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Health Promotion International, Vol. 14, No. 4, 365-375,
December 1999
© Oxford University Press 1999
Healthy Cities and Local Agenda 21: the UK experience—challenges for the new millennium
Department of Health Studies, Faculty of Health, University of Central Lancashire, Preston, UK
Address for correspondence: Mark Dooris, Department of Health Studies, Faculty of Health, University of Central Lancashire, Preston, PR1 2HE, UK, E-mail: m.t.dooris{at}uclan.ac.uk
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONCONCEPTS: CONTEXTS AND EVOLUTIONTHE KEY CHALLENGESADDRESSING THE CHALLENGES: KEY...CONCLUSION: IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
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Healthy Cities and Local Agenda 21 both offer strategic frameworks for the development and implementation of theory and practice in the related fields of health promotion/public health and sustainable development. Whilst the close links between health and sustainable development are widely acknowledged, the two frameworks continue to operate largely in parallel. This paper reviews concepts of health and sustainable development, and relates the evolution of thinking that has taken place to the historical development of the Health for All (HFA) and Agenda 21 movements. It is argued that towns, cities and communities committed to promoting health and sustainability face two key challenges as they approach the new millennium: how to move from the margins to the mainstream; and how to integrate the frameworks. Discussions from a recent national ‘round table’ meeting are used to illustrate a range of key issues and highlight implications for people working at local, national and international levels.
Key words: Agenda 21; Healthy Cities; strategic urban planning; sustainable development
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONCONCEPTS: CONTEXTS AND EVOLUTIONTHE KEY CHALLENGESADDRESSING THE CHALLENGES: KEY...CONCLUSION: IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
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Since its inception in 1987, the Healthy Cities model has increasingly been used as a strategic framework for the development and implementation of health promotion and public health theory and practice. Following the 1992 Rio Earth Summit, Local Agenda 21 has been promoted as a framework for local strategic action towards sustainable development. Whilst the importance of recognizing the close links between health and sustainable development has been advocated by a number of writers (Labonté, 1991a
,b, 1993; Hancock, 1996), Healthy Cities and Local Agenda 21 have in general been viewed as separate frameworks and operated in parallel. By reviewing the concepts of health and sustainable development, it is possible not only to identify the links between them, but also to trace the evolution of thinking that has taken place within the two fields. Furthermore, it can be seen that this evolution has been reflected in and influenced by the development of the Health for All (HFA) and Agenda 21 movements. An examination of the local strategic planning frameworks offered by Healthy Cities and Local Agenda 21 highlights two key 21st century challenges facing towns, cities and communities committed to promoting health and sustainability: firstly, how to move from the margins to the mainstream of the strategic planning process; and secondly, how to integrate the frameworks and strategies in order to minimize duplication and confusion, and maximize synergy and effective working.
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CONCEPTS: CONTEXTS AND EVOLUTION |
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TOPSUMMARYINTRODUCTIONCONCEPTS: CONTEXTS AND EVOLUTIONTHE KEY CHALLENGESADDRESSING THE CHALLENGES: KEY...CONCLUSION: IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
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Health and sustainable development
Health has been defined and interpreted in many different ways. Historically, there is in the UK a long tradition of public health, with 19th century local government seeking to tackle the root causes of ill health through action on the physical environment. Whilst it can be argued that in motivation and practice, this ‘old’ style public health was inherently paternalistic and conservative (Ross, 1991
), it did signal a belief that health was influenced by wider factors than personal behaviour and express a concern to address root causes of ill health. In contrast, the rise of the ‘biomedical’ model of health was characterized by a preoccupation with therapeutics and individual lifestyle, and a focus on illness and death. More recently, the dominance of this model has been challenged by the so-called ‘new public health’—which has revisited the territory mapped out by the 19th century public health movement, adding to it an ecological understanding, and a more positive and holistic emphasis on the inter-related effects of the economic, social, political and physical environments on well-being (Draper, 1991). Recent debate has extended this socio-ecological understanding by highlighting the dynamic and developmental nature of health, and making reference to related concepts, e.g. quality of life, human and social capital, and human development.
