are expected to continue. Nevertheless, a series of factors are interacting to create a ‘perfect storm’, threatening the ability of nations and communities to cope. Increased longevity means a growing elderly population dependent on a falling proportion of wage earners. And while people are living longer, many are subject to disability as a result of chronic conditions such as heart disease, cancer, diabetes and mental illness. Some places exhibit alarming characteristics. In the most deprived neighbourhoods in England at the turn of the century people experienced almost 30 per cent of life with a physical or mental disability (Marmot et al. 2010). Recent data suggests the situation is worsening.2
At the same time increased affluence, technological changes and lifestyle choices are contributing to an epidemic of obesity, evident to varying degrees in almost all countries across the world. In the US, obesity rates increased dramatically between 1990 and 2010, now affecting a third of adults, and being overweight has become the norm (Butland et al. 2007). According to the UK Foresight Report, by 2050 Britain could be a mainly obese society (ibid.). Research suggests that there is a direct relationship between obesity and modal choice: in the US each additional kilometre walked per day is associated with a 5 per cent reduction in the likelihood of obesity, while each extra hour in a car is associated with a 6 per cent increase (Frank et al. 2004). In China the likelihood of being obese is 80 per cent higher for adults in households with vehicles (Davis et al. 2007). In India 50 per cent of those who travel to work by private vehicle are overweight or obese, double the figure for those who walk or cycle. The longer the cycling trips the greater reduction in obesity, diabetes and hypertension (Millett et al. 2013).
Health inequality is a central concern in this emerging crisis. Wilkinson and Pickett, in their seminal book The Spirit Level (2009), demonstrate that, for rich countries, health is unrelated to national income per head, but is strongly related to income inequality. The analysis of the ‘health gradient’ between rich and poor in London is salutary: 40 per cent of the poorest groups suffer from a long-term limiting illness, while for the richer groups it is around 5 per cent (Wilkinson and Pickett 2009). We are recognising that the varied prevalence of non-communicable diseases is a reflection of societal values, economic structures and environmental conditions.
The...
