Does Orthodox Urban Planning Kill?

Martin Wolf, Chief Economics Commentator for the Financial Times of London has harsh words for orthodox economics.  In his recent book The Shifts and the Shocks: What we’ve learned –and have still to learn – From the Financial Crisis, he comes close to dismissing the profession as alchemy.  Does orthodox urban planning deserve a similar judgment? 

There is a strong argument that the primary challenge for this profession is to undo the damage it has done over the last 80 years.  Indeed, in many European countries with some of the most livable cities, urban planning is not even regulated as a separate profession.  For at least four decades, starting even in the early 1960s with the catastrophic failings of urban renewal, the profession has faced significant critiques.  Examples of alternative development approaches notwithstanding, significant change has remained marginal while most cities have continued costly, often barren urban sprawl.  Increasingly, however, the emerging influence of the Healthy Cities Movement, born in the 1980s and now breaking down the historical barriers surrounding a wide range of disparate professional silos, may be priming real change in how we build our cities in Canada.        

The movement is based on first a recognition of how the current approach to the built environment decreases physical activity and connectedness, increases stress and social isolation, threatens the environment, air quality and food supply while homogenizing a shared sense of place and belonging.  But the second big step, flowing from evidence-based research, is the movement’s connection of these outcomes to public health.  More specifically they contribute to if are not the only cause of an explosive rise in chronic diseases.  Instead of cholera, tuberculosis and other infectious diseases generated by the unsanitary and over crowed conditions of 19th century cities, surging rates of obesity, diabetes, heart problems, mental illness, allergies, asthma and even accidental deaths can be directly traced back to how we design our urban form, our workplaces, our homes and our public spaces.

Modern urban planning, of course, originated in the often-appalling health conditions of the new industrial city.  Olmstead’s parks movement, the Garden City movement, zoning to separate industry from homes, and so on, grew out of a public health movement such as the Health of Towns Association in Britain.  The Ontario Healthy Communities Coalition quotes Jessie Parfit, “Many would be surprised to learn that the greatest contribution to the health of the nation [Britain] over the past 150 years was made, not by doctors or hospitals, but by local government.”

With the massive economic and social influence of the automobile and the rise of large real-estate developers in the 20th century, many of the nascent progressive policies of early planning were transformed.  They were used to justify and support suburbanization, marginalization of public transit and the consolidation of car-based retail and services.  Urban planning’s “urban renewal” response to the deterioration of once vibrant urban cores only made the problem worse. Some North American cities like Vancouver avoided the worst pitfalls of modern planning while a few others, such as Portland Ore., took remedial steps as early as the 1960s.  Critical movements such as New Urbanism, Smart Growth, Transit Oriented Development (TOD) and sustainability, often with strong support from some in the planning profession, have sought with limited success to redirect how we build our cities.  Mark Holland is a landscape architect, past director of Vancouver’s Sustainability Office, founding member of the not-for-profit Healing Cities Institute and now developer of BC’s New Monaco, which he promises will be the healthiest neighbourhood in Canada. “For the last 80 years,” he says, “the nature of planning has been driven by ‘urban engineering,’ especially the traffic engineers while planners have taken it on the chin.”  Engineering standards and their rather low, narrow objectives have held sway notwithstanding the nostalgia of New Urbanism.

But the appeal to a qualitatively better, smarter, less publicly expensive and more environmentally sound development has seemed unable to generate a tipping point.  Even the economic prosperity argument of the relationship between city form and the creative economy has not yet fully brought about wholesale changes.

While the Healthy Cities Movement builds on all the ideas underlying these other alternative approaches and appeals to the promise of a more fulfilling way to live in the urban setting, it has subtly introduced a darker, even brutally attention-getting argument.  In the language of a U.S.-style negative political ad, “Orthodox Urban Planning Kills!”  Or how about, “Vote for the Status Quo of Built Form and Doom Your Kids to Die Younger than You,” as some argue.  Even without such overt threats, however, the Healthy City wake-up call just may be having an important impact. 