Sustainable development has similarly been defined in a number of different ways, the most widely used definition being from the Brundland Report [(World Commission on Environment and Development (WCED), 1987), p. 43]:
... development that meets the needs of the present without compromising the ability of future generations to meet their own needs.
Whilst there was little explicit reference to health within the report, there was already a recognition that the concerns were very similar—with Gro Harlem Brundland [cited in (Hancock, 1996), p. 66] commenting to the 1988 World Health Assembly that:
... ultimately the whole report is about health.
That said, the concept's overriding focus has until recently been on the ‘greening’ of economic development in order to avoid future catastrophe—and it has continued to be widely used to imply and justify sustained economic growth (Hancock, 1995; Potter, 1997). It is, however, possible to trace a broadening of understanding over the past 10 years, with more recent definitions highlighting a number of key points.
- Firstly, it is now widely acknowledged that the real focus must be on holistic human development, with economic development being but one (albeit important) means of achieving this. This point is illustrated in the Second World Conservation Strategy (International Union for the Conservation of Nature (IUCN) et al., 1991), which defines sustainable development as:
... development which increases people's quality of life, within the carrying capacity of the earth's life support systems.
- Secondly, it is increasingly recognized that development must be not only environmentally sustainable, but also socially sustainable and ethical. As Hancock argues [(Hancock, 1996), p. 66]:
... economic activity must also not deplete ‘social capital’, irreparably harm individuals and communities through exploitation and disempowerment, or so disrupt the social web of life that holds communities together that they disintegrate.
- Thirdly, and following from the first two points, there has been a growing realization that whilst sustainable development remains inevitably concerned with the future, it must also be concerned with the present—and be committed to achieving equity and justice both between and within generations.
The concepts of health and sustainable development are, then, inextricably interconnected. Not only is human well-being dependent on the creation of supportive environments and the practice of environmentally and socially sustainable development, but, as the recent Jakarta Declaration on Health Promotion (WHO, 1997a) makes clear:
... health is a basic human right and is essential for social and economic development.
Both health and sustainable development have thus evolved to achieve an understanding that is holistic and ecological, their agendas similarly embracing a wide range of interacting social, economic and environmental aspects. This parallel evolution is illustrated by the fact that the familiar ‘three overlapping circles' model—first developed by Hancock (Hancock, 1993) and Labonté (Labonté, 1993)—is now widely used to depict both concepts and is equally familiar to people working in both fields (Figure 1).
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Health for All and Agenda 21
These developments within the health and sustainable development fields have been supported by and reflected in the HFA and Agenda 21 movements. In reviewing their historical development, it is possible to trace a gradual convergence of the agendas, evidenced by the increasing number of overlapping and joint initiatives and the complexity of interlinkages (Figure 2
).
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HFA emerged in the late 1970s, when member states of World Health Organization (WHO) agreed a declaration which was to provide a foundation for the formulation and subsequent development and elaboration of global (WHO, 1981) and European strategies (WHO, 1984, WHO, 1991a). Whilst at a global level the new World Health Declaration (WHO, 1998a) fails to highlight sustainability except in terms of sustainable health services, at a European level, ‘Health 21’ —the new HFA policy for the WHO European Region [(WHO, 1998b), p. 69] highlights the links between health and societal development, and the importance of:
... taking multisectoral action to create sustainable health and development.
The introduction of the term ‘sustainable health’ —a concept recently discussed by Russell and de Viggiani (Russell and de Viggiani, 1997), and first suggested by King (King, 1990)—and the incorporation of sustainability and related concepts into HFA build on a range of earlier developments that demonstrated a concern to highlight the links between environment and health (WHO, 1989WHO, 1991b, 1992b, 1994a,b).
