Urban healthiness

Australian born and raised, I have always been aware of the importance of a well-designed, healthy urban environment. As a doctor, it’s become even more apparent that where we live, the environment around us, as well as the opportunities made available, all shape our health as much as the local general practitioner. Some would say much more. But it wasn’t until I moved to Copenhagen in 2010 to begin a PhD in public health, that I realised the degree to which good health can be catalysed by the cityscape we inhabit. I also realised that many cities could and should be doing much better.

Acknowledging context

The way we live, access to education and employment, quality of housing and the environments in which we work and play all profoundly shape our weight and our health. It’s not simply about people making poor choices. Many people see the current obesity epidemic as an issue of “calories in, calories out”. But a significant reason why people are increasingly overweight is actually related to the urban environments we increasingly inhabit. Look around you. Think about your suburbs and those of your greater cities. I would argue that, in essence, the default position for the modern, urban citizen is actually being overweight. Our cities are no longer designed to make healthy living easy, and this is not right. We must address the growing burden of obesity, but if we are to make real inroads, we must change the central mantra of urban design and development – to make healthy choices the easy choices.

It might seem obvious, but it’s not being done. As a doctor, I know it’s pointless to continue struggling with attempts to coerce populations into making healthy choices while allowing the expansion of increasingly obesogenic urban environments. Don’t get me wrong, I will continue to strive for better health for populations and my patients, but I would argue that for the change we need to achieve, I must also urge for urban settings to be fundamentally altered to make healthy behaviours the path of least resistance.

Making good health easier

But is this change possible? Consider the case of my new home nation, Denmark, a high-income country with a similar Gross Domestic Product per capita to Australia, the United Kingdom and the United States. Yet, with a record of intelligent social and planning policies, Denmark has an obesity rate around half that of Australia or the United States. So how has this happened? Denmark’s capital, Copenhagen, represents an example of an urban environment with key social policies structured towards making good health easier. High-quality, ubiquitous bike lanes, efficient public transport and safe green spaces result in 40% of the population commuting to work by bicycle, including myself. Not at all a biking or fitness enthusiast, I ride simply because biking is the cheapest and easiest option for getting around, and it’s safe. Health is just a pleasant by-product.

The city also mandates regularly spaced small, accessible supermarkets throughout suburban and central districts. Not only does this result in increased competition and reduced consumer prices, it also means that every citizen passes by fresh food options on their daily commute. This maximises the opportunity for incidental food shopping, in contrast to the large, centralised supermarkets I remember growing-up. Urban planning considerations, coupled with strict laws on frequency and signage of fast-food businesses, help to promote home cooking and create barriers to unhealthy eating. Coincidence or not, I am yet to meet a Dane who cannot bake a fantastic loaf of bread. Take-out food is also less accessible. Reflecting high commercial rents and a “fat tax” on unhealthy foods, a Big Mac meal, for example, costs around AU$15, approximately twice the price in Australia [although in November 2012, the Danish government announced it would scrap the “fat tax” after only one year, due to pressure from multinational food and beverage manufacturers, or “Big Food” – ed]. It’s hardly a surprise then, that there’s just a handful of McDonalds restaurants in the city of 1.2 million. There are also stricter laws around advertising these foods.

Finally, safe spaces including well lit, adequately spaced and appropriately sized footpaths and green spaces are essential for urban wellbeing. This is something Copenhagen knows too well, with bike lanes and footpaths wider than car lanes, heavy investment in public green infrastructure and active urbanism projects (such as BIG’s Superkilin urban park in Nørrebro). It has become clear to me that cities must move away from the all-too-common situation of building concrete jungles with inadequate, unsafe public spaces. Instead, cities should provide structural incentives for people to be outdoors and be active. 

Progress has also been made in cities outside of Denmark, as demonstrated through the global expansion of bike-sharing programs, the Copenhagenize movement, as well as increasing attention on food advertising. But many efforts are thwarted by the simple fact that, for many, disease has become easier to achieve than health.

Leading by example

If making the healthy option the easy option is the goal, we need to take a hard look at our public environments as exemplars for healthy living. What then is the place for fast-food outlets in public hospitals (a reality in Melbourne)? Should we follow New York Mayor Bloomberg’s lead and consider bans on fast food and sugary drinks in these places, including soft-drink vending machines?We need to rethink the way our societies are structured so that chronic disease prevention and healthy living become the default option for individuals – Copenhagen has made this clear to me. The current paradigm in which medical and public health communities promote healthy behaviours while we continue to build social environments conducive to the opposite, is a waste of time and money.

Take home message? The easy option, wherever possible, must become the healthy option and our society should strive to create built environments conducive to this. This is not about forcing health on populations, or limiting citizen choice – but creating an even playing field for healthier alternatives. As a collective, it’s time we acknowledge that it’s unrealistic to continue creating environments conducive to diabetes, heart-disease and cancers, and then blame individuals for getting ill.

Feature image of cyclists in Copenhagen, by Mikael Colville-Andersen of Copenhagenize, via CC-license.