Designing Healthy Cities

“By 2030, all developing regions will have more people living in urban than rural areas and homo sapiens will become ‘homo sapiens urbanus’ in virtually all regions of the world.”  - UN Habitat, 2009

While there is a strong global movement towards creating Smart Cities, does this include the concept of ‘healthy cities’? What are the important requirements to make a healthy city? The health of the city has very little to do with hospitals, doctors, vaccines or medicines. What is vital is very thoughtful urban planning that incorporates citizen participation in decision making. It provides basic services like clean and ample water, proper sanitation, waste disposal, well-constructed, affordable housing with safe materials, good connectivity within the city, access to and opportunities for education, health and livelihoods, technology that serves the needs of even those citizens who cannot access it and adequate clean open public spaces including greenery. And, most important, a citizen-friendly, decentralised governance where citizens’ grievance addressal is a priority.  All of these have significant impact on the physical, societal and mental health of the citizens, their productivity and their contribution to their cities.  

Urbanisation of poverty and planet of slums

An outstanding feature of the urban growth of the 21st century is the place of the poor in it. Dispossession of the poor and a deepening disparity within the urban forms has become the central tenant of the urbanisation process across the world. Industrialisation, urbanisation and associated migration have influenced the land use patterns in all cities and land has become the most precious and contested commodity.

 “The urban setting is a lens that magnifies or diminishes other social determinants of health. Urban environments have a number of contextual and compositional attributes such as size, density, complexity and verticality that affects health equity in both positive and negative ways.” (GRNUHE) 

And the people whose health equity is being affected the most are the inhabitants of informal settlements. In all countries the poor end up living in unhealthy places: downstream, downwind, in low lying lands, in flood plains, in landslides, over garbage dumps and near polluting factories. Most slum dwellers in Mumbai are located along the railway tracks, on dumping grounds or near areas prone to floods. In the city of New York all the bus depots are located in Harlem, where the African-American people are concentrated. 

Even though the definition of informal settlement (slum) changes country-by-country, city-by-city and time-to-time, the operational definition of a slum as per the UN Habitat is as follows: “A slum is a group of individuals living under the same roof in an urban area which lacks one or more of the following five conditions: 1) Durable Housing (2) Sufficient Living Area (3) Access to Improved Water (4) Access to Sanitation (5) Secure Tenure.”

The health of the city has very little to do with hospitals, doctors, vaccines or medicines

Mumbai, India’s global city, possesses the dichotomous dualism of being the financial capital of the country as well as the slum capital of the world. With more than 7 million slum dwellers, who occupy a total of 8% of the land, the population density of Dharavi, (of Slumdog Millionaire fame), the largest slum in Asia, is  2,77,136/km2  compared to 38,242/km2 of NYC or 31,398/km2  of Mexico City.

Medical research has repeatedly shown the ill effects of built environment on the mind and body of its occupant, including infectious diseases, chronic diseases, poisoning, accidents and injuries, chronic stress and mental disorders. Anywhere from 45-78% of citizens or rather ‘Non-Citizens’ of Mumbai live in a place that is difficult to be called a home by any definition. 

The meaning of ‘home’ for its inhabitants remains the same across the globe irrespective of their socio-economic, cultural, geographical, ethnic and racial diversities. It reverberates deeply with Maslow’s Theory of Essential Human Needs. A place of security, safety, privacy and rest. It forms a sanctuary, from harm, from disease, a place of rest where relations are built, thrive and continue, where ownership becomes a huge asset and also an expression of one’s ideas and aspirations. Yet, for over 1 billion people in the world today this remains a distant dream. (UNStat-2019)

Despite the effort to achieve SDG No. 11 of Sustainable Cities and Communities, the provision of affordable housing has not kept pace with the rapid urbanisations processes thus ignoring housing as a Human Right. The result is ‘slummification’ of cities globally, but especially so in South Asia. The home, instead of being a sanctuary, becomes the source of many ills for its occupants.   

