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The Healthy Communities Movement: Bridging the Gap between Urban Planning and Public Health |
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Vanessa K. Lund, M.U.R.P
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Urban planning and public health professions both came out of a desire to prevent urban outbreaks of infectious disease. From the onset, town planning involved issues of public health. Unfortunately, the relationship between planning and public health has since grown apart. Despite a professional chasm between public health and planning, community problems span the gap. Complex community issues demand coordination between public health and planning. A worldwide health promotion initiative called the "Healthy Communities" movement has the opportunity to bring planning and public health professionals together to enable measurable community improvement.
If you ask someone to describe a "healthy community," you are likely to hear the following: good schools; strong families; safe streets; a clean environment; a diverse, vibrant economy; and high quality affordable health care. For the most part, when people envision a "healthy," "sustainable," or "livable" community, they do not see zoning regulations, mobile health vans, and bureaucrats. Unfortunately, while most people visualize an integrated community of wellness, the professions that seem most likely to help facilitate this outcome rarely work together to mobilize community health.
The Healthy Communities movement provides an exciting opportunity to build linkages between urban planning and public health — fields that were once strongly allied. Healthy Communities encourage a diverse array of people to work together to improve the overall health of the community. The process unites a broad cross-section of community citizens, organizations, and leaders in a shared purpose: making their community a better place to live. In this process, citizens themselves identify health issues and concerns, prioritize and make decisions, develop and implement a plan to address the identified concerns, and evaluate program success through outcome measurement techniques. By utilizing a broad definition of health, fostering broad-based community involvement, and developing a shared vision of community health, communities engaged in the Healthy Communities process are able to affect real change in how systems in the community operate and relate to one another.
This paper investigates linkages, past and present, between urban planning and public health within the context of building Healthy Communities. The first section briefly describes the origins of the Healthy Communities movement and the tremendous professional overlap between urban planning and public health, which both attempted to deal with the industrialization of cities. The second section provides an understanding of the factors that are influencing a renewed interest in community improvement and provides case studies that describe innovative opportunities for collaboration between planning and public health. In the final section this paper encourages the building of bridges between urban planning and public health to empower positive community change collectively.
"A healthy city is one that is continually creating and improving those physical and social environments and strengthening those community resources which enable people to mutually support each other in performing all the functions of life and achieving their maximum potential." (Hancock 1993, 7)
The Origins of Public Health and Urban Planning
Both the public health and urban planning professions came out of a desire to prevent urban outbreaks of infectious disease. During the late 1800’s European cities industrialized rapidly. Serious health problems resulted from this rapid urbanization and industrialization. Smoke, soot, noxious odors, contaminated water, and generally unhygienic conditions contributed to the blight of urban areas and the poor health of many residents. Improvements in the urban condition required attention to the relationship between one’s urban environment and one’s health.
Some of the first public initiatives to address community health strategically took place in Great Britain. During the 1840’s, Dr. John Snow (a British physician) scientifically proved that London’s cholera epidemic was due to the heavily polluted water supply. Snow’s research led to calls for increase public sector attention to the relationship between one’s environment and one’s health. Simultaneously, the British government formed the Health in Towns Commission to examine the health of the urban poor who lived in the slums of the rapidly urbanizing city of London (Hennekens and Buring 1987). The work of the Commission and of Dr. Snow helped establish public health measures such as housing standards, sewer systems, hygiene regulations and proper public water supplies. The world’s first public health policies addressed issues that one might today characterize as urban planning issues.
During these early years of urban planning and public health, both professions found leadership in visionary notions of holistic community wellness. Sir Benjamin Ward Richardson (founder and editor of the Journal of Public Health and Sanitary Review at the Health Department of the Social Science Confluence in Great Britain) presented "Hygeia," a comprehensive vision of a healthy city. This model city included low-density development, mass transit, ample parks and gardens, reliable water and sewage systems, health-conscious residents (who do not smoke or drink alcohol), and community health centers (Hancock 1997). A few years later, Ebenezer Howard’s vision of Garden Cities sought to remedy urban blight and sprawl through comprehensive community planning. Garden Cities focused on the livability of a community by carefully planning all functions of the community: from agriculture and manufacturing to housing, schools, and parks.