Agenda 21 (UN, 1993) was one of the main outcomes of the 1992 United Nations Rio Earth Summit on Environment and Development—which had its origins in the 1972 Stockholm Conference on the Human Environment and in the Brundland Report (WCED, 1987). Setting out a programme of action for sustainable development into the 21st century, it addresses environmental, social and economic aspects of development. Whilst it devotes one chapter specifically to the protection and promotion of human health—focusing on meeting primary health care needs, controlling communicable diseases, protecting vulnerable groups, meeting the urban health challenge, and reducing risks and environmental pollution—the whole document is in fact concerned with issues that relate to and determine well-being, and there are over 200 references explicitly to health. The centrality of health to sustainable development is illustrated by the accompanying Rio Declaration (UN, 1992) which states the following as its first principle.
Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature.
Since 1992, there have been a number of subsequent international summits that have made it evident that health is ever higher on the environment/development agenda. At a regional level, the European Sustainable Cities and Towns Campaign has further highlighted these links through the involvement of the WHO Healthy Cities Project on its Steering Group.
One of the most significant developments within both HFA and Agenda 21 has proved to be their local interpretation and application. Healthy Cities was established by WHO in 1987 as an attempt to translate the rhetoric of HFA and the principles of the Ottawa Charter for Health Promotion (WHO, 1986) into tangible action. It has evolved from a small-scale European project into a major worldwide movement for the new public health, now involving networks of hundreds of cities, towns and communities worldwide. Local Agenda 21 derives from chapter 28 of the Agenda 21 document, which emphasizes the central role of local authorities and calls upon them to develop local strategies for sustainable development. It has proved to be as dynamic as Healthy Cities, capturing the imagination of local government, community organizations and other local agencies throughout the world. In the UK alone, it is estimated that some 70% of local authorities are spearheading the development of a local strategy for sustainable development (Local Government Management Board, 1997).
Both Healthy Cities and Local Agenda 21 offer holistic strategic planning frameworks for use at the local level. A number of writers (Halliday, 1995; Price and Dubé, 1997) have compared the two frameworks and, building on their analyses, it is clear that, whilst using very different language, they are in fact extremely similar.
- Context
They both focus on local action within the context of a global strategy that advocates implementation at regional, national and local levels.
- Vision
Whilst both are inevitably compromised—reflecting the constraints, tensions and power relations which characterize the United Nations—they articulate an holistic and far-reaching vision of the future which is essentially rooted in radical change.
- Values and principles
They are underpinned by shared principles and values (e.g. equity and social justice, sustainability, community participation and empowerment, intersectoral co-operation, accountability), and by a commitment to ‘systems thinking’ which forms part of the emergent new vision of reality (Capra, 1996).
- Agenda
They focus on the same broad agenda, highlighting quality of life, holistic human development and respect for ecosystems, and advocating action within the interconnected social, environmental and economic spheres.
- Processes and methods
They use common processes and methods (e.g. community development/capacity building, strategic planning/policy development, mediation and consensus building), and highlight the centrality of local authorities in developing new approaches to governance.
Despite their growth into sizeable worldwide movements, both Healthy Cities and Local Agenda 21 have tended to remain on the margins rather than becoming central to the corporate strategic planning process. Furthermore, although links are commonly made between them (e.g. by focusing on a particular topic, e.g. food or transport, and highlighting both ‘health’ and ‘environmental’ issues), Healthy Cities and Local Agenda 21 generally operate in parallel, often alongside other corporate initiatives concerned with such areas as anti-poverty, regeneration and social exclusion. Whilst it can be argued that the existence of two or more separate frameworks and interagency groupings can strengthen and enhance the movement towards health and sustainability, there are obvious dangers of duplication, confusion, inefficient use of resources and lack of synergy.
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THE KEY CHALLENGES |
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TOPSUMMARYINTRODUCTIONCONCEPTS: CONTEXTS AND EVOLUTIONTHE KEY CHALLENGESADDRESSING THE CHALLENGES: KEY...CONCLUSION: IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
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Overview
The above discussion indicates that for towns and cities committed to pursuing the holistic vision of health and sustainability offered by Healthy Cities and Local Agenda 21, there are two key challenges.