Canada as the Point of Origin  

Canadians, we like to think, define in part our national character by our universal health care system.  Thus, it may be no surprise the origin of the revolutionary evidence-based approach to health care and eventually the design of health-care facilities originated out of Hamilton’s McMaster University (Building August-September 2012).  Less well-known perhaps is that the modern Healthy Cities Movement also got its start in Canada.

Most observers attribute Canada’s Lalonde Report (1974) as the first national policy to broaden the range of factors determining health.  While it continued to place major responsibility on choices made by individuals and continued to acknowledge the role of traditional biomedical determinants of health, Lalonde also singled out social and physical environments as co-determinants.  This encompassing approach reflected ideas already being strongly pushed by the American public health policy advocate and educator Nancy Milos.  The idea of an integrated approach where all public policies must apply a health lens was consolidated at the international level with the adoption of the Ottawa Charter for Health Promotion (1986) at the World Health Organization’s (WHO) First International Conference on Health Promotion.  The latter stated: “Health promotion goes beyond health care. It puts health on the agenda of policymakers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.”

Between Lalonde and the Charter, Toronto decided to become the “Healthiest City” in North America. At a Healthy Toronto 2000 workshop in 1984, British expatriate Dr. Trevor Hancock, then Associate Medical Officer of Health for the City of Toronto and American psychiatrist Dr. Leonard Duhl presented their Healthy Community Model.  This was quickly followed by a three-day conference, Beyond Health Care, in the same city where Hancock was able to present his approach to a broader international audience.  A key recommendation from its workshops strongly endorsed the idea that the Canadian Public Health Association take the lead in silo busting by collaborating with professional associations including, among a raft of others, the Canadian Institute of Planners, the Engineering Institute of Canada and the Royal Architectural Institute of Canada to create a national healthy cities agenda.

A key member of this audience was Ilona Kickbusch, the WHO’s European Regi
onal Officer for Health Promotion.  With the help of Hancock and Duhl among others, she immediately initiated a discussion within WHO’s European region on Healthy Cities that culminated in WHO’s first Healthy Cities Symposium in Lisbon. The launch of the European Healthy Cities Project followed. The rest, as they say, is history. The project continues to play a major role in how over a thousand European towns and cities structure their growth policies with a health lens and resulted in WHO’s international program that now encompasses over 7,500 cities in twenty regions around the world.

Healthy Cities – Complexity or Strategic Focus?

Internationally, the concept of the Healthy City has developed as a complex, multi-layered, multi-discipline strategy in which a process “conscious of health and striving to improve it” plays as much a role as does results.  WHO defines a healthy city as one “that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.”  At least ten “environments” come into play in the literature. Not only is a healthier city a function of the built, transportation, natural/sustainable, urban infrastructure and health care environments, it also encompasses economic equity, food security, social architecture and equitable access.

“It is hard to narrow down this very broad field,” says Jennifer Dean, assistant professor in planning with a public health perspective at the University of Waterloo. “The built environment is one important factor among many; the area is so broad and complex that it is difficult to isolate a specific element.  Even within the built environment, if you are looking at what aspects affect health it varies. For example, are you going to look inside buildings in terms such as the healing capacity of hospitals; are you going to look at prevention in terms of the impact of having or not having green space and so on?” 

WHO Europe’s Healthy Cities approach strongly emphasizes equity, participatory governance and solidarity, intersectoral collaboration and action to address the determinants of health (1998).”  In other words, it encompasses the full socio-economic policy spectrum often less prevalent in North America.  This being said, both Vancouver and Toronto have adopted progressive strategies that do confront such issues as income distribution, homelessness and threatened food security.  After adopting a healthy city policy in 2009, the latter’s Healthy Toronto by Design (2011) states “Healthy cities are cities that are prosperous, liveable and sustainable. They are cities with high quality culture, education, food, housing, health care, public transit, recreation, and built and natural environments.”  Vancouver’s  “A Healthy City for All: Vancouver’s Healthy City Strategy 2014 – 2025,” adopted in October of this year is a very sophisticated social blueprint that incorporates detailed sub-strategies with quantitative goals for housing and food security as well as poverty and homelessness reduction.