Housing materials

Use of asbestos as a roof material is commonly used in South Asia even though it has been banned in many developed countries. Passive exposure to asbestos has long been known to cause mesothelioma of lungs and lung cancer. Exposure to lead-based paints or lead pipes in old buildings causes neuronal maldevelopment in children impacting their cognitive capacities throughout life. The American Academy of Paediatrics (AAP) recommends checking lead levels in children at 12-24 months of age to detect lead poisoning early in order to treat it. 

Lack of ventilation and sunlight

Overcrowding and poor ventilation is an invitation to diseases like TB. In Mumbai, an attempt has been made to shift slum dwellers to multi-storeyed apartment complexes with houses that have toilets on the inside. These complexes are composed of densely packed high-rise buildings with barely three metres in between and a nightmarish lack of recreational areas, schools and affordable health care facilities. 

A study conducted in 2018  by IIT-Bombay and a non-profit called Doctors for You has found that poor access to natural ventilation, sunlight and dearth of space has resulted in an abnormally high incidence of TB among the residents of these complexes where one in every 10 households has an occupant suffering from TB that was acquired after shifting to this area five years ago. (Mumbai’s ‘Designed for Death’ Buildings Are Incubating TB, S.Shantha 4/2018, The Wire)

In Kaula Bandar, an unregistered slum in Mumbai where PUKAR (an NGO) has been researching the social determinants of urban health for the past 10 years, a small room of 100 square feet without ventilation hosts 10-15 people at a time; they work with chemicals, (tannery and leather belt making) weaving, (carpets, zari embroidery), tailoring etc. Large amounts of suspended air particles, cotton fibers, threads and fumes exist in these congested spaces (personal observation during research). This may lead to increased incidence of respiratory elements, asthma, allergic bronchitis, other chronic lung diseases, tuberculosis and other air-born infections. Our research revealed that 30% of homes here get flooded during the monsoons. Leaking roofs is a common occurrence in all slums across Mumbai, thus giving rise to continuous dampness in the house and a large number of vector-borne diseases like malaria, dengue and chikungunya that return every monsoon season.

Poor housing materials and poor design also increase the risk of injury. In slums we have often observed collapse of the kachha (unfinished) homes during heavy winds and rains, thus injuring people. And these very homes fall easy prey to fires. Stairways designed with ropes in slums often give rise to falls and accidents. In slums, especially during monsoons when people end up cooking inside their huts with biomass fuels, the smoke causes damage to the respiratory system as well as the eyes, leading to early development of cataracts. 

In the USA, exposed heating sources can cause burns while unprotected upper-story windows and low sill heights can cause falls. Building design and materials influence the risk of injury from fires. 

Overcrowding and poor ventilation is an invitation to diseases like TB

“The social vulnerability in health is not a ‘natural’ or predefined condition, but occurs because of the unequal social context that surrounds the daily life of the disadvantaged and, often, socially excluded groups. Social exclusion of individuals and groups is a major threat to development, whether to the community social cohesion and economic prosperity or to the individual self-realisation through lack of recognition and acceptance, powerlessness, economic vulnerability, ill health, diminished life experiences and limited life prospects. (Social Determinants of Urban Health, GRNUHE & Rockefeller Foundation 2011)

Equitable access to the benefits of urban life

Access to livelihood opportunities are critical to people’s health. Long and expensive commutes to the workplace and lack of easy access to transportation impact both the physical and the economic conditions of the family and makes the urban poor vulnerable to unemployment. In Rio, some workers sleep on benches during the week saving commuting time as well as transportation costs that consume 20% of their earnings. 