- How can Healthy Cities and Local Agenda 21 move from the margins to the mainstream whilst retaining their radical visions to ensure that health, sustainable development and quality of life become core driving forces in towns' and cities' strategic planning processes?
- How can the frameworks be co-ordinated or integrated to minimize duplication and confusion, to enable resources to be successfully harnessed and channelled, and to maximize synergy and effectiveness?
Moving from the margins to the mainstream
Reflecting on the experience of Healthy Cities and Local Agenda 21, it is apparent that each has been influential in putting health and sustainability onto the agenda of towns and cities. However, in the UK and many other countries, the frameworks have rarely become central to municipalities' strategic planning processes. Instead, they have tended to remain marginalized and be viewed by many as discrete ‘projects' or ‘initiatives'. The challenge is to move health, sustainable development and quality of life into the centre so that they become core strategic driving forces, and at the same time to retain and affirm rather than ‘slim down' the radical nature of Healthy Cities and Local Agenda 21. This begs a number of questions.
- Firstly, what is the core mission of local government?
- Secondly, what are the current forces driving the strategic planning process—and why?
- Thirdly, what are the structural and political barriers to putting health, sustainable development and quality of life at the core of the strategic planning process?
- Finally, how best can the profile of health, sustainable development and quality of life be raised?
Co-ordinating and integrating Healthy Cities and Local Agenda 21
In considering how best to co-ordinate or integrate Healthy Cities and Local Agenda 21, it is important to recognize that there is enormous diversity in their actual interpretation and application. At one end of the spectrum, the primary focus of each framework continues to reflect its origins—with Local Agenda 21 being developed as an ‘add-on’ to or reinterpretation of existing environmental work, and Healthy Cities addressing social and welfare concerns (often alongside ‘regeneration’ which tends to be overwhelmingly concerned with economic development). At the other end, both frameworks are interpreted in a truly holistic way that reflects a well-developed understanding of the interconnections between environmental, social and economic aspects of human development.
Progress towards co-ordination and integration will thus mean different things in different situations. Where the frameworks remain rooted largely in one main area, the initial task will be to encourage the development of broader understandings of health and sustainability, which recognize the interconnections between environmental, social and economic concerns. However, where both frameworks are already holistically interpreted, it may be necessary to ask some searching questions.
- Firstly, why are both frameworks being used? Has it been decided that they are both necessary for the achievement of corporate and intersectoral strategic goals? Or are there historical, political, cultural or structural explanations?
- Secondly, how successful are existing mech-anisms in co-ordinating between the two frameworks? Is there clarity about what each is working towards and prioritizing? Are resources being harnessed and effectively channelled? Is there a sense of their individual and joint contribution to a harmonious whole?
- Thirdly, what is the value of using both frameworks? What would be lost—or what might be the ‘added value’—of amalgamating them or directing resources into only one?
- Lastly, if one is to be chosen, which would it be and why?
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ADDRESSING THE CHALLENGES: KEY ISSUES |
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TOPSUMMARYINTRODUCTIONCONCEPTS: CONTEXTS AND EVOLUTIONTHE KEY CHALLENGESADDRESSING THE CHALLENGES: KEY...CONCLUSION: IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
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There are no easy answers to these questions. Rather, they are intended to be a catalyst to further discussion and debate—a process that was facilitated in the UK through a national ‘round table’ meeting on Health and Local Agenda 21, hosted by Bristol City Council. This provided an opportunity for a small number of cities and towns (Bristol, Glasgow, Liverpool, Preston, Sheffield), at similar stages in addressing the two challenges discussed above, to come together alongside representatives from key national and international organizations and networks within the context of revived central government interest in public health, sustainable development and integrated policy development (Dooris, 1998
). Participants found the meeting extremely valuable as a means not only of exchanging experiences, but also of beginning the process of addressing the above questions. A number of key issues emerged during the day which provide useful insights related to the challenges of moving from the margins to the mainstream, and ensuring co-ordination/integration of Healthy Cities and Local Agenda 21.
