Supporting health and wellbeing

 

I wrote this for the GLA Health Committee.  Looking at it, it does not emphasise enough how to do this – which requires geographically based coops.

Supporting the health and wellbeing of all Londoners

Introduction

 

Thank you for this opportunity to submit some thoughts for your work. There is an extremely hoary and ancient joke that someone asked how to get somewhere. Ah I would not start from here.

 

Karl Popper wrote:

 

“I think that there is only one way to science – or to philosophy, for that matter: to meet a problem, to see its beauty and fall in love with it; to get married to it and to live with it happily, till death do ye part – unless you should meet another and even more fascinating problem or unless, indeed, you should obtain a solution.

 

But even if you do obtain a solution, you may then discover, to your delight, the existence of a whole family of enchanting, though perhaps difficult, problem children, for whose welfare you may work, with a purpose, to the end of your days.”

 

I understand the Renaissance concept of Opera, where people work together closely to resolve the issues they face, from a participatory, equal, just, co-operative, sustainable, mutual and whole system perspective might be a valuable way forward.

 

The Three Domains

 

I understand that there are three domains that need to be taken into account in creating excellent living space:

 

  • Buildings
  • Space between buildings, and
  • Transport networks

 

It is not obvious that the governance and professional structures we have reflect these domains, with “Life between Buildings”1 sometimes being a transport related responsibility, at others planning related, one the remit of TfL, the other of the GLA. Where there are conflicting ways of thinking, these may not be being acknowledged.

 

Holistic Government

 

Demos2 have written:

 

The core problem for government is that it has inherited from the nineteenth century a model of organisation that is structured around functions and services rather than around solving problems.

 

Budgets are divided into separate silos for health, education, law and order and so on.

 

The vertical links between departments and agencies in any one field and professional groups such as the police, teachers, doctors and nurses are strong.

 

The horizontal links are weak or non-existent.

 

I started my career in social work, with the work of Seebohm. The concepts of geographical or area “patches” and community work were critical. GP’s were moving into multi-disciplinary health centres. Key parts of my training were whole systems and gestalt.

 

A jargon term that reflects this way of thinking is “villagisation” which is being used by the London Borough of Waltham Forest.3 This concept can be traced back to for example C Hass Klau,4 with the idea of woonerven and earlier People for Places5, the University of California at Berkeley6, the work of Jane Jacobs7 and others.

 

Currently, the concept of making London a national park is being discussed and I would strongly commend this idea8. Much of the preparatory work has been done, for example with Green Chains9.

 

There are two other vectors I would strongly commend, inclusive and ecological design.

 


Inclusive Design

 

A chain is only as strong as its weakest link.10

 

A core concept of the disability world is the idea of barriers. These may be physical, institutional and attitudinal. The idea of an equality impact assessment is to think through clearly what issues someone might face and what physical, legal and behavioural changes may be appropriate. Thinking carefully about someone over their life cycle and on a day to day basis, and looking carefully at what happens, how and why, and how it may be different is very valuable.

 

My experience is like the curate’s egg. There are parts of the movement and transport systems that are impressive; other parts – especially streets and roads are in a backwater. It is not obvious that all the players have even received the message that “Houston, we have a problem”.

 

Urban Ecological Design:11

 

“This trailblazing book outlines an interdisciplinary “process model” for urban design that has been developed and tested over time. Its goal is not to explain how to design a specific city precinct or public space, but to describe useful steps to approach the transformation of urban spaces. Urban Ecological Design illustrates the different stages in which the process is organized, using theories, techniques, images, and case studies. In essence, it presents a “how-to” method to transform the urban landscape that is thoroughly informed by theory and practice. 

 

The authors note that urban design is viewed as an interface between different disciplines. They describe the field as “peacefully overrun, invaded, and occupied” by city planners, architects, engineers, and landscape architects (with developers and politicians frequently joining in). They suggest that environmental concerns demand the consideration of ecology and sustainability issues in urban design. It is, after all, the urban designer who helps to orchestrate human relationships with other living organisms in the built environment.”

 

“The overall objective of the book is to reinforce the role of the urban designer as an honest broker and promoter of design processes and as an active agent of social creativity in the production of the public realm.”

 

Part of the issue is that a person centred, community centred and lifetime perspective is often missing. The following books describe some of the elements of this, Life between buildings1, Great Neighborhood book12 and Urban Transformation6. Another core vector is defining health.

 

The Declaration of Alma-Ata

 

 

The International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 197813 agreed:

 

“The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”

 

I understand most of the pathways and solutions to achieving excellent health, excellent peaceful communities, and high quality human habitats have been worked out and implemented successfully somewhere on this planet.  The issues then are around transference and implementation of solutions.