While the difficult issue of socio-economic form, particularly in a time of increasing wealth concentration, remains vital, greater emphasis in Canada has been placed on built form, the natural environment and, to a lesser extent cultural infrastructure and creating healthy food strategies.  Equitable access, however, has remained a desired goal in play in Canada. 

The Power of Evidence – Pathology, Cause and Solution  

A central concept of the Healthy Cities movement has been the need to break down professional silos to understand chronic diseases, their causes and effects as well as the most appropriate remedies related to the urban and built form.  An evidence-based approach relying on solid, interdisciplinary research replaces received wisdom or so-called common sense as it did with evidence-based medicine. The mythical market’s hidden hand or “market preference” is replaced by dialogue, collaboration and collective decision-making driven by hard evidence from research in which the interlocking environments affecting our health are understood in sync rather than separately.

However, Dean believes a significant evidence gap remains. “In terms of evidence-based, what is happening on the ground is moving much faster than the supporting research,” she says. “Much of what we are doing is still more intuitive and educated reasoning than hard evidence-based.” Both Dean and Milton Friesen, Program Director for Social Cities at the Cardus think-tank believes additional research is required on how attitudes toward city building are determined and how they can be changed. “Does urban form create these ideologies or do the beliefs determine or at least reinforce urban form?” Friesen asks.

Architect Tye Farrow promotes and lectures frequently on a “create health strategy” that focuses less on pathologies than on salutogenesis, the causes of health.  He argues we need to dig deeper into such questions as to why we respond better to older-style streets; why are they more organic; why do they connect at a deeper emotional level?  But he also believes too much reliance on detailed research can be counter-productive. “Often the evidence that comes out of extensive analysis and research can be got by simply sitting down and intuitively determining effects, causes and responses much more quickly and less expensively.” After all, he says, many of the advances in healthcare facility design, an area in which he has worked extensively, were available through good common sense reasoning.  

Farrow advocates for more focus on diagnostic tools that are fully available to communities in order to allow their members to look at existing or proposed environments and understand what it is within that environment that connects or fails to connect; that creates health or perpetrates pathologies.  His own tool focuses on five areas, the presence of nature, a sense of authenticity, the provision of variety, a sense of vitality that includes energy and connectedness and finally a sense of legacy, of being involved in something that will endure. If there are 8,000 known causes of diseases, he argues, let’s find 8,000 causes of health (he admits to isolating 415 to date).

The Urban Land Institute, a key advocacy group for the development industry, has also recognized that evidence clearly shows healthy city developments offer its members a premium return.  In addition to a report on the business argument for healthy developments, it has published a strong endorsement of the Healthy Cities movement that includes ten core principles, even including ensuring equitable access. But, it argues, in part supporting Farrow, “A knowledge gap exists between research and implementation, with health and land use practitioners uncertain of how to apply the mounting body of evidence that shows the relationship between our environment and our health.”

And the Evidence Says?

In fact, there is considerable evidence, not just of the indisputable rapid increase of chronic diseases but increasingly how the built environment contributes towards pathologies and what changes we need and can make.  Holland suggests that within four key sectors of health – physical, mental, social and spiritual – 20 major chronic diseases have been shown to be caused or exasperated by built environment conditions. It is simply not possible here to summarize all of the evidence although the Canadian Medical Association’s Policy on the Built Environment Health
(2013) provides an accessible summary of the rapid rise of many chronic diseases, the contribution of the built environment to this trend and some of the “proven” prescriptive remedies.  These were confirmed in my interviews with Dean, Farrow, Freisen and Holland and the growing documentation consulted on healthy cities.   

