By Claudius Van Wyk
Recently I went to the launch of a report by the UCL–Lancet Commission of Healthy Cities. The report affirmed that the requisite knowledge was in place for transforming a ‘city’ into a ‘healthy city’, however it also acknowledged that how to deliver potential health benefits and how to ensure that they reached all citizens in urban contexts across the world was less well understood. This issue was seen as representing an increasingly important task since the majority of the world’s population now lived in cities and that, with current high rates of urbanization, many millions more would soon do so.
The Commission offered an analysis of how health outcomes were part of the “complexity” of urban processes. It argued against the assumption that urban health outcomes would improve merely with economic growth and demographic change. It highlighted the role that urban planning could play (and is playing) in delivering health improvements through the reshaping of the urban fabric of cities. This, it was asserted, had been seen in a number of case studies, including a study of sanitation and wastewater management in Mumbai, a study of urban mobility in Bogotá, studies of building standards as well as the urban heat island effect in London, and studies of urban agriculture in Havana and Accra. The report launch was followed by discussions of the implications of a complexity approach for the planning of urban environments, emphasizing project-based experimentation and evaluation leading to self-reflection and dialogue.
The key messages identified by the report included the following:
The report referred to a complexity approach to planning of urban environments and claimed to set out a complex systems approach for the understanding of how urban environments affect urban health. Although there were assertions from the floor that there seemed to be confusion concerning the ‘complicatedness’ (the whole is the sum of the parts) of an issue versus its ‘complexity’ (the whole is different to the sum of the parts), the commission argued that its complexity approach looked at the interconnected elements of a system and how that system had properties not readily apparent from the properties of the individual elements. When challenged from the floor about whether the commission universally adopted this approach, citing linearity in the illustrations offered, a member of the panel responded that not all issues necessarily fell within the ambit of that requiring complexity thinking. Not everything, it was suggested, represented what would be defined as a ‘complex adaptive system’ and hence many issues might still be addressed in more ‘linear’ terms. Furthermore the criticism concerning the so-called ‘linearity’ of the illustrations, it was suggested, could also be seen as pointing to difficulties of visually representing complexity.
In respect of the assertion from the panel about the merits and universal relevance of complexity thinking in health delivery, the following challenge might be useful. With the increasing scientific evidence, for example, of the role of an individual’s subjective state of mind in health (see psycho-neuroimmunology), it could still be argued that most issues related to the experience of human wellness within the context of a city could well fall within the ambit of the complexity sciences. Indeed leading thinkers in the complexity sciences are quoted as identifying cities as supreme examples of complex systems. They cite their being far from equilibrium, requiring enormous energies to maintain themselves, displaying patterns of inequality and saturated flow systems that use capacities, as they put it, in what appear to be barely sustainable but paradoxically resilient networks.[ii]
It is within this context that the message that the identified ‘urban advantage’ in health outcomes had to be actively promoted and maintained, including the identified current constraints, merits further consideration. Carried further this assertion needs also to take into account the possibility that the future of cities might currently be premised on an economic model that might – and indeed ought to – change fundamentally. Hence as a consequence this would have significantly altered health outcomes – an economic contextual shift that would result in different emergent properties in respect of health outcomes.
In support of the work of the Commission on Healthy Cities the cross-disciplinary nature was indeed seen as highly commendable, albeit with some debate concerning the merits of ‘cross disciplinary’ versus ‘interdisciplinary’ research. ‘Cross-disciplinary’ is typically described as referring to knowledge that explains aspects of one discipline in terms of another; and ‘interdisciplinary’ is seen as referring to new knowledge extensions that exist between or beyond existing academic disciplines or professions. Consequently members of one, or both participating disciplines, it is declared, may then claim this new knowledge. An emerging new academic discipline or profession may then also claim this knowledge. In respect of the issue of cross-disciplinary versus interdisciplinary research there was a further comment from the floor that the notion of vertical and horizontal integration still appeared to represent mechanistic thinking.
Whilst these comments on the linear slant of descriptions employed probably do have some validity, it is nevertheless also important to note that the initiation of the project itself could be seen as representing a significant step forward. Years ago I asked Professor Phil Tobias of the University of Witwatersrand Medical School what it would take to open a department of Psychoneuro-immunology. His answer was: “Almost impossible, you could hardly get all the necessary departments to talk to each other!” Consequently, concerning the issue of the academic challenges posed in respect of interdisciplinary research, the idea presented at the seminar that a master’s degree offering multidisciplinary modules could be considered was notable. Such a course would surely then be required to encompass an emergent ‘Whole-Systems Science of Medicine’.
Comments in respect of the problems of research funding drew the suggestion that in most cases of research the hypothesis was identified first and thereafter the finding of data to support that hypothesis followed (a moot question in respect of the validity of research finding). This established research methodology was contrasted with a complexity approach, which required the sifting of masses of data to find useful strands to be researched i.e. patterns recognized. The intriguing notion was offered that the shared research agreement between different disciplines could be one of a collective agreement of ‘exploring the unknown’’. An additional point raised related to the prevalence of short-terminism in much of policy making, with the suggestion of the establishment of an alliance of long-term interest groups to research complex issues.
Finally, a significant point offered was in respect of the need for the mapping of behaviours in ensuring healthy cities. This pointed to an urgent requirement to include the behavioural sciences into research on complex healthcare delivery issues. This might have some bearing on the further recommendation in the report that policy needs to have a clear space for debate about the moral and ethical aspects of different approaches to urban health and city environments. This certainly points to the possibility that the unconscious dimensions of thoughts and feelings – the subjectivity of human nature – might still be the most complex issue being addressed by complexity thinking.
[ii] Hancock T, Duhl L., WHO. Healthy Cities project: a guide to assessing Healthy Cities. Copenhagen. FADI Publishers. 1988