INDICATORS FOR A HEALTHY CITY

study of the relationship between a city's environment and the health of its citizens.

Indicators for a Healthy City

Daniel Cappon* Introduction In the beginning there was the word. And the words to define herein are indicators, city and health. Indicators, in my teminology, are conceptual criteria pointing in one direction; in this case away from or towards health. Indices are numerical or statistical criteria. Both terms make up a list of determinants of a state. City is a more or less regular and recognisable agglomeration of buildings and thoroughfares, where people live and work, which is bigger than a town (circa 10,000 souls) and extends in size into metro, mega and ecumenopolis. Health was described by Pericles (495-428 BC) as a "state of moral, mental and physical wellbeing which enables man to face any crisis". Actually health is a concept of a composite of nine states, surprisingly discontinuous with each other (see Figure 1). They are formed by three levels sickness, positive health and fitness; at three dimensions physical, mental and social. Sickness is the absence of health in any of the three dimensions. Positive health is the absence of sickness in any of the three dimensions and the presence of wellbeing and well functioning. Fitness is a state which takes more than average stressors in terms of amount, intensity, duration and onsets and allows a fuller and quicker
Paper presented at The International Conference on "Research for Healthy Cities", The Hague, The Netherlands, 21-23 June 1989. * With the able assistance of Lynne Simons.

return to normality than the average (i.e. positive health state). The standards of sickness fall within the biological and psychosocial sciences, and are measurable in terms of norms or averages. The standards of fitness are also roughly measurable according to the stress definition given. Positive health and the psychosocial dimensions are virtually impossible to measure and depend more on the notion of normal or ideal than what is the average. The discontinuities in these nine cells of health, in which there is no one-to-one relationship across the three dimensions at the same level or down between the three levels within the same dimension, as well as the extreme discontinuities between the subjective range ("wellbeing") and the objective range ("being well" or functioning well), as well as between the scales from individual to collective, are the single greatest challenges to thought and science in this realm. Only such a pristine and vital study of the discontinuities could begin to establish true health sciences. Those which go under that rubric now are mostly and simply sickness sciences. From this it follows that there are three true or positive health activities to be pursued: (1) prevention of health hazards, environmental, including biological, and lifestyle; (2) protection of positive health; and (3) promotion of fitness; in all three dimensions. In these terms no nation has a true positive health policy. The severely limiting factors to pursuing such a policy are: first conceptul, also economic, exponential population increase, arguably technology, sustainable environmental resources and the destructive nature of humans, especially their limited capacity for social intelligence. Indicators Individuals interacting with the physical, natural and manbuilt as well as the human collective and personal environments on all scales account for the majority of sickness. In the context of this article the principal focus is on the city, as a built environment. This concern is due to the fact that the city, once a haven and source of health and wealth, has become the locus for the greatest impact of the aforementioned contending forces between the needs and wants of humans and their environment. UN statistics indicate that the world's urban population has doubled since 1950; and by 2000 AD, three-quarters of the developed countries and up to one-half of the undeveloped will live in cities. Slums and shanty towns increase by 10-15 per cent annually. There are 60 cities each containing 5 million or more humans and more to come as the world population is moving rapidly towards 7 billions. Because most of the earth's land surface is to the north of the Northern hemisphere, the vast majority of humans live more than three-quarters of a 75-year life span indoors.

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Figure

1.