At PUKAR, 30% of my colleagues spend more than three hours each day in jam-packed commuter trains exposing themselves continuously to a wide variety of air-borne infections. In Mumbai, where 7 million workers travel on the commuter trains, 19 persons are killed each day in train related accidents (Myth of Urban Development in Mumbai by Dr. S. Parasuraman). Better urban infrastructure and a well-planned transport system that provide safe options for getting around the city are needed to curb the rise in traffic deaths. (UN Habitat, State of the World’s Cities, 2006/7).

Access to health care facilities

In Kaula Bandar, a 60-year-old unregistered slum in Mumbai, PUKAR discovered that there is no primary school for this community of 15,000-18,000 residents and that the nearest health service delivery facility is 2.5 kms away with no public transportation available to reach that facility. (PUKAR-‘Off the Map’ Environment & Urbanisation 2012). When our research revealed the immunisation rate of children to be 32% in this slum, we took this data to the Municipal Commissioner and asked for health camps in the community.

With bi-monthly health camps and door-to-door education of the mothers for 18 months, we could increase the immunisation rate from 32% to 90.6%. When a massive fire broke out in Kaula Bandar in 2009, the fire brigade trucks could not reach the space due to very small non-negotiable lanes, thus destroying 300 households and displacing many people for months. Our research also revealed that those who rented spaces versus owners, gender and religion played a key role in the process of inclusion and exclusion for the compensations received from the local municipality.

Access to water and sanitation, infectious diseases and malnutrition

There is plethora of literature, elucidating the association between lack of toilets, lack of adequate water and diarrheal diseases. In developing countries, in an average two-week period, an estimated 82 million children aged 0-5 years old have diarrhea and an estimated 24,000 children die each day due to diarrheal illness that is related to lack of access to clean water and sanitation (WHO 2008). Worldwide, 780 million individuals lack access to clean drinking water and 2.5 billion lack improved sanitation.  

In Kaula Bandar, we found that only 3% of households had access to a toilet in their home. Of the 97% of households not having a toilet facility in their home, households had to use a paid toilet (59%), or a public toilet (39.6%), or just go outside in the open near the sea (13.7%). Of the residents 91.2% stated that the lack of water affected the health of their family members. Inaccessible, insufficient, unaffordable and unpredictable access to water is another source of poor health in a majority of the slums. In PUKAR’s research of 959 household and Seasonal Water Assessment, in which 229 samples were collected for water quality testing over three seasons, the data revealed that households spend an average of 52 to 206 times more than the standard municipal charge of Indian Rs 2.25 (US dollars 0.04) per 1000 litres for water and, in some seasons, 95% use less than the WHO-recommended minimum of 50 litres per capita per day (PUKAR Paper 2012).

At PUKAR, 30% of my colleagues spend more than three hours each day in jam-packed commuter trains exposing themselves continuously to a wide variety of air-borne infections

Safe living environment

Urban design has an important role to play in terms of physical activity, accessibility to open spaces and walkability around the neighbourhood. This has a major impact on health through behaviour modifications and safety. Safety on the roads for the pedestrians and elderly, children’s safety in the playgrounds, safety from violence and abuse for women, occupational safety for labourers working on the roads, and safety from natural and man-made disasters. Approximately 1.35 million people die each year as a result of road traffic accidents (WHO Feb. 7, 2020). Road traffic injuries are the leading cause of death for children and young adults aged 5-29 years. In India, road traffic accidents are almost always underreported and in addition to the pedestrians, the pavement dwellers often are the easiest victims of road injuries in cities like Mumbai. Even though most Indians walk, absence of footpaths and constant negotiation with vehicular traffic makes walking a hazardous experience in major Indian cities.

Physical activity and walkability 

Physical activity is strongly influenced by the design of the cities through the density of the residences, mix of the land uses, the degree to which the streets are connected, the ability to walk from place to place and the provision of and access to local public facilities and space for recreation and play (Report of Commission on Social Determinants of Health, WHO, 2008). There has been little attention paid to this part in the context of urban planning in India. The national average walkability index was 0.52 as compared to that of London, which is 1.5 to 1.7. 