 

Keri Smith “How to be an explorer of the world”14 is probably a valuable starting point “You have immense powers”.

 

 

Audit and experimentation

 

I understand the starting point for implementation should be audit.  This is a very wide use of this term, and is actually about individuals, families, communities, neighbourhoods, villages, towns, and cities defining and agreeing what to do together, using ecological, economic and equality tools.

 

This immediately causes a structural issue – what to audit, how to audit, how to learn to audit, how to report, how to learn to report.

 

I understand this is an educational function – it is not only academic and theoretical, but hands on, involved, learning, thinking, iterating, experimenting, adapting.  It needs to become a core function and way of working of universities and governmental agencies.

 

Living Labs

 

Dr Kes McCormick has said15:

 

As outlined, it’s been absolutely fascinating watching the rise of the urban agenda. So I became interested in environmental issues in the mid 1990s, and at that point I was studying mostly climatology. Cities with places without environment where nothing environmental happened. 10 years later, people had realized the cities had environments, that they have greenery, biodiversity, produced waste, required clean water, clear air and so on, and suddenly urban environments became important.

 

What I think has happened in the last five years is that cities have become seen as the places where environmental solutions can be found as well. So they’re not just places that produce environmental problems. There are actually places that can enable the development of solutions.

 

The key element of this is the way cities learn to become more sustainable. I think that is the core element of this idea of living labs that really holds some promise. They offer a way for cities to learn how to become more sustainable. And that’s really the main theme of the talk today.

 

The talk is split into two halves. I’m going to start off by just outlining some of the practices, what these urban living labs are, their characteristics so far as we can determine them.

 

Before what, moving on to discuss some of the opportunities and potential for cities to use these things in the future. I’m a geographer by background, so there are going to be a lot of places. That’s kind of the way my brain functions, it looks at what’s going on in one place, looks at what’s going on in another place, and try and figure things out from there.

 

We now accept broadly that we have a problem with climate change, science is done, it’s broadly accepted. We know we’ve got to do something about it. We have some pretty good ideas of where we wanna get to. Sustainability, resilience – these are all worthy goals. The tricky bit is how we get there, and this is really a question of governance. There’s been a profusion of theory about how we might get there: adaptation, transition, classic innovation theory. And each of these has abstract models about how change happens, whether it’s market forces, evolutionary economics, regulatory steering, and so on.

 

But of course, as we know, we haven’t really got there yet. We’ve had a number of things, proven technologies. PV, as Lena says, so much cheaper now. And yet, not exploited anywhere near as much as it could be. Why is that? So people are suddenly turning to experimentation as this kind of missing link. How do we get from these abstract solutions to concrete action?

 

And that’s really where this model of urban living labs I think has gained traction in cities. And they essentially function in terms of this learning loop. The idea that you can stage some kind of real world experiment, whether that’s deploying a new technology, or involving citizens in managing part of a city. Or developing a more collaborative construction model for buildings or designing buildings or public realm, and then the critical part is this experiment is somehow monitored in a rigorous way. So to see what actually works, and that doesn’t just mean in terms of carbon emissions.

 

It also means in terms of social wellbeing, happiness, satisfaction, and then the idea from that is that it provides an evidence base for some form of rigorous learning. How could we do this better next time? How should we do this elsewhere? They tend to be institutionally bounded, so they take place literally in the specific places, they’re usually groupings, partnerships of specific institutions. So they are bound in that sense, and they’re about making material interventions.

 

So this is not just about some abstract “on the internet activity”. They change the city in some way. They change the urbanization process in some way. In some senses they’re very familiar. And I think this is another reason why they’ve become so popular with cities, they fit into a familiar way of doing things. Cities everywhere are having to work in partnership with private industry, with citizens, with universities.

 

Living labs are very much about this, they’re about bringing together all the stakeholders in a specific place to address a specific problem.

 

Future Search

 

Another way of auditing and working out what to do is Future Search16.

 

“Future Search is a PLANNING MEETING that helps people transform their capability for action very quickly. The meeting is task-focused. It brings together 60 to 80 people in one room or hundreds in parallel rooms.

 

Future search brings people from all walks of life into the same conversation – those with resources, expertise, formal authority and need. They meet for 16 hours spread across three days. People tell stories about their past, present and desired future.

 

Through dialogue they discover their common ground. Only then do they make concrete action plans. The meeting design comes from theories and principles tested in many cultures for the past 50 years.

 

It relies on mutual learning among stakeholders as a catalyst for voluntary action and follow-up. People devise new forms of cooperation that continue for months or years.

 

Future searches have been run in every part of the world and sector of society.”

 

Participatory Rural Appraisal17

 

is similar. The aim is to research and adapt these and similar methods for life in and between buildings.