The States of Health

Dimensions Levels Sickness Positive health Fitness

Physical Disease

Mental Disorder

Social Deviation NB Subjective criteria Individual and collective dimensions

Thus the city is becoming the sole physical environment of most humans, while the natural environment is being relocated to merely a resource hinterland, it is paramount to determine the interaction between the health of the city qua city or environment, and the health of its citizens in all three dimensions. This relationship is not always oneto-one any more than the relationship between the nine states of human health is continuous. A relatively unhealthy city may contain surprisingly healthy people, at least in one dimension of health, and vice versa. In order to determine better the relationship between a healthy city and the health of its citizens, so as to know where and how to intervene directly in the built environment and/or directly in human health, we need to run parallel if not corresponding indicators for the health of the city and that if its inhabitants. In order to make this comparison between city and human health, for the sake of prevention of hazards, protection of extant health and promotion of greater fitness, particularly in the psychological and social dimensions, we need indicators. We can then base an orderly and rational policy and its implementation in controls and programmes, on an order of priority for those indicators. Futhermore we need two sets of indicators: those aimed at prevention of hazards largely accumulating from the past and accelerating in the present the easier of the two tasks; and the indicators aimed at the protection of health in the present and in the future and ideally the promotion of a Utopian level of fitness, which takes in the notion of sustainable resources, both human and environmental. Towards a Taxonomy of Hazards In the time during which I have taught a generation of environmental students at my university health policy especially based on the prevention of environmental and lifestyle hazards to human health, I had begun by abandoning totally the post-hoc medical model and developed a comprehensive taxonomy of hazards with a view to proactive and thus preventive action. Medicine, after all, can only barely cope with the largely unnecessary victims of an environment rendered pathogenic to humans. It is neither equipped nor interested

in the larger issues of mass prevention. Moreover, nosology or classification of sickness is largely descriptive, organic system based and not aetiological or causation grounded. Hence I endeavoured to incorporate in broad strokes medical or sickness content in the health schema given above and to put sickness and eventually positive health and fitness on a comprehensive aetiological basic, however wanting, unequal and tentative. Moreover in psychiatry and social pathology prevention is the only cure. Sweeping up after the psychogenic horse parade has gone by, through physical methods, medication and rehabilitation is even less productive and possibly even more expensive and wasteful than medical intervention. Hence I have also taxonomised lately the broad hazards to mental health. Andfinallyin this context, it was the sanitary revolution and the micro-organism warriors such as Pasteur and Fleming that has accounted for the doubling of life expectancy in this century, not the corpus of medicine. In the decades in which I have used these notions, taught, discussed and refined them with the enormous help of a generation of students, the world seems to have turned closer to this notion. But the intellectual efforts seemed to have been often vacuous, fragmented into serendipitous salads and used by "professional" media and politicians mostly as rhetoric, until lately. And the decades have gone by during which hazards have become critical for the entire planet. What seemed to have been needed, for the purpose of effective, rational and systematic intervention, was and still is a conceptual framework. Then the courage and determination to put it into practice. The original taxonomy I had used, and modified for this article, is based on the epidemiological model which takes the collective (humans) as the chief pathogen (in some 20 major hazards); then the same collective is taken more as the transmitter than the originator of hazards (some 10), andfinallywhere humans are the target or victims of pathogens, viz; natural disasters and micro-organism attacks (some 3). Yet everywhere the collective has a sullied hand, even in lifestyles where the individual's choice is severely limited by the collective (from culture to economics).

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Biology, in terms of genetics, degeneration and aging, has been incorporated as an environmental hazard. The taxonomy ranges through the three different basic environments natural, man-built and social; and the three scales macro, meso and micro. This can be seen in the tables which follow, especially in the major category of the physical city as it interacts with the natural environment, in its housing and transportation forms. Because nothing concerning humans can be clear cut, for the purpose of city as an environment I have attempted to separate the more physical aspects therein called places from the mixture of people places, which takes in the human biota of populations, economic factors, life supports, human service organisation, public behaviour, collective power, social structure, environmental concerns and communication (see Table I). In neither of these major divisions of places and people places have I attempted to impose a rank order because this would be even more judgmental than these indicators have to be; and because I considered that priority setting among these should be a matter of global, national, regional, and especially city determinance. For the same reasons the subcategories under each special indicator or rubric should also be produced for priority setting according to scale and place. Although this part of the taxonomy is the result of years of carefully considered and systematic collection, it is obvious that the places division is much more descriptive, objective, and measurable than when people get into them, which is necessarily more intuitive and opinion based. In the division of people's sicknesses (Table I) and health (Table II) the only order imposed is that of the three dimensions. I resisted the temptation to superimpose an aetiological or major hazard-related grouping, for the sake of simplicity and readability. Here too there is no rank order of importance on a range from more to less easily collectable statistics to evaluate each indicator to be processed locally in terms of priority. Table I sets out a comparison between the sickness of a city as environment and that of its inhabitants, hence its use is prevention of hazards. Table II sets out necessarily a much more intuitive and judgemental comparison between the health of a city and that of its inhabitants, hence its use is for protection and ideal promotion. Both these conceptual formats are capable of expansion through addition and elaboration of their subcategory determinants. At worst they act as flags; at best they could each yield numerical overall and disaggregated indices. (Table I some 175 indicators of city and 60 of sickness; Table II some 88 indicators of city and 58 of health.) There are, of course, many more indicators for hazards and sickness in Table I than for health in Table II because humanity has had a far longer experience and knowledge of dealing with sickness than of even conceptualising health.

