Join former WHO Europe Director for Policy and Governance for Health and Healthy Cities, Agis Tsouros, as he discusses the 21st-century urban health agenda and critical issues for making cities healthier.
hello good afternoon I give sewers and I’m really delighted to be able to connect with you all and share with you my experience and ideas about healthy cities about urban health how to promote health well-being equity and sustainable development in cities perhaps I should say a few words about me I’m a public health physician I have had the privilege to start working for WH o at the end of the 1980s and my first assignment was to begin to develop a new project at that time which was called healthy cities it was quite unique by any means because it was an initiative that did three things first it recognized the importance of local action the importance of working in urban settings and also most importantly the importance of the role of local governments of mayors of city councils in the promotion of health most un organizations like the WHL are basically organizations that work normally with national governments but this was the unique opportunity to begin to build links with city leaders why because as we all know most of the determinants of health and since those days the evidence has accumulated very rapidly are actually related to what cities do to create the living and working conditions for people transport education social services health services environment a wide range of sectors are actually creating the circumstances which affect directly or indirectly our health so it was felt that it was appropriate to work directly with leaders of cities who had closer proximity with communities which is very important and at the same time they could command they could be convenors of inter sexual partnerships before I will have the opportunity to answer your questions and have a dialogue with you I want to say that healthy cities is a project and initiative which is today a global movement everywhere in the world there are healthy cities thousands of them emerged from an era that marked the beginning of the new public health it was when the World Health Organization in the early 80s launched the health for all and later as you probably know the famous Charter for health promotion the Ottawa Charter it was an era when we started talking about equity the importance of addressing inequalities the importance of involving communities in health development the importance of developing platforms where ownership for health and development will be something that should not happen in a top-down way but in a both top-down and bottom-up engaging both the leaders and the representatives of various community groups please submit your questions during the talk and perhaps I could pick the first question that I see on the monitor that I stated in a talk yesterday that modern approaches to public health challenges in the 21st century require a whole-of-government approach and that the health sector alone cannot do it this is a great question because I would like to to perhaps explain that for so many years and many people continue to think that health is only the absence of illness the absence of disease and yet the the earliest comprehensive definition of health in the 1948 constitution of the WTO talks about social and mental well-being which goes way beyond hospitals and nurses and health sector establishments but in more recent years there has been a revolution in our understanding of where health is created and the literature or to start with on the social determinants of health than on the environmental determinants of health the commercial and the cultural determinants of health have given us a wealth of information which is making a very strong case that yes the health sector has an important role in making sure that health services have the appropriate quality sensitivity to our needs they are accessible and affordable to us but basically health is everybody’s business and everybody’s business means that other sectors should be aware that health can contribute to achieving their goals but also that they with their activities can have a negative or a positive effect on health so let’s take some examples of modern approaches in public health today we talk about equity and inequalities if you ask me I would say that probably one of the most noble and important objectives of a healthy City today is to create a city for all for all the citizens to to be aware to measure the differences in life expectancy in experiences in disease in living or working conditions that is experienced across the territory of a city and do something about it in addressing inequalities and the causes of the causes as we say what is it behind those inequalities whether social environmental and other factors it requires a cooperation between different sectors and this cannot happen by the health sector alone the health sector alone is can be a very strong advocate to other sectors but it is not enough because it’s a Power Balance within a city or within a national government it will have to be the goal of the whole of local government it will have to be the mayor and the City Council who will create the conditions the circumstances for different stakeholders to sit around the table to think about health to be accountable for health to contribute in the achievement of goals that cannot be achieved by one sector alone take today the social the sustainable development goals agenda I think this is the agenda that legitimizes action at all levels and across governments around the world it is an agenda about health sustainability climate change poverty education everything that that defines today the the viability of this planet as well as the quality of life of people who mostly and increasingly work and live in cities but to address those goals as I said before you cannot do it in a siloed way you have to to have the ability the capacity the leadership the governance to create mechanisms that can really fulfill those goals let me give you one of them achieving a healthy start in life for all our children this is not about having only good health services this is about having education social services environment housing they should all work together with a family at a neighborhood level to create circumstances that will become the assets for a