Equity,sustainability and governance in urban settings

Introduction

Every setting is a ‘node’ in our lives, both a physical place where we live, learn, work and play and a social space where we interact with family, friends, co-workers and neighbors. Since settings exhibit both physical and social properties, we focus on two such aspects at the urban level – ecological sustainability and social equity – their interactions and the process of urban governance needed to address them. The latter is crucial; simply identifying a problem is not enough. We need new approaches to address these serious issues that are suited to the 21^st century.

Urban settings as a place of equitable and sustainable action

The urban transition is painful for many. Europe and North America experienced this in the 19^th century, Latin America did so throughout the latter part of the 20^th century, and it is taking place today in Asia and Africa. In the process, cities become unhealthy for many of their inhabitants – especially the poor − and for the local and even global environment. But experience in Europe and North America provides an indication that more just, sustainable and healthy cities can be created while giving some warnings about what not to do.

Social inequalities are exacerbated in cities. In Latin America, as in many developing regions and countries of the world, rapid urbanization has surpassed the countries’ capabilities to offer adequate services, while increased job instability in cities leads to further increases in economic and social inequities. The major strain from the recent global economic crisis has resulted in unemployment and loss of job opportunities, in turn leading to deteriorated welfare and increases in social problems that inhibit the population’s ability to meet its most basic needs such as housing, food and the acquisition of durable goods (1,2). During such economic crises, competition increases for scarce resources within the city government and between city and national governments.

Urban infrastructure affects the health status of the population by facilitating or hindering access to both ‘hard’ infrastructure, such as clean drinking water, sanitation, electricity, and transportation, as well as ‘soft’ infrastructure such as education, health and social services, communications and public spaces for recreation and sports. These problems are exacerbated by problematic social, family, community, and gender relations. This translates into major inequities that are not consistently captured or detected by health and other information systems, while documented evidence tends to average out the large inequalities within countries and cities (3).

In addition to insufficient infrastructures, major contributors to ill health include violence, alcohol abuse, tobacco use, the prevalence of vector-borne diseases, and chronic non-communicable diseases. These health issues tend to be much more prevalent in the lower socioeconomic populations, again highlighting the challenge of inequity and the role of the social determinants of health.

An increasing number of urban poor are settling in potentially dangerous areas mostly outside official and legal frameworks of building codes, land use regulations and land transitions. They live downwind, downstream, downhill (or uphill if the hills are steep and dangerous), on flood plains and low-lying estuaries. This puts them at much higher risk of suffering the consequences of natural disasters, such as flooding and landslides (4). These problems are exacerbated by climate change, bringing rising sea levels and increased frequency and severity of storms.

Cities are also increasingly vulnerable to other aspects of global ecological change as we enter the Anthropocene, a new geological era in which humans have become so large a force in disturbing the planet that our mark will be left in the fossil record (5). Not only are we causing a sixth Great Extinction (6), but all these impacts combined will disrupt our agro-ecosystems as well as natural ecosystems, affecting our ability to provide food and water to the population and creating large numbers of eco-refugees. Small wonder that The Lancet has published a manifesto for planetary health (7) and together with the Rockefeller Foundation established a Planetary Health Commission (8).

Ironically, urban sprawl − the most energy-inefficient and resource-wasteful form of urbanization ever devised − contributes to these problems, especially climate change. It has reached its zenith in North America and Australia, with serious adverse health effects (9). Troublingly, many urbanizing nations are copying this unsustainable and unhealthy approach, as a visit to any large Chinese or Indian city will confirm.

But while the impact on the majority of the population who live in cities will be large, cities − if well planned and managed − also hold out the prospect of yielding significant economic and social benefits. They could ‘reduce greenhouse gas emissions’ while at the same time reducing ‘urban infrastructure capital requirements’ (10).

There is a growing body of evidence on the health benefits of improved urban design; indeed, the health benefits of Smart Growth (a key urban development solution to urban sprawl) has been likened to a ‘medical miracle’ (9).