Discussion

Apart from the possibility of both qualifying and quantifying these indicators and using them as instruments of policy, planning and implementation, they may yield important theoretical information. For instance if a quite objective and easily ascertainable indicator like population impact is thought to be and then turns out numerically a crucial (validated and reliable) factor in a city's health status and in that of its citizens, this can then be dissected into subcategory determinants or scales like total national population per area, per region, urban density (coverage per area), actual crowding in habitats, workplaces, public places and in transportation. With a much more complicated indicator, if the same importance is given by judgement and fact to "material deprivation" or poverty for example, then its determinants may be examined and introduced as vital subcategories, such as whether "material" deprivation is mainly financial, or poverty of information, perception, emotion, or lack of control; or more directly whether immigration, status, demography and therefore cultural preferences, experiences and physical factors (like nutrition), historicity, or the static or sessile poverty factor or the Darwinian genetic kill-off in the population dynamics of an animal (P. sapiens) which jumped out of its niche, is the crucial determinant. Of course it is important to realise when relating people's health to places that there are a number of pitfalls if one attempts to ascribe causation to an association. Perhaps the most pervasive is the ecological fallacy whereby a place is thought to determine the cause of sickness whereas the sickness is caused by the movement of sick people to the place rather than by the place itself. A fallout benefit of such a study as herein described is its academic and professional transdisciplinary nature, which would bring brains trust together in order to help solve problems too urgent to wait for final solutions. Also, priority ordering would make for a rational, testable and incremental implementation of solutions. Consequently, when these tables are refined and validated (or otherwise) against the experience of others, this schema ought to become a valuable tool for combating non-sustainable developmental pressures and altogether for formulating a health policy for a city, a nation and for this small, threatened planet. At least it ought to help us know better what we want to do, what we must do and what we can do in order to protect human health and heal our badly damaged planet. Space permits only general highlighting remarks on the specifics illustrating factors in these tables. The Food and Agriculture Organisation (FAO) and World Bank report that 19 per cent of the developing world has no access to habitable housing and basic hygiene, like latrines, waste disposal, personal and food hygiene. On most of these indicators tabled there is hardly a city of any large size in the USA that is healthy; and 17 per cent of American children live under the poverty line.

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ENVIRONMENTAL MANAGEMENT AND HEALTH, AN INTERNATIONAL JOURNAL 1,1

Table

I.

Health Hazards for Prevention

The City The People's Health Physical (Column 3) Mental (Column 4) Social (Column 5)

Places The physical environment (Column I) A. Macro-natural environment

People/places mixed physical and human environment (Column 2)