child to be to achieve and to fulfill their aspirations for life later so it will I will come back to this idea of whole of government and whole of society because this is the essence of modern public health to be aware of the influences of the environment of the importance of our policies and I would like to end this this answer – to – to your question by underlining especially what we know today that health is a political choice it is a political choice because leaders have to think what sort of society they want and mayor should say I want my city to offer the good opportunities the good schools services roads healthy neighborhoods access to grains not only in one part where the most privileged live but everywhere this is the key issue for a healthy City a healthy city should be a city that does not discriminate that offers opportunities to all its citizens and it does something specially it goes out of its way if you like to address their special needs so the the second question is how do you define such success when developing a healthy City well a healthy city is not a city that has achieved good marks on all those aspects that I’m describing but it is a city that is conscious of the importance of health in social in human development in sustainable development why is it that today health is no longer the topic of discussion in ministers of health the biggest decisions that affect our health today in our planet on our planet are actually made outside of ministries of health health health has now been increasingly on the g8 agenda many global fora will discuss the big challenges of our planet from issues of non communicable diseases climate change ageing of the population issues that relate to preparedness and response to various disasters community resilience and so on health is always there it is indispensable I hope one day it will become a performance indicator of the performance of of whole of societies of governments and of course of cities so this is the the the the success of a healthy City today is to be conscious to be aware of the factors that affect the health of citizens but not only words one of the most famous as motors of the health promotion Charter is make the healthy choices the easy choices well take cycling we will talk a little bit about cycling later well it’s easy to say that making that cycling is a healthy choice but it can be a deadly choice if you don’t have the cycling lanes or the support by your transport authorities in your city so choice is not enough to be made on the basis of our knowledge of what is good for us we talk about healthy eating yes healthy eating is important most people know what is good for them but it has to be affordable it has to be accessible it has been to be an easy choice cities must make the healthy choices the easy choices and this is again something which is part of a new culture the appreciation that health is the capital is an asset for the future of the city for the development for its prosperity for its economy for the well-being of its citizens so maybe this is also an opportunity to mention some of these new concepts in in modern public health that today as I said before can only be implemented through an approach to health which demands the presence the inputs the cooperation from other disciplines you really need to to find a way to speak the language to be on the same page with the perspectives from other sectors I’ll give you an example in in healthy cities Europe we started some years ago a dialogue with urban planners well we all have an instinctive understanding of the importance of the build environment the physical environment and health but we cannot assume that health is a value it is a term that is necessarily used in in the context of other professions and yet urban planning which was by the way very closely linked to health in the late 18-hundreds that those two disciplines went their different ways today we know that interventions in the build environment from the neighborhood level addressing architectural barriers access to greens access to – to various to local shops and various social activities can have a huge effect on social inclusion and and and participation they can affect the direct health of people who live in those places but it took us about 10 to 15 years working with urban planners to develop a methodology to develop some standards to develop some typology of what it is to integrate health in urban planning and it was not easy it’s never easy when we try to share an understanding with another discipline with another sector and and this is also my advice you will read in in in public health literature you will come across constantly inter-sectoral action health in all policies and so on this does not mean that just because you have the evidence from science that other sectors and other disciplines are going to tell you oh yes we are ready to change everything we do or prioritize our activities according to your scientific understanding no it doesn’t happen like that you need platforms to have dialogue to create a to understand where they come from to develop common agendas and there is the basis the capital to create true inter-sectoral action not for one isolated project but to begin to work in a different way where health well-being and sustainable development will be there as as a beacon as as a lens to to consider all our policies in our cities how can leaders make sure that interventions to plant healthy cities include the poor and the marginalized well you know I have discovered that one today every city can be smart use the right terminology and everybody will talk about sustainable development many will talk about equity many will talk about convivial and inclusive communities when you look into their plants and you look what they actually do sometimes you see that they pay lip service to those great concepts so to address the question about marginalized groups if you are a leader you are the mayor you are a department of that that looks at the big issues in in your city you have to to be aware and to measure those issues that determine the health of your citizens to develop as we call it in the healthy cities networks in Europe to develop a health profile of your city but a health profile not to only include statistics statistics of morbidity and mortality that everybody can do it but look into