The first includes the obesity “epidemic” (and the related precipitous decline in physical activity) and its casual relationship, among others, to high blood pressure, stroke, heart disease, mental health, type II diabetes and some cancers; the increased prevalence of asthma and other respiratory diseases as well as environment related illnesses such as cancer and heart disease; transport related death and injuries; and increased prevalence of illness and death related to heat exposure. In terms of causes, the policy cites, for example, extensive evidence that “less walkable, auto dependent built environments have been correlated with higher body weights and obesity” as well as lower levels of physical activity.  In terms of remedies, the policy cites that walkable neighbourhoods with a mix of land uses and interconnected street networks increases by a factor of two to four times the likelihood of achieving minimum daily activity levels.

Similarly, British Columbia’s Provincial Health Services Authority, as reported in the CIP’s Healthy Communities Practice Guide finds that walkable neighbourhoods with pedestrian-friendly streetscapes and good public transit are associated with more active travel behaviour, lower body weights, fewer traffic accidents and less crime.  Increased density, it reports, is associated with less pollution (thus responding to respiratory and heart problems) while the built environment, particularly the immediate availability of nutritious food over fast food, affects nutrition, health and weight.

Multiple studies strongly indicate that communities with high public transit use are more active than car transport dominate ones.  In terms of equity, however, a CIT backgrounder cites evidence that while children in poorer neighbourhoods are more likely to take “active transportation,” they tend to live in areas with higher pollution levels, greater risk of pedestrian-vehicle injury and greater distance to healthy food retailers.   

The built environment, evidence suggests, has also contributed to an increase in mental illnesses through increased social isolation and the decline of interactive public space.  Freison points out the social isolation rate has increased three-fold over the last few decades and the risk of early mortality when socially isolated is about the same as smoking and twice that of obesity.  As one response, Cardus, with its roots as a Judeo-Christian think tank, helped Calgary integrate into its urban plan a strategy to respond to the needs of faith-based communities.  Dean isolates the extensive work on therapeutic landscapes in evidence-based medicine as both a physical/mental remedial tool.  She and others argue that the state of and access to natural environments at various scales has a key role to play.  Holland points out studies that suggest that the access to the simple act of gardening can reduce dementia by as much as 30 per cent. 

The Movement Gains Momentum and Structure – at Least Until Now

While WHO picked up the ball in Europe and at the international level at the end of the millennium, back in Ontario, Hancock was busy setting up the Healthy Communities Coalition.  This coalition was not with planners but with the Ontario Landscape Architects Association and evolved into an even broader coalition of provincial associations.  In 1993, the province provided funding for three years a secretariat.  He would also play a key role in 2005 in promoting the establishment of the BC Healthy Communities initiative.

Over the last decade in Canada, some, if not all the relevant professional silos have been breached, more research has come forward on both causes and remedies and stronger relationships between researchers, planners, architects, developers, public policy drafters and politicians.  As Vancouver’s and Toronto’s healthy city strategies have demonstrated there is an appetite for change even if the worth of the policy pudding still awaits the tasting. 

Healthy Peel by Design is a broad initiative by Peel Region north of Toronto under the leadership of Peel Public Health.  Its objective is “staying ahead of the curve by focusing on built environments as a strategic priority.”  A major step has been the development of a Healthy Development Index with the help of St. Michael’s Hospital and McMaster University.  This evidence-based index identifies seven elements of the built environment linked to health impacts.  The tool, endorsed by Peel Regional Council as well as other surrounding municipalities, is applied to proposed developments and guides staff comments on the merits of the proposal.  Eventually, developments will have a public rating assigned as to their healthy city status.  Waterloo became the first region in the country to have an integrated focus on a sustainable food system in its official plan.  Similarly Sainte-Catherine, Que. applied a healthy city assessment tool to rigorously focus on the health implications of a proposed major transit oriented development, the result being substantive recommendations to improve the plan.