A Population impacts (1) Explosion city expansion metro (1) Energy density: coverage per sq. depletion, scarcity m./hectare increasing nuclear dependency (2) Implosion increasing fossil use - over-density in public nuclear plants within city and private buildings and transportation (2) Environment degradation - overcrowding (a) globally lethal - highrises contributions by city to number of persons/room the: (3) Displosion group - CO2 greenhouse tensions and warfare - O3 depletion (4) Large in and out (b) locally lethal migrations - acid rain (c) generally air, water, soil (5) Dislocations in habitat pollution from industry, and workplaces heat/cold supply & (6) Inchoate vicinities transport (d) auditory and visual noise (7) Lack of infrastructure for immigrants (e) solid waste disposal (8) Lopsided demography in (f) no safe beaches neighbourhoods, viz., too (3) Scarcity of renewables young or too old potable water supply B. Economic wood loss of agricultural land (1) One industry dependency metals squandering (2) Insufficient and inadequate economic (4) Weather modification base for energy, water local island of polluted supply, trade, industry, precipitation manufacture and food (5) Extreme events supply lack of prevention and (3) Deep pockets of povertyprotection from natural cyclical and static or disasters shifting pockets B. Macro-built environment (4) Material deprivation (5) Un- and under (1) Size-unlivable employment without (a) excess population (beyond relocation and retraining metro 3 millions) plans (b) excess sprawl hence transportation (6) Gross municipal (c) excess densities indebtedness (d) merging cities not (bankruptcy) separated by wide green (7) Insufficient property belt ownership (e) dirty streets - asphalt C. Life support system jungle (1) Inadequacy of 10 (2) Housing stock services; fire, police, (a) decay, blight, slums hydro (energy), water (b) lack of renewal and and food supply, garbage redesigns disposal, communication(c) excessive vacancy rates postal and phone; (d) excessive highrise in heat/cold, hospital offices and habitats (over emergency and transport 10 per cent) (2) Inadequate infrastructure (3) Anatomy for services to vulnerable (a) concentric population sections - very (b) core rot young, very old, (c) lack of identifiable grand, handicapped, retarded, populated centre mentally ill, newcomers, (d) lack of adequate district victims of crime, poor (regional) multi-centres and vagrants. (Cont Column 1) (Cont Column 2)

(1) High suicide rates (1) High mortality (2) High frequency of (2) High morbidity psychosomatic sickness (3) High infant mortality and and stress reaction morbidity especially urban stress (4) High mature age mortality and morbidity (3) High incidence of admission to mental - loss of work time hospitals (5) High industrial mortality (4) High incidence of and morbidity "criminal insanity" (6) High accident rates in (5) High rates of drug traffic and at home addiction (7) High rates of medical care and of abuse of care (6) High rates of alcoholism (7) High rates of sexual (8) High rates of deviation, e.g. incest, hospitalisation paedophilia, etc. (9) Frequent epidemics (8) High incidence of (10) High incidence of psychopathy, especially endemic diseases social (11) High rates of VD, (9) Perceptual and emotional especially herpes and poverty AIDS (10) High incidence of (12) Poor geriatric care, e.g. unchecked epidemics in excessive drug use psychiatric disorders, e.g. ripple effect of (13) Poor dental care schizophrenia or especially young obsessive compulsive (14) High incidence of hunger neurosis and malnutrition

(1) High crime rates of (especially nonpassionate) homicide, maiming, torturing, assault (2) Low criminal apprehension and conviction rate (3) High population of prisoners (4) High home violence rate, especially "granny bashing" (5) Low report of crime, violence and abuse (6) High incidence of strikes (7) High rates of work absenteeism (8) High rates of runaway children (9) High rates of child prostitution (10) High frequency of broken homes and single parents (11) High rates of insufficient schooling, e.g. 8 years or less; or inappropriate schooling, e.g. technical and crafts (11) High incidence of (15) High incidence of (12) Poverty of information anorexia and obesity inhalation diseases, e.g. (13) High rates of migration, air pollution syndrome; (12) High incidence of especially emigration and industrial or occupational autoimmune disorders, of dislocation lung diseases e.g. allergy (14) High rates of (13) High failure rates in (16) Water bome infections, unemployment and schools or low standards toxins underemployment (14) Widespread agoraphobia (17) Upper respiratory (15) High rates of juvenile infections in schools and (15) Large mental hospital delinquency and violence, workplaces, e.g. population e.g. gang activities like tuberculosis swarming (16) Lack of personality (18) Hospital cross-infections strength and control (16) Lack of friendship and (19) Epidemics of lung and networking, e.g. breast cancer widowhood (20) High rate of (17) Widespread social cardiovascular morbidity isolation and mortality (18) Widespread anomie (21) Abuse of hospital care and alienation (22) Environmental (19) High rate of induced hyprosensitivity abortions (20) Child neglect and (23) Rising incidence of systemic poisoning and desertion environmental toxic (21) High rate of families on effects welfare (22) Vigilante justice and vendetta (23) Discontent and demoralised essential service and HSO workers - police, medical, hydro (24) Neglect of the elderly

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Table

I.