the the the living circumstances some of your citizens to look into the social structure people in different social situations ethnic groups lifestyles to have a good picture to measure inequalities there are huge inequalities even in in the most advanced countries of the world I can show you in London within a square mile from the famous Oxford Street and Mayfair which is let’s say top of the market to Kings Cross which is an area less privileged differences of life expectancy of the order of 12 years that’s in London but then I go to other places and cities and they say we don’t have any qualities but how do you know you need to measure them you need to be aware of the needs and and the and the expectations of different groups but it is not enough only to work on the underprivileged the very poor you have to to to to have policies and programs that will address the needs of all the social gradient you have to be able to to address inequalities in a more comprehensive way not to to limit action on equity and the marginalized in one place of your city it has to be a central value this idea of building a city which is a city for all the citizens and there are excellent examples of how this can be done there is a question about how a political leader can do to create a city that is bike friendly well cycle cycling lanes is you can say that are increasingly popular in many countries and they also symbolize they symbolize something about the the quality that we all want to have in our physical environment the friendliness of the city the easy accessibility and mobility in the city but they come to – two Nordic countries on some countries like the Netherlands Denmark Sweden and other countries they seal is fantastic infrastructure for for cycling and they say well we are not Scandinavia we can not this we cannot do this and I I i lived in copenhagen for about twenty five years because this is where the the headquarters of the regional office of w-h-o for Europe is and I have worked with Danish politicians and cities and I can tell you this cycling lanes in in Denmark and in Copenhagen were not created by God on the seventh day of the creation no it took years and years of political debate of a lot of addressing a lot of concerns of course because creating sighting cycling lanes it’s not only expensive but it also takes a lot of space where you have a road with four lanes now you only have two lanes one in one sense and the other in another so this means slowing down the the traffic but it was a vision there was a vision years ago there was this anticipation of what is to be if our city grows and grows and grows there would be more and more car and then how is it going to be because the Danes have a great interest in in creating environments that are good for people human cities and then the result you can see today 45% people who work in copywriting go to work every day by bicycle 45% in all weathers not only in the to warm months of the summer but this was a vision that was not a uni sectoral vision cycling is good for energy it’s good for the environment is good for traffic is good for health it is good for conviviality you can’t imagine what the the Danes will say about their cycling lanes it’s another culture but it is a culture that has given the city aim has made the city more humane it has enabled people to interact more easily if you are there in the morning between 7:00 and 9:00 o’clock there are thousands of bicycles around kapa haka once I invited a champion of cycling it was an urban planner to speak to one of our conferences it was a woman and she said that when they surveyed women in in Denmark to to find out about their their appreciation of cycling concerns and so on many women she mentioned I can’t remember now the percentage said that they adored cycling because they could wear high heels and go to wearing high heels because they didn’t have to work so bicycling it was easier to wear the shoes you wanted to wear but but it is not an intervention that it isn’t one of thing if you come to Denmark you will see that municipalities will do regularly surveys they want to find out who are those who don’t side and why they don’t cycle a recent survey by the Copenhagen whimsicott municipality showed that there were says a number of ethnic minority groups who didn’t think that I cling was something they should do they were various explanations around ah around this survey and the nd and the results what I felt was very important is that they made an effort they were going out of their way to reach out to those who didn’t and encourage them to cycle so it is a huge investment by the city as I said before and I know some will say all but our cities are not as flat as Copenhagen they are very hilly we cannot have those great cycling lanes because Copenhagen they the bicycles are at a different level is quite safe you have the pavement you have the level of the of the cycling lane and then you have the road so cyclists are independent of course in crossing roads you have to interact with cars but it is a network which is absolutely fantastic and and it is very safe for all ages so it takes a vision it takes strong leadership it takes a commitment to to change and create environments that will be good not only for the generations of today but also for the future and of course when we talk today about cities becoming carbon free by the year 2030 or 35 and someone leading by example the cycling investment is of course a great investment what do you think are the most critical areas for cities to put resources toward in the coming decade as they rapidly grow well it depends where these cities are but there are some challenges that relate to all cities we all face the non-communicable diseases epidemic and and also the the the obesity epidemic and I think it’s a major priority for cities to to to to make sure that that we address this seriously obesity especially obesity of our children we have some countries in Europe where this is this is a major public health problem cities need to create conditions and environments that will support children and whole families to address this issue in the long term and this of course is multi sectoral approach from the school the family the environment where they live the issues of physical activity nutrition and so on issues of equity cities cannot afford today not