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There is no need for cities to be the unhealthy places that so many are, argues David Satterthwaite in this global review of the potential for positive change. Cities contain many of the world's most unhealthy living environments. More than a third of the urban population in Africa, Asia and Latin America live in housing of such poor quality with such inadequate provision for water, sanitation, drainage, garbage collection and health care that their health is constantly under threat.
In such circumstances, it is common for one child in three to die before the age of five and for virtually all infants, children and adults who survive to have disease burdens many times higher than they should. Diarrhoea, tuberculosis and respiratory infections (each among the largest causes of death worldwide) are generally much increased by overcrowding. Many accidental injuries happen when there are three or more persons living in each small room in shelters made of flammable materials and there is little chance of providing occupants (especially children) with protection from open fires or stoves.
But cities also include some of the world's safest and most healthy neighbourhoods. High densities allow much lower costs for supplying each household with piped, treated water supplies and most forms of health, educational and emergency services.
It is not so much the overall population density as the quality of the housing that is the problem; most squatter settlements have densities no higher than expensive central-city residential areas in Europe. Sanitation and drainage may be costly in cities, as complex systems are needed to cope with high densities and large population concentrations but city households can generally afford to pay more - and are prepared to do so if they get a good service.
Cities may be considered ecologically unsustainable because of high consumption and waste levels but well planned and managed cities can combine high living standards with remarkably low levels of energy-consumption, resource use and wastes. The concentration of people and production creates many more possibilities of collecting and recycling wastes and for walking, bicycling and a high quality public transport.
For many, city-life is one of excessive workloads and drudgery, yet cities remain centres of culture - including the visual and decorative arts, music, dance, theatre and literature. Most cities have a large reserve of young people on whose initiative and energy they could draw to improve conditions - yet most such people find that their cities offer them little hope and little prospect of employment. If cities have such potential to provide healthy, stimulating and valued places to live and work for all age groups, why do so few achieve this?
Most households who want their own home cannot afford to purchase one - or at least one that is legal. They cannot obtain housing loans so the cost of the house purchase can be spread over a number of years - as they cannot meet the (usually) inappropriate conditions set by banks or housing finance institutions. If they turn to building their own home - as most do - they have to occupy or purchase the site illegally. They often have to build on dangerous sites - in floodplains or on slopes with frequent landslides or mudslides - as the cost of safer sites is too high.
Even if they can qualify for a housing loan, most such loans are for finished houses, not for incremental construction. And even when they have developed their own home and neighbourhood into a viable residential area, governments usually refuse to provide these with roads, water supplies, drains and other essential infrastructure, because they are 'illegal'.
What would cities look like today if governments had supported these individual and community efforts by ensuring that and, building materials, credit and technical advice were as cheap and readily available as possible? Or if government-community partnerships had been formed to, at least, improve water supply, sanitation, drainage and health care.
There are enough examples of innovative programmes to show how much more could have been achieved, if this approach had been more widespread. These include the Urban Community Development Office in Thailand and the work of the People's Dialogue and the South African Homeless People's Federation described later in this issue.
They include the work of the people in Orangi, a huge low income settlement in Karachi and the NGO, the Orangi Pilot Project that helped 70,000 households dig their own sewers and drains at a seventh of the unit cost that the municipal authorities would have charged them.
They include the remarkable range of community health, water, sanitation and child development initiatives developed in Guatemala City through partnerships between low income groups, different government ministries and international gencies.
These last two "community" initiatives even received commendation from the Prince of Wales in a recent speech in Hong Kong. Although these are still "the exceptions" they give an idea of how much could be achieved, even where funds are limited.
These work within what is often called the 'social economy' - the great variety of initiatives and actions that are organized and controlled locally and that are not profit-oriented. The social economy includes the work of citizen groups, residents' associations, street or barrio clubs, youth clubs, and parent associations that support local schools. It includes many voluntary groups that provide services for the elderly, the physically disabled or other individuals in need of special support. It often includes many initiatives that make cities safer and more fun - helping provide supervised play space, sport and recreational opportunities for children and youth. It may provide formal or informal supervision or maintenance of parks, squares and other public spaces.
As David Korten has pointed out, the social economy not only 'gets things done' but also creates a dense fabric of relationships that allows citizens to work together in identifying and acting on local problems. Its value to a 'healthy city' is enormous, even if it is often forgotten by governments and international agencies.
The capacity of city authorities to govern is not the same as the capacity to invest, since these authorities can do much to encourage and support the social economy. City authorities can often greatly increase the supply and reduce the cost of land for housing by changing inappropriate regulations, streamlining planning and land use control procedures and making better use of publicly owned land.
They can often improve the quality of public transport by providing the right framework for private firms; the much admired public transport system of Curitiba in Brazil is provided by private sector bus companies but within a framework set up by the city authorities.
City authorities should also have the main role in enforcing legislation on air and water pollution and occupational health and safety. This does not require large investments by public authorities, but it can do much to improve health and the quality of life in a city.
Good governance also means managing competing claims and finding common ground between enterprises, trade unions and residents about what should be done to make the city more healthy.
Identifying and acting on this common agenda is the core of the Healthy Cities Programme developed by the World Health Organization. Here, much of the 'health-promoting' action is taken not by ministries of health or health professionals but by individuals, households, communities, NGOs and enterprises - and the effectiveness of such action can be much increased with appropriate support from health professionals and city authorities.
Achieving a healthy city needs a representative political system through which the priorities of citizens and businesses can influence policies and actions. Democratic structures remain among the best checks on the misallocation of resources by city and municipal governments. Actively involving a wide range of local groups in developing 'city governance'helps ensure that the different priorities of a wide range of groups are addressed.
In the lead up to Habitat II, the key issue is not so much identifying
what should be done to achieve more healthy cities. This is well known. It is
identifying how it should be done, especially how governments and international
agencies can support a vast range of activities by individuals, households and
communities that help build and maintain healthy cities - which to date they
have ignored or even (for many governments) repressed.
David Satterthwaite is Director of the Human Settlements Programme at the International Institute of Environment and Development.
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