Continued
The City The City People/places mixed physical and human environment (Column 2) D. (1) (2) (3) (4) (5) Human service institutions Inadequacy: education, health, welfare and recreation Excessive government and bureaucracy Drug traffic rise Crime rise Lack of transitional shelters for victims of home violence and abuse (children, women, elderly) Ditto for rehabilitation of mentally ill and criminals Lack of facilities for chronic care: oncological, degenerative, geriatric and palliative Lack of planning for prevention of accidentally caused disasters and emergencies: e.g. radiation leak, industrial and chemical accidents, spills, major transportation accidents High illiteracy rates Poor public health standards and insufficient industrial and occupational health control Excessive public sector services and insufficient voluntary and private sector involvement, e.g. child care Lack of adequate employment opportunities and forecasts Inadequate shelter and services for the aged Public behaviour Little control of violence, riots, looting, strikes, vandalism, break and entry Abuse, rudeness and indifference by public servants, sales personnel, etc., to strangers and natives Discrimination and injustice to minorities on racial, ethnic, religious, political grounds Poor crowd control including in public transport Lack of colourful cultural and festive assemblies and parades Lack of firearm control Collective power and social structures Overcentralised with no grass rooting Overconcentrated power financially and politically; lack of multi-elites Technocracy and mediocres in key decision making (Cont Column 2) (4) Places The physical environment (Column I) No autonomous housing (common energy source, recycling etc.) (5) No easy access to parental visiting rights and extended family (elderly) (6) Insufficient physical infrastructure for cultural and lifestyle diversity (7) No preservation of historical sites and buildings (8) Insufficient hotels, hostels, shelters (9) Lack of variety in restaurants (10) Lack of variety in shopping places both quality and size, e.g. comer store (11) Lack of care for handicapped G. Transportation (1) Insufficient, unsafe rapid transit (2) Poor access to transportation nodes (3) Lack of integration of modes of transportation-air, train, bus, cars, especially airports (4) Lack of traffic separation and control; rush hour psychosis (5) Insufficient accident control (6) More than 1 hour commuting (4) (5) G. (1) People/mixed physical and human environment (Column 2) Over fragmentation Poor justice system with poor access to inadequate courts Environmental concerns Lack of public organisation and advocacy for resource degradation, depletion, scarcity, e.g., recycling and conservation Lack of local global power to act in latitudinal direction Lack of co-ordination on major concerns Communication Lack of full facilities for public and private mass media communication and access, e.g. the press, radio, TV and modern technology Lack of freedom of information Poor quality communication services, e.g. mediatransmitted violence and lifestyle hazards

Places The physical environment (Column 1) Siting and design in the middle of nowhere - no body of water, mountains, no aesthetic topography (b) inhuman scale height, massivity for habitats and workplaces (c) Insufficient and insecure pedestrian spaces, streets and malls (d) no large, safe parks and gardens (see London) (e) no monumental public places and buildings (f) no performing arts core (g) insufficient art and museums (h) no zoo (i) insufficient and inadequate physical access to social (institutional) infrastructure, e.g. government, courts, police, human services (j) no quiet, safe areas (k) poor, unvaried architecture and unidentifiable urban spaces (1) insufficient and neglected homes especially private vegetable gardens (m) not within striking distance (100 miles or 2 hours) of larger city with maximal amenities C. Meso-built environment uninhabitable (1) Excessive pedestrian impedance to schools, churches, stores and public transportation modes, libraries etc. (2) Lack of attractive meeting places (cafes, pubs, playgrounds) (3) Lack of identifiable neighbourhoods and marketplaces (see Europe and the East) (4) Lack of indoor and outdoor recreational facilities (5) Lack of access to hinterland and wilderness (6) Smoking in public places D. Micro-built environment - poor quality (1) Indefensible spaces (2) Poor workplaces, e.g. offices; ambience - biophysics, micro climate, privacy, environmental control, e.g. fenestration, public spaces (3) Poor habitats; lack of privacy; vandalised elevators; insecure parking; lack of morality lights; vandalisable spaces (Cont Column 1) (4) (a)

(2) (3) H. (1)

(6) (7)

(8)

(2) (3)

(9) (10)

(11)

(12) (13) E. (1)

(2)

(3)

(4) (5) (6) F. (1) (2)

(3)

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Table

II.

