The History of Public Health
A literature review
Public health and urban planning are quite interconnected where the urban environment clearly influences the health and wellbeing of individuals in a city. The early nineteenth century shows how a series of issues including industrialization, lack of sanitation, rapid urbanization, inadequate water supplies, waste collection, high levels of pollution and lack of control measures, and inadequate housing for the poor could cause the spread of disease and unhealthy environments (Kenzer, 2000).
As people continue to move into cities, there is an increasing emphasis placed on urban public health. This issue is addressed globally by the Healthy Cities movement, and locally, through governmental intervention such as the Active Design Guidelines. The Healthy Cities Movement draws on innovations in health promotion, urban planning, and ecosystem perspectives. Politically, it moves towards decentralization of government services, as well as community-based work and inter-departmental action. At its core this program is a long-term plan that is adjustable in order to address local public health issues.
The root of the Healthy Cities project extends further back than its first meeting in Copenhagen in 1986, but to the mid 19th century when the public health movement just began.
“In the twentieth and twenty-first centuries, our understanding of how the planning of cities could affect health outcomes widened to incorporate a greater range of health impacts — obesity, asthma, cardiovascular disease, cancer, to name but a few — and aspects of urban planning such as green space provision, traffic management, urban climate control, air quality management and building standards (Rydin, 2012).”
The following literature review will look at five important phases in history that appreciate how building health into cities is an important role in planning systems (Rydin, 2012). Niyi Awofeso’s paper structures this public health timeline by the following eras from the mid 19th century: Miasma Control, Contagion Control, Preventive Medicine, Primary Health Care, and Health Promotion (Awofeso, 2004). The authors and theories presented underneath this timeline will provide the framework to see how public health concerns have transformed throughout time.
a. Miasma Control (1840s-1870s)
The dominant paradigm during this period was how addressing unsanitary environmental conditions could prevent the spread of disease (Awofeso, 2004). Yvonne Rydin points out how public health concerns arising from poor sanitation drove major urban planning reforms in industrialized countries in the nineteenth century (Rydin, 2012). Reviewing the extensive literature that is available on health and cities, Rydin shows that there is a strong degree of consensus on what makes a city healthy: clean water and good sanitation, clean land, safe homes, secure neighborhoods, and other characteristics that would later be developed in the 21st century (Rydin, 2012).
The public health movement and subsequently the Healthy Cities Program developed much of its strength from the Health of Towns Association, which was founded in 1844 by Edwin Chadwick in Exeter, England (Ashton, 2002). Authors such as John Ashton and Jason Corburn see this association as developing out of the Health of Towns Commission, which was first established by the British government in 1843. However, it wasn’t until 1875, when Sir Benjamin Ward Richardson, an editor of the Sanitarian in Brighton, England, spoke about the health of the city. Richardson’s speech entitled, “Hygeia: A City of Health”, described his vision of an ideally healthy city that still proves relevant today (Hancock, 1993).
Jason Corburn discusses in, Toward the Healthy City, how the built environment was stratifying mortality rates in Manchester, England. Frederick Engels at that time wrote the landmark report, Conditions of the Working Class, in 1844 to bring attention to how class and wealth could unjustly affect health.
Although much attention to health came out of Europe at this time there were two initiatives according to Corburn, related to health in New York City. In 1845 John H. Griscom, New York City’s Sanitary Inspector, published Sanitary Conditions of Laboring Population of NYC, which called upon health recommendations from Chadwick’s Health of Towns Report some years earlier (Corburn, 2009). Almost twenty years later, a New York City survey of the urban landscape for infectious diseases showed wealthy merchants the connection between economic growth and environmental health. These two studies in New York are important to note since there is a definite connection between physical and social planning with the early public health goals that dealt with infectious diseases and sanitary conditions.