Well-thought-out urban planning and design certainly has the potential to reduce the health impacts of the new lifestyle enhanced by the urbanisation processes, vehicular dependence, rampant availability of unhealthy foods made easily affordable through policies of subsidies, thus creating lifestyle related diseases. City design that would inspire and increase physical activity and in doing so lead to distributive justice, increased social cohesion and community gatherings, will have a very positive impact on both the physical and mental health of the citizens. 

Two of the most famous examples of this spatial and distributive justice are Curitiba in Brazil and Bogota in Columbia. Bogata’s visionary mayor Enrique Penlosa executed one of the most ambitious plans of reducing private automobile traffic, expanding and improving bicycle paths, increasing the easy accessibility of affordable bus rapid transit system and increasing the open public spaces for people to connect.  

Bogota’s TransMilenio systems averages 1600 passengers per day by bus, reducing travelling time by 32%, reducing gas emission by 40% and decreasing accidents by 90%. The CicloRuta, the bicycle path of Bogota, is one of the longest bicycle networks in the world, stretching 340 kms of bicycle-only lanes. This has increased physical activity for the rich, connectivity for the poor and decreased GHG emission of 36.6 tons of CO2 in Bogota. 

It is important that urban planning gives priority to walking pathways, cyclying pathways and creates affordable and easily accessible mass transport infrastructures in every city. All the above mentioned planning startegies contribute towards making a city healthy.

Access to natural environment within cities

The natural environment in which people live and interact has a large impact on both physical and mental health. Many great scholars from Charaka to Hippocrates have stressed the importance of environment in the health of the individual. Environmental pollution, including water, air, noise and soil pollution, has increased considerably due to rapid industrialisation. Air pollution due to noxious factory fumes and vehicular exhausts have become serious problems in many Indian cities, at times causing a complete halt in city activities, as it happened in the winter of 2019 in Delhi. Studies on air pollution and mortality from Delhi found that all natural-cause mortality and morbidity including respiratory and asthma related illnesses increased with rising air pollution. (Indian J Community Med. 2013 38(1): 4–8. Air pollution in Delhi: Its Magnitude and Effects on Health, Rizwan et al) 

Another critical part of urban design relates to the Urban Heat Island effect, secondary to climate change. The absorption of heat by the concrete surfaces results in urban areas having higher temperatures than surrounding non-urban areas causing heat-related illnesses and deaths. Therefore, ensuring trees, open parks, greenery as a part of urban planning will provide both cool shade and carbon sinking capacity in the cities. 

The natural environment in which people live and interact has a large impact on both physical and mental health

Healthy by design

A planners’ guide to environments for active living was released by the National Heart Foundation of Australia (Victorian Division) in 2004. The development of ‘Health by Design’ was assisted by key stakeholders representing planning, recreation, health, transport and community-building sectors and with support from the Planning Institute, Australia, Victoria Division. This design tool has been widely adopted by local government and developers in Victoria, Australia (Sutherland & Carlisle, 2004).

Urban Planning policies and proposal should encourage the following:

1. Healthy exercise
2. Social cohesion
3. Housing quality
4. Access to employment opportunities
5. Local low impact food production and distribution
6. Community and road safety
7. Equity and reduction of poverty
8. Good air quality and protection from noise
9. Good water and sanitation quality
10. Conservation and decontamination of land
11. Climate stability

Conclusions

Urban planning and design have a large and critical role to play in creating healthy cities by providing creative and equitable urban built form. Through the medium of physical environment, urban planners can enhance the physical, mental and social health of the communities. This can be achieved through various means from land use patterns, mixed zoning patterns, good connectivity, affordable and effective transport mechanisms, affordable low-cost housing with tenure security and accessibility to all advantages of urbanisation. Building health equity through urban design and urban planning, thus building healthy and wealthy cities, will lead to Smart and just Cities. That should become a major goal of the urban planning and design processes.