Positive Health for Promotion and Protection

The People's Health Physical (Column 3) (1) Increasing life expectancy (2) High quality of life in longevity (3) Low rates of general morbidity (4) Low accident rates in transportation and at home; also protection against toxic chemicals Mental (Column 4) Social (Column 5)

The City Places People/places mixed physical The physical environment and human environments (Column I) (Column 2) A. Macro-natural environment (1) Energy self-sufficiency minimal dependence on central grid, i.e. regionalised no nuclear plant in vicinity (2) Environmental quality clean air, water bodies potable water supply soil conservation safe solid waste and sewage disposal low noise levels (auditory and visual) (3) Supply independence water, self-sustaining food supply in vicinity, wood safe beaches (4) Weather and climate unmodified seasonal temperatures protection against disasters B. Macro-built environment (livable) A. Population impacts (1) Limit size of city in relation to resources and sustainable environment - low density per sq.m. or hectare (2) Allow for "natural" segregation yet overlapping (3) Encourage stable and cohesive communities and neighbourhoods (4) Encourage full range in demographic distinction (5) Infrastructure for newcomers, transient workers, expanding elderly population B. Economics (1) Self sufficient municipal income, viz., not in debt and over-dependent on central government solvency (2) Maximum self-sufficiency in energy, food, water supply and waste disposal (3) Planned distribution of heavy, medium and light industry peripherally in "parks" and distinct location of light manufacture and offices (4) Renewal and relocation of pockets of poverty without gentrification (5) Maximal and full employment, with reduced and staggered hours if necessary (6) Maximal free enterprise and private ownership C. Life support systems (1) Excellence in the function of the ten services with emphasis on prevention, e.g. fire, anarchy, emergencies (2) Fully planned services to vulnerable populations: very young, old, handicapped, etc. D. Human service organisations (1) Excellence in education, health, recreation and minimal welfare dependency, viz., food banks (2) Minimal government and bureaucracy and maximal enterpreneurial and grass-root activity (Cont Column 2)

(1) Siting body of water, mountains, waterways, forests, fauna protection and preservation of natural features, topography and hinterland size well below metro level (3 millions) space - no uncontrolled sprawl (below 500 sq.m.) expansion limited by natural features, wide green belt and zoning; no merging highrise limited to 10 per cent of total housing and to 20 stories clean streets and thoroughfares; trees and flowers access to wilderness (2) Housing stock no slums constant renewal variety of designs (3) Anatomy spine and/or radial identifiable centre or heart contour rather than grid basis (4) Design human scale, no massivity grand architecture for public buildings only arts, science centres, museums etc. (Cont Column 1)

