Healthy Cities
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:
- Cities were seen as complex systems with the accompanying conclusion that health outcomes could be identified as ‘emergent properties’. The premise was that urban health outcomes were dependent on many interactions and feedback loops, so that prediction within the planning process was fraught with difficulties, and unintended consequences were common.
- The identified “urban advantage” in health outcomes (urban areas offered greater access to healthcare resources than was possible in rural areas) had to be actively promoted and maintained.
- Inequalities in health outcomes were to be recognised at the urban scale. (An example of this is that studies of a number of countries found substantial inequalities in access to health care, which meant that the ‘urban advantage’ was virtually non-existent for many urban poor despite proximity to services.)
- A linear or cyclical planning approach was identified as being insufficient in conditions of complexity. (Linear planning is described as employing a mathematical method for determining a way to achieve the best outcome in a given mathematical model. Cyclical planning is described as being designed to achieve the goal with iterative trial-and-error strategies. The following quote is typical of such deterministic approaches: ‘(there is) an advanced model encompassing a two-phase simulation optimization algorithm that integrates the genetic algorithm and response surface-based linear search algorithm that is geared to developing an optimal cyclic plan in a multi-echelon environment during the maturity phase of the life cycle of a product or service’[i]).
- Urban planning for health needed to emphasise experimentation through smaller-scale projects that could be amplified if proven successful.
- Evaluation leading to dialogue between stakeholders and self-reflection were essential.
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.
[i] http://arizona.academia.edu/LianaNapalkova/Papers/719513/Two-phase_simulation_optimisation_algorithm_with_applications_to_multi-echelon_cyclic_planning
[ii] Hancock T, Duhl L., WHO. Healthy Cities project: a guide to assessing Healthy Cities. Copenhagen. FADI Publishers. 1988
Just some info, Greg and Claudius, you probably know of these, but:
Becky Malby and Martin Fischer, and others have done great work applying complexity to health – they started out at the King’s Fund about 15 years ago, which is how I met them.
I hope this particular conference didn’t fail at its own aim of getting out of the rigid disciplinary boxes, and that it doidnt also fail to learn from the KF’s pioneering work.
There was a piece in Atlantic Cities about Sim City as a model of the complexity of cities yesterday, I think. Personally I think the approach uninteresting, but then I’m not a modeller so what do I know? Might be worth a look.
Best wishes
Arthur Battram
Given current sensitivities about reforms of the NHS in the UK and within a global context of economic uncertainty the Commission’s report is certainly valuable. It advocates a way of planning recognizing complexity that cannot fail to be seen and appreciated by health authorities – and in turn has far-ranging implications into other areas of service delivery. But implementation is probably going to require some courageous pioneering.
I should have also mentioned the ‘Edgeware’ project and website from back then also, based at the VHA in the US.
This was spun out as the Plexus institute.
I think their work of complexity ideas applied to health predates the KF.
Are you the author of ‘Navigating Complexity’?
I am. Not many Battrams in the world; the Canadian ones make ice hockey gear…
Hi Arthur,
Last time we were in touch, was some 15 years go, around Mike McMaster’s Complexity seminar in London. Since then I shared your Complexicon with many of my clients. You’ve been truly one of the pioneers of the field in the UK.
It’s good to see that we’re still moving on resonant tracks…
george