“Combining economic efficiency, public health, and morality arguments, sanitarians began to gain the political support they needed to implement their reforms and link the professions of city planning and public health (Corburn, pg. 31, 2009).”
b. Contagion Control (1880s-1930s)
The late 19th century saw improvements in sanitary conditions through large infrastructure projects and improved housing conditions (Corburn, 2009). David Valhov describes urbanization in his paper entitled Cities and Health, noting that in some cases industrialization and urbanization rather than city size was the most powerful predictor of mortality, which was a public health concern in the late 20th century. From 1864 to 1923 there was an overall decline in mortality. Recent studies have shown that improvements in survival among urban residents was due to a variety of factors including certain sanitary reforms such as paved streets, construction of sewers, disinfection of water, pasteurization, better nutrition, surveillance, and the isolation of sick individuals.
The 1900-1920s public health centered on the idea of Germ Theory and Contagion, which was the spread of disease through exposure. To combat this problem, Neighborhood Health Centers emerged, and in 1916 zoning was enacted in New York. During that period Benjamin Marsh argued that zoning, borrowed by the Germans, was a way for governmental agencies to focus on providing healthier urban spaces and control over the city landscape. The first act of citywide zoning in New York City divided the area into residential, commercial, and industrial uses and limited building heights and setbacks (Corburn, 2009).
With a new understanding of urban representation, the emergence of the City Beautiful Movement began to show planners how “it was not so much as the city beautiful as the city healthy (Hancock, 1993; Lee Niles, 2006).” Proponents of City Beautiful looked to create cities that were not only pleasurable, but also spacious and orderly. These cities would contain public spaces and buildings that demonstrated moral value. This movement was led by the middle and upper classes that were concerned with rising urban issues of sanitation, crime, and over-crowding. The City Beautiful Movement was meant to address these issues. The twentieth century continued to incorporate health into the urban framework through the Biomedical Model and Pathogenic City, the Neighborhood Unit, and through Urban Renewal (Corburn, 2009).
c. Preventive Medicine (1940s-1960s)
As the 20th century continued, the 1950s began the unequal distribution of wealth that was brought on by deindustrialization. After the City Beautiful Movement, planners were met with a crossroads, to stay along this path of creating aesthetically pleasing and efficient cities or to address the urban poor, a group that had seemingly always been neglected (Corburn, 2009). An advocate for the latter, Benjamin Marsh, in his book An Introduction to City Planning, argued that city planning interventions should be judged on how they improve the health and livelihood of the poor within the city and that “no city is more beautiful than its most unsightly tenement (Marsh, 1909:27).”
A change in city design occurred in response to the poor health of some inner city neighborhoods. Sprawl and suburban design raises many issues concerning the health of people and sustainable infrastructure development, as discussed by Vlahov et al. Theses issues or effects of sprawl on health include increasing automobile pollution and accidents, sedentary lifestyles, the rise in obesity and diabetes, increased social isolation, and the break-down of social capital (Vlahov, 2006).
Within the city, planners and architects such as Frederick Law Olmstead were concerned with designing cities that would support health; however, many city planners at this time had ignored the housing conditions of the poor. Thomas Fisher speaks about the public parks movement and most notably, Central Park and Prospect Park in the mid-nineteenth century. Olmstead was one of the first to connect landscape architecture and the planning of public parks to the planning of healthy cities (Fisher, 2010). The Miasma Theory, as previously discussed, was used in some part by Olmstead to advocate for the creation of public parks. To Olmstead, public parks were considered the ‘lungs of the city’, where residents could enjoy life in open fields and breathe clean air (Fisher, 2010). The planning for public parks within cities was the first step to accepting how design could alter the health of the city.
However, just as public parks were providing opportunities for urban residents to better their health through open space and recreation, there was a growing social inequality that was being carried over to the 1960s. Thomas Sugrue speaks about how inequality from racial divisions in the mid-20th century was affecting health. In his book, The Origins of the Urban Crisis, Sugrue specifically looks at race and inequality in postwar Detroit. However, what he notes in terms of the widening gap between the rich and poor can be seen throughout other cities in North America. This gap is something that affected the social determinants of health including income, education, and housing.