North America soon followed Great Britain’s lead. During the early part of the 20th century the United States and Canada organized healthy city initiatives. Both the U.S. Commission on Conservation and the Canadian Federal Commission on Conservation promoted not only the conservation of natural resources, but also "vital resources" of health and prolonged life. The Public Health Committee of the Canadian Commission forged close linkages with housing and town planning efforts and greatly influenced many town-planning bills throughout Canada. Interestingly, while the "city beautiful movement" was at its peak (following the Chicago exposition), Charles Hodgetts (Ontario Canada’s Chief Medical Officer of Health) stated that "it is not so much the city beautiful as the city healthy that we want for Canada." (Hancock, 1993)
The Canadian commitment to a holistic approach to improving public health yielded highly successful results. Toronto emerged as a model city of health. Through policies ranging from industrial hygiene, social welfare, housing, school health, and municipal housekeeping, Toronto demonstrated a marked improvement in the health of its citizens. The modern day Healthy Communities movement owes its inspiration Toronto’s example.
Founded in 1946, the World Health Organization (WHO) was a response to a proposal at a United Nations Conference to establish an autonomous international health organization. In 1977, The World Health Assembly defined a very important goal: "health for all the citizens of the world by the year 2000 to a level of health that will permit them to lead a socially and economically productive life." (World Health Organization 1998) Fundamental conditions for the broad-based vision of health included: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.
The method of achieving such an ambitious health goal became clearer during the late 1980’s. After attending a Healthy Cities conference in Toronto, WHO’s Dr. Ilona Kickbush organized the WHO Europe Healthy Cities project (Flower 1994). Although the project initially hoped to recruit six to eight model cities to participate in the project, interest grew rapidly. By June of 1992, 495 delegates from ninety-two cities in thirty counties expressed their interest in Healthy Cities by attending the WHO Healthy City Symposium (National Civic League 1997, 16).
The cities that have engaged in this community building process have implemented actions such as: "greening" cities; encouraging healthy workplaces; incorporating ecological and health concerns in urban planning and design; establishing mechanisms to ensure community management of health projects; and establishing inter-sectoral governmental decision-making and policy development. From the onset of the movement, European Healthy City partnerships demonstrated broad inter-sectoral collaboration. In the United States, the Healthy Communities movement has been embraced more readily by the healthcare sector; inter-sectoral partnerships have proved to be less prevalent.
The modern day Healthy Communities Movement utilizes a strong international network of community builders to link and learn about how to effect positive community change. Healthy communities begin at the local and regional level, with people and institutions within the community taking the lead. Healthy communities embrace a complex set of factors that contribute to good health: quality education, adequate housing, the availability of gainful employment, access to job skills and training, access to efficient public transportation, the availability of recreational opportunities, healthy and clean physical environments, and access to education and health education, and preventive services. These community improvement initiatives generally use the following vehicles to achieve community health: partnerships between a variety of community sectors, local governmental involvement, community involvement, sustainability, holistic approaches to health, and a focus on human development.
While the Healthy Communities movement seeks to involve a broad interdisciplinary coalition in its health improvement endeavors, the process tends to be led by healthcare institutions (either hospitals or public health departments). Four critical healthcare trends influenced the emergence of, and continue to sustain, the modern Healthy Communities movement in the United States: 1) the federal devolution of health and human service funding; 2) a demand for accountability for community benefit; 3) the growth of managed care; and 4) community mobilization. These healthcare trends have had a strong impact on the prevalence and the form of the United States’ Healthy Communities initiatives.
1) Federal DevolutionDevolution is a term used to describe how responsibility for the development and management of various public policies and public services is shifting from the federal to the state and local levels of government. (W.K. Kellog Foundation 1999) This movement of funding has provided people and institutions within communities to take the lead in solving health challenges. (Kurland 1997) This interest in decision making at the local, rather than the national level, came to a dramatic crescendo when the national healthcare reform initiative failed during the early 1990’s.
2) Demonstrating Community BenefitsUnits of government and citizen groups increasingly ask healthcare institutions to demonstrate that they actively understand and meet community needs. This demand may be spurred by a challenge over tax-exempt status, a court appraisal of a healthcare system merger, a grant application, or a governmental review.