to to take seriously the growing inequalities which themselves are extremely destructive but addressing inequalities today is even more challenging because the composition of urban populations because of the migration flows in Europe is a mega issue as you probably know they have to be even more sensitive in the way they do it in Copenhagen I was referring to there are 220 languages spoken populations are not as uniform as they used to be before so if you are a doctor a planner a social worker an educator you have to think and and to understand where all these various groups come from and what are their expectations in in a wide range of services as I mentioned before education social culture and so on so the issue of inequality and understanding this multi ethnic and multicultural composition of our societies increasingly today there are very important issues that relate to as we said before making the city accessible in every sense to families to people issues of safety and violence and being age friendly and child friendly are very important the aging of the population is a mega issue it’s not a public health problem but it is a challenge how do we fit how do we adapt our cities today to a growing aging population and older people have expectations for good life they they they they are fit for long periods after the retirement and they expect the city to fulfill also their own expectations another issue is preparedness for public health emergencies today you you have it in your country very frequently with this various weather phenomena and they will have them increasingly so I mean climate change creates many many challenging situations which by the end of the day affect local communities and who pays the worst price when those catastrophes hit our cities they were soft so that’s where the issues of inequalities when when when cities are flooded it is the the worse of communities which pay the biggest price and and and so when we think about preparedness we have to think yes of good plans command control having the means to to respond quickly but also we have to think that this has to be a response that will be also proportional and and and equal to to to to to and addressing sensitive with sensitivity the needs of different groups I want to give you the example it’s something that I was of you who may have heard me speaking would know it’s an example of of a program I watched in the UK it was a BBC Panorama programme but the it’s something which I thought was so effective when a journalist stood on top of a hill of a northern eastern city in England called Sheffield and she did something very simple he pointed to one part of the city and he said the children who are going to be born in that part of the city they are going to to live longer they are going to go to good schools they will grow up in neighborhoods that are healthy they will have access to greens and parks and gyms and you name it and then later they will have good education and greater opportunities for employment and they will live longer and the children who are going to be born in that other part of the city they are going to grow up in environments which are degraded the physical environment the service is not of high quality the schools not of high quality and their nutrition that the whole circumstances of life will be detrimental to their health not only at that particular time but also will be a kind of a kind of negative determinant that will affect the rest of their lives and they will live much less than those other children a very effective way to think about our cities today so these are important issues and of course when I spoke about the the preparedness don’t forget thinking now about Europe because of the climate change in the temperatures we also have now diseases in the southern of Europe we didn’t have before they stopped the north of Africa now they are prevalent also in in in in many countries European countries so cities are uniquely placed to safeguard and promote the health of their citizens and they need the support of their governments there are governments that recognize that the government in Finland gives the responsibility for health promotion fully and squarely to measures to local governments because that’s where it can happen that’s where community resilience can be developed and built up that’s where inter-sectoral partnerships can can become a reality that’s where even the corporate sector can can be part can be part of platforms that share the same goal to create sustainable and level comparable communities what are the first steps we can take to make us it is adopt a healthy City culture well I’m glad first of all that you put it this way because it is about changing the way cities understand and deal with health so it is a cultural issue and it is only when we we as cities City leaders we can say yes we recognize health is important for me it’s this leadership issue having a vision work for the city where health and well-being of the citizens becomes a priority and recognizing how it connects with so many of our policies and plans for for economic development for social development and so on the a very important starting point because I have colleagues who tell me oh well let’s be practical there’s a lot of there are a lot of misunderstandings about the word being practical practical and been strategic practical if you mean by practical that we introduced a few we introduced a few projects which can be perfectly good interventions by all public health standards here and then in the city and then say ok this was a great first step and then maybe tomorrow with more resources we can add to them and so on this is great but to me and to to the vision of a healthy City this is not enough because the the challenge of developing a healthy City and as you say a healthy City culture means that this culture has to permeate to to become a common goal and a common aspiration for the whole of the leadership of the city and this has implications for how the various departments the various sectors the various services will then consider how health and inequity lens could become almost something like an automatic response in the planning and designing and envisioning what we would like to do this is a healthy City sculpture to think of the important values of a healthy City that I mentioned before equities and