Governance for just, sustainable and healthy cities

Working through healthy settings has been one of the more successful strategies for putting health promotion into practice in the countries of Latin America (11) and elsewhere. Based on the notion of health as quality of life, the actions of the Healthy Settings Strategy focus more on the underlying determinants of health than on their consequences in terms of disease. The ultimate goal is to promote the processes that enable people to improve their living conditions.

Based within the concept of health promotion, an important part of the Healthy Cities approach involves both personal and communal empowerment. This requires both informal social networks and organizations being recognized and engaged in the process of governance − ‘the sum of the many ways individuals and institutions, public and private, plan and manage the common affairs of the city’ (12) – and in formal processes of democratization.

Although local government has a key role to play in creating a healthy community, it cannot play that role alone. Regardless of their priority area of concern – whether it be the environment, social activities, education, safety, public works, or any other − community members and organizations are also responsible for improving the living conditions, health, and quality of life of the people living in their community and they are and need to be participants in that process (13).

In Latin America, the implementation of the Healthy Settings Strategy was developed and implemented in the context of the democratization and decentralization processes, with local government expansions of fiscal and political authority that were taking place during the major societal upheavals of the 1980s. As military dictatorships were falling, many countries were reconvening citizen assemblies to rewrite constitutions that now included language related to health and democracy. Because the Healthy Settings Strategy emphasizes community participation and local government control, these coinciding trends were very supportive of the movement’s subsequent adoption and rapid expansion.

This, together with the inspiration provided by Paulo Freire’s concepts of popular education as a means to empower and liberate the poorest populations (14), has resulted in the emergence of some inspiring new approaches to governance, especially in Brazil. Three key examples are the development of ‘participatory budgeting’ in Porto Alegre (15,16), the creation in Belo Horizonte of the position of Municipal Deputy Secretary of Democratic Governance (17) (every city and town should have such a position), and the creation of a national Ministry of Cities (18).

In 2008, 12 countries of the Americas ⁱ participated in a Regional Healthy Municipalities, Cities and Communities (HMC) Survey carried out by the Pan American Health Organization and ISALUD University of Argentina (19,20). In these and other studies, common factors that contributed to success in social participation included: increasing the use of participatory instruments (e.g. assessments, evaluation, and participatory budgeting); establishing intersectoral committees; and increasing participation of civil society organizations in local projects and initiatives (21,22). The use of virtual forums and networks was one of the most promising emerging strategies for channeling these participatory and collaborative processes (20).

A way forward

Collaboration needs to include new forms of social participation (development of virtual networks and e-government tools) and social media by employing effective tools that facilitate citizen decision-making, thereby improving governance processes through empowerment. A people-centered participatory approach can help to ensure continuation of policies and programs, even when there are major changes in government, with active participation of all sectors of society (public, private, and civil society) in decision-making processes at the local level, as well as in mechanisms for planning, management, monitoring, and evaluation of policies and programs. However, many cities exclude a large portion of their inhabitants, namely the urban poor, from the process of decision-making, as elites or interest groups dominate the process. Therefore, it is particularly important to foster the participation of excluded groups such as the urban poor and women.

Future alliances should focus strategies on the generation of new relationships, engaging the more dynamic players and sectors, such as cultural, youth, academic, business, and social movement organizations.

There needs to be a shift from the currently predominant focus on lifestyles and services to an increased focus on values-based urban planning, economic development, transportation, and housing, while addressing the unrecognized challenges of mental health and prevention of violence. We also need to address these global ecological and social challenges through local action in the settings where people lead their lives (23) – and cities provide the overarching setting and context for this by including their homes, schools and universities, workplaces, hospitals, and communities. A key strategy needs to be linking ‘healthy setting’ initiatives and ‘sustainable setting initiatives’ through global, regional, national and local networks specific to this purpose.

Finally, governments must develop healthy public policies focused on the social determinants of health, sustainable local development, and health equity, and adopt planning and management mechanisms that include intersectoral collaboration and participatory decision-making processes, accompanied by information systems that address inequities and excluded populations.

Facing the linked challenges of unsustainable and inequitable development, what better way is there to inspire the young and future generations than to create with them a vision of more just, sustainable and healthy cities and equip them with the participatory tools and processes that will help them make a difference in the settings where they live, learn, work and play.