In some states, tax-exempt hospitals have been challenged to prove that they are worthy of public subsidy via their tax-exempt status. In such cases, hospitals frequently work with professional researchers to quantify the benefit that they provide to the community. In some cases, this requirement is a result of hospital mergers. (The merger of non-profit and for-profit healthcare systems often results in a court mandate for community benefit planning.) In theory, if a non-profit hospital enjoys tax exempt status for a long period of time and is then sold to a for-profit hospital, profit (which largely exist because the public has supported the institution via tax breaks) must be shared with the community. As a result, most hospital mergers result in the creation of a grant-making foundation that serves the local community.
While few states or funding institutions have a firm mandate for community health planning, the linkage of funding to such a requirement acts as a very strong catalyst for this type of planning. Many sources of healthcare financing now demand that healthcare institutions understand and meet community needs. In states such as Texas, New York, and Kentucky, state funding for healthcare services is linked to quantitative community health indicator projects and community health improvement services. The Healthy Communities model often provides an ideal structure for this process.
3) The Managed Care Revolution
The managed care revolution is dramatically changing the financing and operations of the United States’ healthcare system. In the United States, we provide more healthcare services, at higher costs, with roughly twice the physicians per capita, than any other country in the world. Unfortunately, the United States provides minimal incremental improvements in health status while spending a substantial quantity of money on healthcare services. In 1992, health care costs soared past fourteen percent of United States Gross Domestic Product (GDP) (National Civic League 1993, 5). As a result, the healthcare industry (particularly insurance companies) recognized that to contain healthcare costs and improve health status, health must be redefined to focus on risk behaviors that underlie health status. Leading health problems such as heart disease, stroke, lung cancer, and injury from accidents are to a great extent influenced by individual choices such as high fat diets, poor nutrition, lack of regular exercise, tobacco smoking, abuse of alcohol and other drugs, and failure to wear seatbelts. By moving toward a "capitated" healthcare system (paying healthcare providers a set dollar amount for each person enrolled in their practice) the insurance industry theoretically has created an incentive to promote health. (Flower 1995) Of course, this theory is only a theory — universal capitation has not yet occurred, and it certainly creates a set of problems that are beyond the scope of this paper. Nonetheless, shifts in the financing of healthcare services have led most hospitals to increase their investment in preventive health services. The Healthy Communities process links these increasingly cost-conscious healthcare institutions with other community members to plan effective and efficient collaborative approaches to community wellness.
4) Community Mobilization
Finally, and most importantly, bottom-up change is being demanded by community residents. Community groups are savvy, organized and dedicated to building (and in some cases, rebuilding) their communities. The Healthy Communities process affords maximum benefits to all community players as it thrives upon a wide spectrum of citizen participation, the involvement of leaders from many sectors, local government commitment, cross-sectoral professional input, and community-wide consensus building.
The core tenant of the Healthy Communities movement is that citizens must come together to build a holistic community of health. This means that citizens– not governments, consultants or hospitals– identify health issues and concerns, prioritize and make decisions, develop and implement a plan to address the identified concerns, and evaluate the initiative’s progress. The Healthy Communities process depends upon the involvement of those who are affected by decisions being involved in the decision making. Most importantly, this process works to build consensus among a diverse group of people, more appropriately reflecting the desires and interests of the community. Finally, the Healthy Communities movement defines health beyond "traditional" health issues and considers the underlying factors that produce individual and community health. These health factors not only include disease prevention and health promotion, but also encompass issues such as clean and safe environments, adequate housing, affordable and quality education, community revitalization, and the provision of basic needs (National Civic League 1993).
The result of the Healthy Communities movement has been vast. State-wide networks have been established in California, Colorado, Indiana and Pennsylvania to name a few. Large and small municipalities have cultivated comprehensive, community-wide strategies, and internationally, communities everywhere are conducting innovative initiatives to embrace a broad definition of health and to develop a strong sense of the shared responsibility for community well-being. (National Civic League 1993)
Communities throughout the United States and abroad have implemented Healthy Communities initiatives successfully. While the process and outcomes of these projects have differed, all have been collaborative, results-driven efforts. The following highlighted communities are just a few of the creative examples of communities that are working to achieve their vision of health.
1) Community Health Council of Lebanon County, Pennsylvania
The Community Health Council of Lebanon County aims to identify the undermet health needs and improve the overall health status of residents of Lebanon County through a cooperative community effort involving the local hospital (Good Samaritan Hospital) and other community organizations. The collaborative group also aims to serve as a community catalyst for creating, linking and supporting community-based partnerships that engage in activities to improve the health and quality of life of the citizens of Lebanon county. The Health Council has formed task forces to address the following health issues: 1) teens and family support; 2) family health care needs; and 3) county-wide wellness.