- Governance, ownership and public participation
In considering the purpose of local government, or indeed, the core mission of any public sector agency, it is essential to reflect on issues of governance. Participants echoed Hancock's assertions that the purpose of governance should be healthy and sustainable human development (Hancock, 1995, 1996), and that this can only be pursued with new structures which facilitate action on 21st century issues rather than 19th century problems (Figure 3), and with new styles (e.g. with consensus replacing conflict, collaboration replacing competition, negotiation replacing directives).
It was suggested that Local Agenda 21 and Healthy Cities not only highlight such ‘21st century’ issues, but in many ways challenge the bureaucratic nature of local authorities and their relatively narrow focus on ‘electoral democracy’. Many cities and towns have found it extremely challenging to strike the right balance between respecting existing cultural constraints and facilitating meaningful ‘bottom-up’ participation by all stakeholders. They have also struggled to achieve a sense of shared ownership across departments and agencies, and the recognition of interdependence which Kooiman [cited in (Ranadé, 1995), p. 4] argues is intrinsic to effective governance:No single actor, public or private, has all of the knowledge and information required to solve complex dynamic and diversified problems; no actor has sufficient overview to make the application of needed instruments effective, (or) the potential to dominate unilaterally in a particular governing model.
That said, there is a wealth of experience and good practice within the Healthy Cities and Local Agenda 21 movements, and all the cities and towns participating in the round table had established interagency structures and at least begun the process of facilitating meaningful public participation. There was a widely held conviction that greater co-ordination and integration would enhance synergy, and also a belief that both movements could contribute different, but equally important, lessons concerning the processes of participation, empowerment and interagency working. For instance, Healthy Cities has effectively harnessed the rich experience gained by the community health movement, whilst Local Agenda 21 has drawn on a range of relatively new innovative participation methodologies and demonstrated a capacity to engage marginalized communities, e.g. those involved in direct action and protest.
- Regeneration: opportunity or compromise?
Regeneration strategies, whilst less obviously holistic in their understanding than either Healthy Cities or Local Agenda 21, are generally understood to be at the heart of local government. This can be understood as a pragmatic response to European and central government funding opportunities. However, cities and towns differ in their attitudes to the regeneration agenda. Some (e.g. Sheffield, Liverpool) have chosen to use regeneration as a key vehicle for raising the profile of health and sustainable development, whilst others are more sceptical, citing the likely dominance of economic development above social and environmental concerns as a reason for caution.
- Integration or co-ordination?
Whilst there was a general commitment to the goal of achieving enhanced co-ordination between Healthy Cities, Local Agenda 21 and other relevant strategic initiatives, cities differed in their enthusiasm for integration. For example, Preston has had a long-standing commitment to developing an integrated approach, reflected in the Council's appointment of a Healthy Environment Coordinator and the establishment of a multi-agency ‘Healthy Preston 21’ Steering Group charged with coordinating health and sustainable development issues. In contrast, Sheffield favours a pluralistic approach as a means of engaging a wide range of constituencies. A well-developed Healthy Sheffield partnership and a parallel Local Agenda 21 ‘Living City’ initiative actively interlink and feed into an overarching City Liaison Group for Regeneration.
- Structures, mechanisms, action and cultural change
Many cities and towns have succeeded in establishing appropriate structures and mechanisms that should enable co-ordinated and/or integrated work on health and sustainable development to take place at a strategic level. These include the adoption of corporate objectives, the establishment of corporate subcommittees and the development of corporate plans. However, it is evident that these structures and mechanisms do not automatically result in meaningful integrated action. A common challenge is how best to bridge the gap between structures/mechanisms and action—through putting in place useable implementation and monitoring systems that ensure meaningful and tangible action, and facilitating effective ‘cultural change’ within and between organizations.