(1) Zero population growth but better balance with quality of genetic pool (2) No enforced leisure, viz., un- and under employment or "retirement" (3) Good circulation in careers between private, public including teaching (5) and voluntary sectors (4) High reporting rates for social misbehaviour (6) (5) Falling rates of (nonpassionate) crimes and (7) assault (8) (6) High rates of apprehension of criminals (9) (7) Low rates of prisoner population (9) Falling incidence of (10) Good dental care and (8) Low incidence of strikes home based psychiatric hygiene disorders with ripple or (9) Low incidence of (11) Low urban stress absenteeism epidemic effect (12) No hunger and minimal (10) Low incidence of runaway (10) Good perceptual and malnutrition (including children emotional status in voluntary) citizens (11) Low rates of child (13) Low rates of inhalation prostitution (11) Falling incidence of disease anorexia and obesity (12) Low frequency of theft (14) Low rates of air pollution (12) Falling rate of auto and break and entry syndrome immune disorders (13) Falling rates of "broken" (15) Low incidence of water homes (13) High success rate in borne disease (14) Rising literacy and schools of high (16) Low incidence of upper standards duration of schooling respiratory infection (and (14) High proportion of (15) Falling rates of emigration TBC) and dislocation mentally fit people (17) No significant hospital enduring stress well (16) Falling rates of juvenile cross-infection delinquency and violent (15) Halfway houses for the gang activity (18) No abuse of hospital care mentally ill and for rehabilitated criminals (17) High frequency of (19) Diminishing rates of friendships and oncological diseases (16) Personality strength and networking control (20) Prevention and research (18) Falling frequency of social on degenerative diseases isolation, anomie and (21) Falling rates of alienation cardiovascular diseases (19) Falling frequency of (22) High proportion of fit induced abortion people actively (20) Low incidence of child participating in sports desertion and neglect (23) Diminishing rates of (21) Low incidence of families environmental toxicity on welfare (22) Virtually no vigilante organisations or vendetta cases (23) No widespread discontent among essential service and human service organisation workers (24) No neglect of elderly reinstatement of extended family (Cont Column 5)

(1) Low suicide rates (2) Diminishing rates of psychosomatic and stress reactions (3) Diminishing rates of mental hospital admissions (4) Diminishing rates of criminal insanity Low accident and toxic (5) Falling incidence of drug effect rates in industry addiction and occupations (6) Falling incidence of alcoholism and drunk No epidemics or pandemics driving Low work stress (7) Falling rates of sexual deviances Low VD rates and AIDS control (8) Falling rates of psychopathy, especially Good gerontological social services

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15

Table II.

Continued
The People's Health Physical (Column 3) Mental (Column 4) Social (Column 5) (25) High proportion of citizens capable of adversity and social stress - control over their environment (26) High rates of literacy - informed and concerned population

The City People/places mixed physical Places and human environment The physical environment (Column I) (Column 2) large, safe, district parks system; linked ravines; botanical gardens; zoos; tree-lined boulevards and streets monumental and historical buildings and sites, e.g. cathedrals, museums district and neighbourhood distributed indoor and outdoor sports and recreational centres, associated with schools and churches open and closed pedestrian market places, malls, plazas with shops and restaurant variety but human scale distinct natural contour (topography) and culturally centred designs no smoking in public places C. Transportation (1) Uncrowded, clean, speedy and safe (2) System linked vertical and horizontal in nodes and terminals (3) Excellent rapid transit systems - expandable (4) Traffic separation (goods and people) and control: no excessive peak rush hours but staggered (5) Accident prevention (3) Involvement and co ordination of all three society sectors in human service organisations (4) Maximal drug use prevention and control (5) Alcoholism prevention and control, viz., drunk driving (6) Transitional shelters for victims of home violence and crime (7) Rehabilitation centres for mentally ill and criminals (8) Adequate facilities for chronic care (9) Prevention of man-made disasters (10) Low illiteracy rate (11) High public health standouts (12) Continuous creation of job, career opportunities co-ordinated to national needs E. Public behaviour (1) Balance crowd control with right to assembly and protest (2) Safe festive occasions, parades, cultural assemblies

(3) Prevention of (6) Minimal single driven cars discrimination and D. Meso-built environment injustice to any minority (habitable) (4) No private firearms (1) Easy access to schools, F. Collective power shopping, churches, libraries and transport (1) Balance between central nodes, sports, recreation government and grass (2) Attractive meeting places roots (cafes, pubs, playgrounds) (2) Multiple elites based on (3) Neighbourhood planned public and private fountains, gardens, golf performance clubs, etc., sports and (3) Minimal bureaucracy and recreation arenas and administrative and legal fields, art and sculptures, regulatory power community approved architectural designs (4) Ample access to justice E. Micro-built environment and court system (1) Defensible spaces G. Environmental concerns (2) Healthy room: sun and (1) Active advocacy and climate entrained changes; organisation of public for personal environmental vigilance and participation control, viz., fenestration, in conservation personal touch, privacy (2) Linkage to global for habitats and latitudinal power system workplaces (Cont Column 1) (Cont Column 2)

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Table II.