A number of initiatives developed by this dynamic partnership have involved close relationships with urban and regional planning experts. For instance, the teen and family support task group has been working closely with local planners to site and develop gathering places for the community’s youth. Also, improvements in transportation services to healthcare and social service resources have required planning expertise.
2) Butler County Community Health Advisory Council
Now in its eighth year, the community health movement in Butler County, Pennsylvania has accomplished two complete cycles of health assessments, program delivery and evaluation. The Butler community health program was a national pilot program for Voluntary Hospitals of America. The Community Health Advisory Council provides ongoing advocacy, leadership and process tracking through a board of thirty community organizations.
One of the Council’s most applauded successes has been its ability to improve infant health measures. While this may not sound like an issue that effects urban planning, a key component of initiative to improve infant health was to improve transportation services in the area so that pregnant women could receive proper pre-natal care. Transportation planning improvements have measurably improved the community’s access to healthcare services.
Once again, planning and public health find themselves at a crossroads. Both disciplines seek to improve community well-being and both cannot significantly impact community well-being without intersecting. The outcomes of health community initiatives are numerous and complex. In some communities, initiatives result in seemingly simple outcomes (a mobile health van, a pre-natal care class, etc.). Yet in the real world (filled with bureaucracy and politicking) few outcomes are simple. Some communities retain a hospital-focused solution and strongly link hospital community building with the health community effort. In other places, community groups or businesses take the lead.
Planners are no strangers to innovative, community-up planning. While planners may be familiar with the non-profits in their communities and multiple task-oriented community planning initiatives, planners will need to pay close attention to the role of health care institutions in addressing community well-being. Healthcare institutions have multiple incentives to invest in the health and vitality of citizens in their service area. As major employers, the healthcare sector requires a vibrant labor force. As service providers, healthcare institutions strive to best meet the needs of their populations. As pieces in the healthcare puzzle, healthcare institutions need to minimize their costs. As leaders, healthcare institutions want to effect positive community change.
The healthcare sector has a strong incentive to engage the community in their endeavors and planners have a wealth of experience facilitating community-led change. If we (meaning planners and public health experts) are going to achieve our community improvement goals, we must work together.
How do you think we can work together to build healthy communities?
Flower, Joe. 1994. In The Beginning… An interview with Ilona Kickbush. http://www.well.com/user/ bbear/kickbush.html. (2 January, 1999.)
Flower, Joe. 1995. "Healthier Communities" and Healthcare. http://www.well.com/user/ hc_healthcare.html. (2 January, 1999).
Hancock, Trevor. 1993. The evolution, impact and significance of the healthy cities/healthy communities movement." Journal of Public Health Policy 14, n.1 (Spring 1993): 5-18.
Hancock, Trevor. 1997. Healthy Cities and Communities: Past, Present, and Future. National Civic Review 86, no. 1:11-21.
Hennekens, Charles, MD and Buring, Julie. 1987. Epidemiology in Medicine. Boston, Toronto: Little Brown and Company.
Hunter College Center for Occupational and Environmental Health. 1998 Meeting the Urban Health Challenge: A Joint Public Health and Urban Planning Conference. 18-19 September at Hunter College, New York, NY.
Institute for Healthy Communities and Tripp Umbach and Associates. 1997. Apple 2: A Guide for Implementing Community Health Improvement Programs. Harrisburg, PA: Institute for Healthy Communities.
Kurland, Judith. 1997. The New Federalism. Keynote Address at The Second Annual Pennsylvania Healthy Communities Summit. 10-11 November at the Hershey Lodge and Convention Center, Hershey, PA.
National Civic League (NCL). 1993. The Healthy Communities Handbook. Denver, CO: National Civic League Inc.
W.K. Kellogg Foundation. "W.K. Kellogg Foundation Releases Major Survey On Public Attitudes Toward Welfare Reform and the Nation’s Healthcare System." http://www.wkkf.org/resources/newsroom/ devolution_13Jan99.htm. (13 Jan. 1999).
World Health Organization. 1998. History of WHO and International Cooperation in Public Health. http://www.who.int/aboutwho/en/history.htm. 22 January, 1999.