sustainability the right to health I mean the right to health it may be something that we all instinctively agree with but it is so often violated in so many different ways you can see evidence of that in the treatment of migrants I have seen it again and again in the treatment of older people because the right to hell which is linked to fundamental human rights it is not just the right to to to health services because yes for the whole of the planet a key goal of WH o is called universal health coverage but universal health coverage not universal health services coverage which means how can we offer our people those circumstances that can protect safeguard and promote their health and when they the situation when the conditions are not good for the health how can they can we seal them how can we protect them with our social policies social protection education services and so on so this is the the challenge to become to promote a healthy City culture is also to recognize that unlike other times in the past today we have also huge legitimacy through some of these global policies and plans and most notably the sustainable development goals I know you may think all but this is these are too remote from our reality no they are not remote from a reality your governments have signed up have endorsed this 17 sustainable development goals and although you will see that number three is the one which is totally devoted to health there is a number 11 which is totally devoted to cities but if you look through carefully you will see that all those goals are both highly relevant to health and to what happens in cities huge political legitimacy for a leader today to say I want to implement those goals in our midst and health is central as many other issues that to poverty to equity to education and so on and this is what leadership can need can can use today together with with appropriate capacity because it doesn’t happen because some people state that they want to do this to fulfill those goals and I think that the timing is right now – to – to enhance to strengthen the leadership role for health equity and sustainable development of cities and I would like also to end this at this part by mentioning a seminar where I go I took part last week in st. Petersburg in in Russia which was devoted to City diplomacy for health and well-being I know it may sound a little bit theoretical but it is now recognised that the complexity of global health and the issues that relate to this sustainable development and health development cannot possibly be addressed by one sector with we said that before by one level of government we said that before is a multi level of government kind of challenge and also the issues that relate to negotiations to getting health into different agreements to making sure that the voice of countries but now through diplomacy but now also the voice of cities is effectively represented in those various platforms and global fora why because a lot of these strategies and plans that we all talk about that relate to – to – to our planet ultimately require action at level so today cities through their networking twinning representation branding and so on can put health much more visibly in the way they wish to present their city because mayor wants their city to be economically attractive to business they want them to be a good family address a good address to educate children a good place to play and have fun to have tourism all those issues are very much connected to the idea of health so today mayor’s can be effective voices not only within their communities but also outside and they should demand to be heard because as I said before most of the issues that relate to the public health challenges of our time are actually delivered or are related to what happens at the local level how did healthy cities planning change in the in decades you’ve worked the W so how do you think it will continue to involve in the next decade great question healthy cities was not launched as a static project with a set agenda and mechanisms and priorities and then let cities develop and apply it it was launched as a dynamic concept it was in fact launched as a concept that would be more like a framework of important principles like a commitment to equity explicit and commitment to community participation explicit a commitment to work in across sectors explicit a number of priorities but the flexibility to adapt to implement it within the socio organizational context of a given city so cities like Barcelona did not have to do it the same way cover heigen Stockholm London Athens or cities in in Eastern Europe and someone did it but they all set a similar approach to the fundamental values to the fundamental approaches and then as time evolved as you said of course new priorities emerged I mean a great thing that happened in more or less when healthy cities was launched in 1998 it’s the the fall of the Berlin Wall you can imagine that we started working with communities and cities in the former Eastern Europe at the time where they were undergoing mega changes and of you of course even the meaning of a number of terms that we were using resonated differently in different societies I remember we organized in 1989 a conference in Hungary and the theme was community participation well community participation as it was understood there and as it was understood in other parts of Europe differed widely and this is very common in public health and in other sciences I’m sure that the same term changes over time and it’s it it is affected by the context by the evolution of of science and the accumulation of evidence so when we spoke about equity in the 80s it’s not the way the same way we understand equity in the 2010 and so this is what how healthy cities have evolved on the one country was this dynamic evolution of of its principles as they were applied in societies that were evolving themselves and quite rapidly second it embraced as it has long those periods whatever was important globally so in 1992 we had the real declaration for sustainable development of course country cities embraced that agenda and sustainable development became one of its main priorities and you may recall there was also a local expression of that sustained agenda that was called agenda 21 and else the the evidence on issues on such as the social determinants of