Can Healthy Cities be made really healthy?
Authors: Helen Cole, Galia Shokry, James J T Connolly, Carmen Pérez-del-Pulgar, Jordi Alonso, Isabelle Anguelovski
Journal: The Lancet Public Health (2017)

Strategies such as the Healthy Cities project aim to place health at the centre of urban interventions.1WHOHealthy Cities.http://www.euro.who.int/en/health-topics/environment-and-health/urban-health/activities/healthy-citiesDate: 2017Google Scholar Such programmes seek to create cities with adequate housing and public transportation, quality health care, and safe places to exercise and play. However, these common transversal approaches also carry a risk of perverse effects, especially when the effect of market-oriented regulatory processes and uneven dynamics of policy formation are not considered. As a result, the Healthy Cities project and similar approaches, such as the WHO's promoted Health in All Policies,2WHOHealth in All Policies: Helsinki statement framework for country action. World Health Organization, Geneva2014Google Scholar might in some cases bolster rather than reduce established trends toward urban social and health inequities. In theory, provision of healthful amenities in cities with the crosscutting policy approach has positive effects on health equity. However, environmental privilege, or inequitable exposure to environmental issues or amenities on the basis of social privilege, is not easily undone in the context of urban growth that concentrates extreme wealth and large exclusion. The gap in family wealth, income, educational achievements, and access to housing continues to widen in many cities worldwide, and is often an expression of deep racial, ethnic, or social class divisions. For example, in Boston, MA, USA, white families have a median net worth of US$247 500 compared with $700 for African Americans, which can affect access to housing and mental health resources.3Muñoz AP Kim M Chang M Jackson R Hamilton D Darity WA The color of wealth in Boston. Federal Bank of Boston, Boston2015Google Scholar Such inequities are often expressed spatially so that low-income residents and minority populations have worse access to clean air and water, green spaces, healthy and affordable food options, and efficient public transport systems.4Anguelovski I From toxic sites to parks as (green) LULUs? New challenges of inequity, privilege, gentrification, and exclusion for urban environmental justice.J Plan Lit. 2016; 31: 23-36Crossref Scopus (153) Google Scholar These differences in exposure and access are one cause of inequities in urban health and one manifestation of environmental privilege—a form of privilege characterised in a socially and racially exclusive manner.5Park LS-H Pellow D The slums of Aspen: immigrants vs. the environment in America's Eden. New York University Press, New York2011Google Scholar When public health interventions are incorporated into varied stakeholder agendas, they risk becoming justifications for actions that expand rather than reduce social inequities. An example of how this scenario might play out is when the US city of Milwaukee, WI, engaged in an extensive greening programme partly to improve the health of residents.6Environmental Collaboration OfficeReFresh Milwaukee. Environmental Collaboration Office, Milwaukee2013Google Scholar During this period, nearly 16 000 homeowners received notice from lenders of impending foreclosure, with African Americans disproportionately affected. In 2013, the city owned and maintained about 900 foreclosed homes and 2700 vacant lots, of which owners had failed to pay property taxes.7Wisla M Five neighborhoods with foreclosure problems.http://urbanmilwaukee.com/2015/01/07/five-neighborhoods-with-foreclosure-problems/Date: Jan 7, 2015Google Scholar The city, non-profit organisations, and businesses have teamed up to convert these sites into gardens and urban agriculture; a prime focus of healthy city interventions to build resilience and provide healthy living environments for residents who can afford them. Similar to Milwaukee, many healthful city interventions, through which added amenities ultimately help to revalorise urban real estate, gain wide support among those who traditionally control decisions on urban land use, especially local government, business, and finance interests. A danger exists of crosscutting health initiatives in cities becoming justifications for new rounds of high-end development and gentrification, but not for intervention on behalf of those who are on the margins of growth cycles. In such a circumstance, health inequities might be exacerbated. Ensuring of healthy and equitable cities requires the incorporation of health and equity as objectives across sectors. Despite the consensus of various stakeholders (eg, public health departments, urban planners, environmental justice activists, and other social justice advocates), the success of the Health in All Policies movement and the development of healthy and equitable cities has proven more difficult than anticipated. The submission of urban planning and social policy to market-oriented regulatory processes is preventing policy interventions from effectively promoting health and environmental equity. For strategies such as Health in All Policies and Healthy Cities to have an impact, crosscutting health initiatives need to become politically unifying agendas for existing social equity and environmental activism in cities to really reduce health inequities. This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on October 31, 2017 This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on October 31, 2017 We declare no competing interests. We acknowledge funding from the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 678034). Correction to Lancet Public Health 2017; 2: e394–95Cole H, Shokry G, Connolly JJT, Pérez-del-Pulgar C, Alonso J, Anguelovski I. Can Healthy Cities be made really healthy? Lancet Public Health 2017; 2: e394–95—In this Comment, an acknowledgment has been added: "We acknowledge funding from the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 678034)." This correction has been made to the online version as of Nov 1, 2017. Full-Text PDF Open Access