- Global/local perspective
Despite the essentially global nature of both Agenda 21 and HFA, the majority of Healthy City and Local Agenda 21 initiatives fail to reflect and take account of this in a high profile or meaningful way. It was generally felt that there could be considerable value in integrating health and sustainability agendas to develop a stronger focus, whereby all locally focused initiatives are explicitly located within a global context. One example of this is Preston's ‘Local Action, Global Agenda’ initiative, which seeks to raise awareness of the global health and sustainability impacts of local action, e.g. purchasing and investment.
- Indicators
There was a consensus that measurement is an important stimulus to and means of monitoring change. As well as being valid and reliable, it is important that indicators are meaningful to people—that they are demystified and developed not only by epidemiologists, but by and with the communities whose health and sustainability is being measured. Whilst an increasing number of indicator sets include a degree of ‘cross-over’, e.g. Lancashire's ‘Green Audit 2’ indicators include a small number of health indicators, many cities and towns continue to operate with a number of parallel sets of indicators. The challenge is to develop and legitimize appropriate and integrated approaches to the development of indicators for health and sustainability.
- Advocacy
The large number of Healthy City and Local Agenda 21 initiatives provides a rich pool of experience, and a potentially strong and articulate voice for sustainable development and public health. However, there was a sense that this potential is largely untapped, and that a challenge for the future is to develop an effective common voice and advocacy role through working with national and international networks and organizations.
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CONCLUSION: IMPLICATIONS |
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TOPSUMMARYINTRODUCTIONCONCEPTS: CONTEXTS AND EVOLUTIONTHE KEY CHALLENGESADDRESSING THE CHALLENGES: KEY...CONCLUSION: IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
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This paper began by reviewing concepts of health and sustainable development, highlighting the links between them and reflecting on the development of the HFA and Agenda 21 movements. It then went on to consider the striking similarities between the local strategic planning frameworks offered by Healthy Cities and Local Agenda 21, before exploring the key challenges facing towns and cities committed to promoting health and sustainability: how to move from the margins to the mainstream; and how to co-ordinate and integrate the frameworks.
In relation to the first challenge, Ranadé [(Ranadé, 1995), p. 4] has suggested that, for HFA (and it could be argued, by implication, for Agenda 21):
... the challenge ... is to move from the sidelines to centre stage by demonstrating the increasing relevance and practicality of its principles and their congruence with effective methods of governance in the 21st century.
Kickbusch [(Kickbusch, 1998), p. 272], speaking at the Jakarta Conference, has echoed this sentiment, highlighting the need to:
position health promotion as a key element of good governance ...
However, the experience of the five cities and towns involved in the round table on Health and Local Agenda 21 reflected the findings of Goumans and Springett [(Goumans and Springett, 1997), pp. 315, 319] that Healthy Cities is:
... still often perceived as something additional to mainstream activity, largely running projects and encouraging communication ... the window of opportunity for any real change in the political agenda to occur has yet to be opened ...
In relation to the second challenge, it is clear that extensive thinking is going on regarding how best to ensure effective co-ordination between Healthy Cities and Local Agenda 21, but that there is still a long way to go before truly integrated approaches are prevalent.
The themes raised during the round table debate point to an issue which has clear implications for those working at local, national and international levels to address these two challenges: that of language and the ‘mindsets' thereby created. There is still a strong tendency for different professional and sectoral groups to hold on to a particular language (and by implication, framework), and to advocate the use of this with an almost evangelical and fundamentalist fervour. The ‘mindsets' developed and reinforced by these processes tend to preclude a genuine openness to the possibility that even like-minded people may have different, and equally valid, ways of seeing and making sense of the world.
