HEALTHY COMMUNITIES

Ever since humans first started to live in urban settlements, people have tried to build healthier communities. Hippocrates, the Greek "father" of medicine, wrote about the location and planning of human settlements around 500 b.c.e., while the Romans undertook massive engineering and public works programs to provide clean water and sanitation. In Renaissance Italy in the fourteenth and fifteenth centuries, the Boards of Health established codes to regulate all manner of practices and behaviors in the interest of public health.

The roots of modern urban public health can be found in the Health in Towns Association established in Britain in the 1840s. Victorian pioneers, such as Sir Benjamin Ward Richardson, who wrote about "Hygeia, a City of Health" in 1875, and Ebenezer Howard, who pioneered "garden cities" in the 1890s, led the way in planning communities that were more environmentally and socially healthy. In North America, cities such as New York, Toronto, and Milwaukee were leading lights in the development of public health in the early twentieth century.

With the advent of modern medicine in the 1930s, however, this public health approach to creating healthier cities and communities became overshadowed by medical interventions focused on the individual. It was not until the mid-1980s that a new healthy cities and communities movement was brought into being by the European Region of the World Health Organization (WHO) and a wide variety of national and local organizations. The movement has grown since then to involve thousands of cities, towns, and villages around the world.

The concept of a healthy community is a simple one, rooted in the recognition that the major determinants of health have little to do with what is known as the health care system. Rather, health is determined by equitable access to such basic prerequisites for health as peace, food, shelter, clean air and water, adequate resources, education, income, a safe physical environment, social supports, and so on. While these assumptions form the basis for the approach, every community understands and applies the concept somewhat differently, asking itself two simple questions: What is a healthy community, and how do we get one?

WHAT IS A HEALTHY COMMUNITY?

WHO defines a healthy city as "… one that is continually creating and improving those physical and social environments and expanding those community resources that enable people to mutually support each other in performing all the functions of life and in developing to their maximum potential."

Two key points in this definition are worthy of comment. The first is that it is a definition of a process, not of a status. A healthy city or community is not necessarily one that has a high health status but one that consciously seeks to improve the health of its citizens by putting health high on the social and political agenda. Second, the process is to enable people to increase control over and improve their health through applying the concepts and principles of health promotion at the local level.

WHO (Europe, 1986) also suggested a set of eleven key components that together make up a healthy city:

1. A clean, safe, high-quality physical environment (including housing quality)
2. An ecosystem that is currently stable and is sustainable in the long term
3. A strong, mutually supportive and nonexploitative community
4. A high degree of public participation in and control over the decisions affecting one's life, health, and well-being
5. The meeting of basic needs (food, water, shelter, income, safety, work) for all the city's people
6. Access to a wide variety of experiences and resources with the possibility of multiple contacts, interaction, and communication
7. A diverse, vital, and innovative city economy
8. Encouragement of connectedness with the past, with the cultural and biological heritage, and with other groups and individuals
9. A city form that is compatible with and enhances the above parameters and behaviors 10. An optimum level of appropriate public health and sick care services accessible to all
10. High health status (both high positive health status and low disease status)

HOW DO WE GET ONE?

What makes the healthy community approach unique when compared with other communitybased health promotion programs is its focus upon the role of local government, for whom the health and well-being—the quality of life—of their citizens should be a key objective. Historically, local governments have played a significant role in creating physical and social environments supportive of health, and many of the policy decisions that shape our health are made by local governments.

Policies relating to urban planning, transportation, housing, community and social services, parks and recreation, education, policing, and public works, among others, can play a significant role in shaping the health and well-being of the residents of the community. Failure to engage local government in the process of creating a healthier community is thus to miss an important and powerful partner.

But local government alone cannot create healthier communities. What the healthy city process tries to do is to put health on the social and political agenda of a community, ensuring that the sectors whose actions affect the population's health and well-being accept their health role, adopt policies and develop programs that consciously seek to promote health while achieving their own objectives. It takes the combined effort of all sectors of the community, including local businesses, the voluntary sector, community organizations, schools, and health services. The creation of healthy community coalitions that bring together partners from many different sectors is thus a fundamental objective of the healthy city and community approach.

Health promotion requires the empowerment of individuals and communities, enabling them to exert more control over all of the factors that contribute to their health and well-being. This means that the community—both as individuals and as members of community and neighborhood organizations—has to be centrally involved in the process of creating a healthier environment. They or their representatives need to be at the table as active participants in the citywide coalition as well as in neighborhood coalitions. Identifying and mobilizing the community's capacity and ability to take action in the interests of its health is another key aspect of a healthy city and community project.

The modern healthy cities and communities movement, because it is locally relevant and community-based, provides a powerful means of achieving better health for all.

Trevor Hancock

(see also: Built Environment; Ecological Footprint; Health Promotion and Education; Homelessness; Urban Transport )

Bibliography

Ashton, J., ed. (1992). Healthy Cities. Milton Keynes: Open University Press.

Hancock, T. (1997). "Healthy Cities and Communities: Long Tradition, Hopeful Prospects." National Civic Review 86(1):11–21. Available at http://www.healthycommunities.org/healthycommunities.html.

Price, C., and Tsouro, A., eds. (1996). Our Cities, Our Future: Policies and Action Plans for Health and Sustainable Development. Copenhagen: WHO Europe.

World Health Organization Europe (1986). Healthy Cities: Promoting Health in the Urban Context. Copen-hagen: Author. Available at http://www.who.dk/healthy-cities/.