Much of the coordination, collaboration and funding for this and other multiple similar projects have been the result of the Healthy Canada by Design CLASP Initiative. Started in 2009, it was funded by Health Canada through the Canadian Partnership Against Cancer’s Coalitions Linking Action and Science for Prevention (CLASP) program.

The initiative brought together, says its web page “a partnership of public health, planning and transportation professionals, and non-governmental organizations, from across Canada that are working together to create healthy and sustainable communities that support and foster physical activity, active transportation and public transit.”  Thus it linked such organizations as the Heart and Stroke Foundation, the Urban Public Health Network (UPHN) directly with the Canadian Institute of Planners as well as a network of regional health authorities.

Its core objective Kim Perrotta, former Knowledge Translation and Communication Lead for the initiative tells me, was “to respond to the pressing need to translate evidence into policy and then into action.  The first need was to get researchers from multiple disciplines to understand how policy works and then feed this research into the planning process.”  A very effective initiative, she continues, was to marry Public Health Commissions and Boards with a planner to show the former how they could better intervene in the planning process to ensure health outcomes/implications where understood and applied.  For example, in Halifax planners working with health officials were able to develop a complete set of street design guidelines that subsequently found support from city council.

By 2012, the Healthy Canada by Design CLASP Partners had developed new research, state-of-the-art tools and resources to facilitate the inclusion of health considerations into land use and transportation planning decisions. Phase I was followed in 2012 by a second two-year phase which included communication and collaboration at the national level and funding for CIP to develop its Healthy Cities Guidelines for Practitioners as well as a series of evidence backgrounders. Phase II saw seven additional health authorities in the Atlantic and Prairie Provinces as well as Ontario receive support to work with planners, transportation engineers and other groups, to further healthy ci
ties research, evidence gathering and policy drafting.  A draft list of outcomes, as the second phase wound up this September, is contained in Healthy Canada by Design – Product List found at (

Will We Snatch Defeat Out of the Jaws of Victory?

And what of the future?  It is clear that the Health Cities Movement is starting to have a significant impact on urban design and architecture.  Even the 10th Design and Health World Congress took place this July in Toronto. But as those of us who have worked in social policy know so well, governments are adept of snatching defeat out of the jaws of victory.  Remarkably, there is no new funding for a phase III of the CLASP Initiative; and whether or not the movement has reached a tipping point is very much up in the air.

Perrotta endorses the findings of the CIT’s recent Healthy Communities Legislative Comparison Survey Report (December 2013) that found significant variations in legislative and policy support across provinces. “Without the funding,” she says, “most provinces will have difficulty as silos still remain.  Transportation officials and engineers remain a stumbling block and are not yet as fully on board in terms of rejecting more roads and freeways as the way to relieve congestion.”  Dean appears ambivalent about the planning profession’s ability to press the right values suggesting, “There is a need for municipal politicians to establish the standards that give planners the tools and powers to require change to the approaches used.”  And while the 2014 World Architecture Day theme last October, was “Healthy Cities, Happy Cities,” Canada’s architects’ organizations need to rise to Farrow’s challenge to lead on healthy building design guidelines.  This means not only addressing the direct physical health implications of building design but also their too often-potent negative emotional impact on our well-being.

Exceptions may be Ontario and B.C.  In both there is a significant official policy base for change and the movement’s organizational structure is stronger.  In the former, Provincial policy requires health to be a key lens when developing and implementing all policies and includes the impact of the built environment in Public Health Standards.  What remains to be seen is whether or not the current review of the Ontario Municipal Board (OMB) will remove that body’s reactionary drag on progress.

The rise of health as a core quality of life issue may be the very heavy straw that finally breaks the back of the orthodox urban planning’s camel.  “Urban planning, like most other social activities,” Italian architect and planner Pietro Garau has said, echoing Dean, “is driven by the encounter between economic forces and political agendas.”  Nothing quite mobilizes the political agenda like the threat of one’s premature death. 


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