Yet the truth is that they do. For every health promotion or public health specialist working within the confines of a medically dominated health service who has eagerly seized upon HFA/ Healthy Cities for its redemptive and legitimatory possibilities, there is an environmentalist who has grasped the holistic concept of sustainability and the radical all-embracing framework of Local Agenda 21. Labonté [cited in (Dooris, 1995)] has spoken of the need for public health to find a niche in the ‘post-modernist pastiche’ of today's world: finding that niche and successfully working for health and sustainability may require a willingness to let go of Healthy Cities as the dominant framework—and even to let go of the language of ‘health’. As Goumans and Springett [(Goumans and Springett, 1997), p. 321] have argued:
... moving forward is most likely to be accomplished by a pragmatic approach rather than one focusing too much on the word ‘health’.
Labonté (Labonté, 1991a) argues elsewhere that the languages of both health and sustainable development are essentially ‘wild’: they embrace a richness of meaning, integrate knowledge and information from a range of disciplines, and manage to retain the wealth of nuances and resonances that have come to be associated with the concepts. They are therefore best understood as metaphors, and what is important is to find a language or metaphor that is appropriate for a particular community at a particular time. Whether this is ‘health’, ‘sustainability’, ‘quality of life’ or something else does not much matter, what really matters is that the approach is integrated, that resources are effectively used, that the common vision and values underpinning Healthy Cities and Local Agenda 21 are retained, and that the metaphor and framework chosen reflect community concerns and capacities, not a struggle for professional, sectoral or political dominance.
There is now a wide-ranging recognition and deeply held conviction that new integrated approaches are needed if meaningful human development is to be achieved (WHO, 1997b). At a European level, this is evidenced by a number of recent developments. The 1995 International Healthy and Ecological Cities Congress served an important role in integrating Agenda 21 principles within the Healthy Cities agenda (Fudge, 1996). The Strategic Plan for the Urban Health/Healthy Cities Programme 1998–2002 (WHO, 1998c) takes this further by highlighting Health 21 and Agenda 21 as dual foundations for Healthy Cities, with the designation process for the third phase of the Healthy Cities Project—launched in Athens in June 1998—specifying that (WHO, 1997c):
... cities must produce and implement a City Health Development Plan ... which reflects the values, principles and objectives of HFA for the 21st Century and Local Agenda 21.
Furthermore, the resulting ‘Athens Declaration’ (WHO, 1998d) included sustainability as a key principle and emphasized the importance of:
... continuing action aimed at HFA and sustainable development in the 21st century.
This builds on the WHO Health and Local Agenda 21 ‘Multi-City Action Plan’ (MCAP), which worked within the framework provided by the European Sustainable Cities and Towns Campaign to facilitate an exchange between participating municipalities, produce a series of handbooks (Price and Dubé, 1997; WHO, 1997d) and support wider networking (Dooris and Garritty, 1997). Nationally, a number of countries are exploring ways of facilitating such networking, and within the UK, one important outcome of the national round table discussed above was a decision to prioritize future networking by working through and between existing organizations.
Returning to the ‘three overlapping circles' model referred to earlier, it can be argued that, whatever the chosen metaphor, progress will be characterized by a gradual convergence of the three circles, indicating a co-ordinated and holistic approach to human development that integrates the social, economic and environmental, and is at the centre of cities' planning processes (Figure 4). The ‘Verona Initiative’ (WHO, 1998e), co-ordinated by the WHO Regional Office for Europe, provides a good example of this approach: whilst making no explicit mention of Agenda 21 or sustainable development, it highlights the importance of:
... the search for health investments in social, economic and environmental policies as well as public health policies.
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Fig. 4: Progress towards a healthy and sustainable society. Adapted from Salsberg (Salsberg, 1995
As the new millennium approaches, health promotion and public health not only face the challenge, but have the opportunity of helping make what has until now remained largely a conceptual model, a practical reality.
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ACKNOWLEDGEMENTS |
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The author would like to thank members of the Health and Local Agenda 21 MCAP for their contribution to the development of the ideas expressed in this paper. He would also like to thank Dominic Harrison for the useful comments on the draft.
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REFERENCES |
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