Addressing population health had underlying social justice principles. Population health was concerned with assessing and addressing why some social groups were healthier than others and in particular how social inequalities determined health inequalities (Corburn, 2006). Mary Evelyn Northridge and Lance Freeman are two such authors that address health equity in their paper Urban Planning and Health Equity. In the mid 20th century, residential segregation was an indication of exposure whether that was to urban form, food environments, physical activity spaces, or environmental hazards. Despite mixed consensus in regard to race, ethnicity and environmental hazards, exposure to amenities or unpleasantness in the urban landscape was a sign of the widening gaps in society (Northridge and Freeman, 2011).
d. Primary Health Care (1970s-1980s)
In the 1970s, Civil Rights activists organized urban areas to link social, environmental, and health justice. At this time governmental policies such as benign neglect and planned shrinkage were affecting cities such as New York negatively, dimensioning governmental funding and support for inner city neighborhoods. An example of one such activist group was the Young Lords in New York City’s neighborhood of East Harlem (Abramson et al., 1971). In order to address health disparities this group organized street cleanups when the sanitation department was absent, day care programs in local churches, and were trained to go door to door conducting lead-poisoning screening and tuberculosis testing (Corburn, 2009). The Young Lords are an example of East Harlem’s commitment to health advocacy as far back as the 1970s.
A major shift in recognizing urban health as a problem came in the late 1970s. Nationally, the Center for Disease Control (CDC) began to seek improvements that would not only look at the physical characteristics of a neighborhood, but the social and psychological effects from housing relocation and displacement (Hinkle and Laring, 1977). Author Trevor Hancock, sees a global shift in the 1980s when the World Health Organization begins reconnecting public health and urban planning (Hancock, 2009). Hancock notes two important dates as the Conference on Health Public Policy in 1984, which leads to Healthy Cities Movement, and Healthy Cities Toronto 2000.
Extensive documentation on the connection between the history of public health and the creation of healthy cities has been documented. Authors Hugh Barton and Catherine Tsourou in their book Healthy Urban Planning give a brief connection, but mainly focus on the process of how the program was developed and the influential meetings that helped to shape this vision of the WHO in creating healthy and sustainable communities.
The World Health Organization’s project began with the Healthy Cities Symposium in 1986 in Lisbon. From that point on the program has caught the attention of cities all over the world and has been developed on a local level as a way to reconnect city planning and public health. It does so by requiring participating cities to first develop a health profile, and a city health plan; secondly, it demonstrates how their goals will be met, and finally, establishes and staffs a Healthy Cities Office within their municipality (Corburn, 2009). Cities around the world have felt that this concept has provided added value to urban performance, related to both the environment and nature of development (Barton, 2000).
e. Health Promotion (1990s-Present)
In the 1990s, social epidemiology was born and Healthy Cities, which was first introduced in 1986, emerged as a global phenomenon. In the previously mentioned WHO published book, Healthy Urban Planning, authors note the importance of when Healthy Cities became one of four subthemes at the World Health Assembly Technical Discussions in 1991 (Barton, 2010). Furthermore in June 1992, the 7th Annual Healthy Cities Symposium in Copenhagen marked the end of the 1st phase of a 5-phase plan (Barton, 2010). Caroline Hall, in her paper Health in the Urban Environment, pinpoints the five phases that make up the Healthy Cities Model and speaks about how each one has built upon the work of the last.
Health equity is addressed by the Healthy Cities program calling attention to the social determinants of health including poverty, social exclusion, and the needs of vulnerable populations (Hall, 2009). The importance of health equity is further seen in The Belfast Declaration from the 2003 International Healthy Cities Conference. Author Michael Bentley calls attention to the program’s commitment to ‘reducing inequalities and addressing poverty’ and to “building safe and supportive cities sensitive to the needs of all citizens (Bentley, 2007).” According to both authors, Caroline Hall and Michael Bentley point to a new direction of healthy urban planning. Phase V of the Healthy Cities plan expired last year and plans for Phase VI (2013-2018) will continue to reduce urban health inequalities through better governance and intersectoral cooperation. Looking at the future of Healthy Cities we must recognize the past and the public health movement that the WHO was born out of. Protecting vulnerable populations and addressing poor sanitary conditions was where the public health movement began; it now continues to be a driving force in governmental decision-making and urban planning.
**A literature review taken from a Masters of Science Thesis in City and Regional Planning. Topic: Active Design in East Harlem: Improving Access to Physical Activity through the Adoption of the Healthy Cities Model