health healthy cities launched as a network the social determinants the solid facts in 1998 it was the first network that actually took the evidence from science converted it into into a publication that was meant for city leaders but also other national leaders and began to experiment and I will say began to struggle with the understanding and the implementation of upstream approaches to public health because until then it was mostly interventions that were more proximal more close to the the not the causes of the causes as we say in the language of the determinants of health but they were mostly addressing the issues that were immediate within the health sector and the environment mainly sectors so healthy cities if you see its initial declaration you will recognize the principles and the approach but if you look at its content today of course it has been enriched tremendously by three things experienced after all these years and adaptations new evidence that has accumulated from science and thirdly global movements I mean healthy cities today I mean if you read this document which is a healthier happier cities for all the Copenhagen consensus of Mayors which is the document the political if you like declaration for the next five years of healthy cities of course it’s designed around this the sustain of development goals agenda it cannot ignore that agenda and I have to also emphasize here ending my answer to this question that those who are champions and leaders of Kansas City’s they should not do this in in isolation of what else is happening in the city they will have to connect and work with other agendas they have to link up it is not it a healthy cities coordinator today who by the way can be a doctor can be a social worker can be a planner do you know that in Europe the healthy cities offices in many cities are based in urban planning departments and not in health departments the ideal city for a place for a healthy cities program in a city is to be as closely as possible to the mayor to be close to where strategic decisions are made it can be physically anywhere in a municipality building but it’s important to operate as a catalyst as a convener as a driving force for change not to be a little project somewhere in a corner of of the municipality it doesn’t work like that that’s why also to be a good champion in your city to be someone who makes friends not enemies someone who connects who who begins and enables dialog with different groups is essential for the success and the introduction as you put it before of a healthy city’s culture so now maybe I would like also to mention the examples of some cities in Europe that that have actually not only lets say devoted they became passionate devotees to to the healthy cities idea but the youth the healthy cities also as as an entry point to to to develop partnerships with other cities and to promote this culture for well-being and equity that they wouldn’t have done otherwise I should add that this year back in October we celebrated 30 years since the healthy cities project was launched in Europe there are about 1500 cities that are members of healthy cities there are healthy cities Network in the Americas in North America in South America the big networks in most of the countries there are healthy cities networks in the Arab countries in the eastern Mediterranean region there are healthy cities in in the western Pacific very strong in South Korea in Australia in Japan in China is something an emerging initiative which has attracted a lot of interest and in in Africa and and so on in every region of whu-oh today you will find initiatives they are not all the same and they’re always adopted – as I said before – different contexts for example there are the islands initiatives in the western Pacific where there are so many states island states so it’s another approach but as I said before they all share a common agenda a common understanding of the priorities what I always say to – and that was probably my main conclusion at the opening of the thirty years of healthy cities conference was this yes healthy cities brand is is very spectable it is a brand it is a concept that it is very attractive to politicians many boast their healthy cities logos and activities for many years but my main point was don’t waste a great concept by doing trivial things if you really if you if you want to embrace this concept do it but in order to address the difficult issues where you will really have to to break barriers barriers and silence but where you will have to build bridges with corporate sector with communities well you will have to build partnerships with other cities towards national agendas but do it for the big issues to create to promote equity to promote community resilience to address issues of preparedness and climate change to address some of the big public health issues which relate to the determinants of health so that addressing introducing the idea of healthy public policies is not only doing health impact assessments that’s a small part of what you can do with a great concept such as healthy health in all policies and this is what I meant before today we have the experience we have the evidence we know what are the priorities we have the know-how and we have a great legitimacy because of these global movements and especially the sustainable development goals agenda for these reasons I think every city leader today can can can adopt and can can introduce a healthy cities agenda as a way as a platform and as a catalyst and as a mechanism to promote sustainable development well-being and to basically shape visions for the future which are more citizen-centric were communities more empowered where the issues of Public Health and healthy choices the easy choices and health integrated in urban planning and the activities of different sectors can be easier because they through the leadership they will demand this to happen and they will hold accountable those who fail to to to address those priorities I hope this has given you a feel of the work that we have been doing I hope you will find ways to approach and Priscilla ties your leaders in your cities these are initiatives because they are political in nature that can be really powerful but they take time and a lot of energy but they can deliver great dividends it was a pleasure to be with you thank you