Continued
The People's Health Physical (Column 3) Mental (Column 4) Social (Column 5)

The City Places People/places mixed physical The physical environment and human environment (Column 1) (Column 2) (3) Autonomous housing (common energy, recycling etc.) (4) Safe parking, garages, morality lights and alarm systems; safe elevators, surveyance of strangers, children (5) Easy access for visits in "broken" families (6) Diversity for culture and lifestyle (7) Suitable hotels, hostels, and shelters (8) Variety in restaurants (9) Variety in local shopping including corner stores (10) Designs for elderly and handicapped (11) Fitness centres; gardens (12) Access to hinterland and to larger city H. Communication

(1) Maximise face-to-facing; telemetry where necessary (2) Freedom of information and of press (3) Prevention of media incited violence and media-promoted noxious lifestyle hazards

A similar diagnosis applies to most large and growing cities on three of the other continents, although, on the whole, European cities fare better than those elsewhere. Even my own city, Toronto, luckily one of the healthiest of all (no thanks to its founding and present Fathers), is deteriorating rapidly, especially due to social pathology. Sweden is one of the wealthiest countries in this world, having been at peace for two centuries, experiencing a very high standard of living, virtually no poverty, no great influx of newcomers and possessing physically healthy cities and people. But their health and welfare statistics, 1978 (see Levi) indicate that every third person has psychological problems; every seventh worker is psychophysically exhausted at the end of the day; every tenth man is an alcoholic, 2,000 people commit suicide every year and 20,000 attempt it.
Conclusions

and also a taxonomy aimed at what is healthy in the physical and social city and its citizenry and so what is worth protecting and promoting to an ideal level of fitness. Of course, this pristine attempt is flawed but it should enable others to correct its flaws and arrive at a better model and taxonomy. We cannot await for someone with the genius of a Linnaeus to do the job, nor can we afford to regard it as impossible, which in any case, according to Nansen, "only takes a little longer". There are four principal global hazards to the physical environment which threatens cities also: the accumulation of CO2, the thinning of O3 and especially toxic radiation from nuclear plants, damaged and sunken submarines, not to mention accidental wars and the increasing number of terrestrials. Thefifthhazard is social: the drug abuse epi demic. WHO estimates that there are 48 million drug abusers in the world. Most of these and the rest of hazards stem from the city. In order to rationalise the health of a city and its citizens, one must judge sustainable development and offset the current demands of a healthy economy and its burgeoning technology against the longer-term demands of healthy survival. One must also persuade politically the whole of humankind that they are equal custodians of this fragile, small and resource limited planet. In order to intelligently reach effective solutions to the virtually unaddressable issues contained in these

There have been others who attempted seriously to invent some sort of appealing model in order to conceptualise the health field, notably the WHO and Ottawa Ministry of Health's bureaucrats; and others still playing the matrix game. But I am not aware of those who have attempted to use a conceptual model in order to apply it to a comprehensive and systematic yet flexible and dynamic taxonomy aimed at the indicators of man-built hazards in the city and their measurable possible consequences in citizens, so a to compare them and intervene preventively;

INDICATORS FOR A HEALTHY CITY

17

problems, science and reason are far from enough. The nature of these indicators and the great complexity of the large variables involved render decisions to be made replete with Catch-22 problems, hardly susceptible to science and to analytical problem solving.

Both sides of the human brain-becoming-mind must be brought to bear in decision making
Ultimate global and even regional success depends on changing the direction of political power from nationalvertical or longitudinal power, to global-horizontal or latitudinal power based on brains, trust and devotion to life and its quality now and in the future. And both sides of the human brain-becoming-mind must be brought to bear in decision making, with larger emphasis than ever on the right side of the mind, which houses the precious faculties of intuition and creativity.
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Daniel Cappon is based at the Faculty of Environmental Studies, York University, North York, Ontario, Canada.