 

Participatory Rural Appraisal (PRA) describes a growing family of approaches and methods to enable local people to share, enhance and analyze their knowledge of life and conditions, to plan and to act. PRA has sources in activist participatory research, agro ecosystem analysis, applied anthropology, field research on farming systems, and rapid rural appraisal (RRA).

 

In RRA information is more elicited and extracted by outsiders; in PRA it is more shared and owned by local people. Participatory methods include mapping and modeling, transect walks, matrix scoring, seasonal calendars, trend and change analysis, well-being and wealth ranking and grouping, and analytical diagramming.

 

PRA applications include natural resources management, agriculture, poverty and social programs, and health and food security. Dominant behavior by outsiders may explain why it has taken until the 1990s for the analytical capabilities of local people to be better recognized and for PRA to emerge, grow and spread.”

 

I have met John Rowan18 and his work is also about this:

 

Sets forth a new paradigm for the philosophy and practice of research in fields of human activity: a collaborative, experimental approach in which inquiry is firmly rooted in subjects’ experience of their lives. Covers the philosophy, methodology, practice and prospects of the new paradigm, showing how to do research with people rather than on people. Synthesizes material from researchers pursuing similar paths in Europe, North America, Africa and India as well as relevant reprints and appreciations of classical material.

 

Charles Leadbetter19 is arguing for similar approaches

 

Learning from the Extremes

 

Published early in 2010 by Cisco, Learning from the Extremes examines how social entrepreneurs around the world are devising new approaches to learning in extreme social circumstances – favelas, slums, informal settlements – when there are few teachers, schools, text books. The radically innovative approaches they develop challenge conventional wisdom about schooling and provide new insights into how the developed world should reform its education systems.

 

For, With, By and To

 

In the spring of 2010 I began work on a project called For, With, By and To, which argues there are only four main ways in which we organise most social activities or address social changes. For solutions are delivered to us. With solutions we devise cooperatively with other. By solutions depend on self-motivation and DIY. To solutions depend on instruction, command and coercion, to get things done. Crudely speaking the 20th century was shaped by the rise of more complex, powerful and sophisticated For and To solutions in virtually every walk of life, at the expense of With and By solutions, cooperation and self help. This dependence on For and To solutions has come at great costs, not least the ability of those delivering to abuse their power. We need to redress this imbalance and develop more effective With and By solutions in virtually every area of life, from learning and health, to ageing and dying, to politics and the environment.

 

Sustainability

 

A comprehensive audit must include sustainability, or as the Germans put it “ecological orientation20”. Friends of the Earth and the PSI define sustainability in the context of four principles.

 

Futurity

 

The effects of any human activity must consider the needs and aspirations of future generations, of your great grandchildren’s great grandchildren. The planetary support systems and a minimum environmental ‘capital’ stock should be maintained.

 

Environment

 

The full and true environmental cost of any human activity should be taken into account.  The precautionary principle should be used.

 

It is very difficult to define sustainability constraints, although work is being undertaken on critical loads and habitats.  It is better to define development paths which will not breach possible constraints.

 

Equity

 

Futurity can be understood as inter-generational equity.  Intra-generational equity, between the first and third worlds, between women and men, between adults and children, the young and the old, the able and disabled people, the poor and the rich, is the third principle of sustainability. The entire planet cannot achieve Western resource consumption levels and these pathways are not sustainable for the long-term future.

 

Participation

 

Participation is a logical result of seriously addressing equity.  Everyone’s views matter. Government becomes responsible for ensuring participatory,co-operative action occurs.  Everyone needs to be enabled to share equally in the processes of decision making and implementation.

 

Audit questions and mapping

 

There are many other examples of audit systems, for example of energy and village needs mapping. These have been used in many areas, and there is no reason why the same principles and types of mapping should not be used in many different ways in London.

 

I believe that for example the state of roads in London have not actually been fully and comprehensively audited and mapped, using the types of questions in these audit processes.

 

There would seem to be an urgent need to bring together and unify these and other audit systems. I understand a lot of work has been done, but it is in silos within separate organisations with different legal relationships.

 

My experience is that the various initiatives like health and wellbeing strategies are still at early stages in terms of understanding individual and community life cycle issues, and I understand the GLA Health Committee has a critically important role here, for example with concepts like ecological public health21 and urban ecological design11.

 

Common mapping and auditing principles need to be defined that fully integrate issues of ecology, health and inclusion and result in detailed and comprehensive asset management plans.

 

Milton Keynes Energy Cost Index

 

“In order to ensure that houses in the Energy Park are indeed energy efficient and the degree of their efficiency could be understood by both technical interests and the public the Development Corporation developed the Energy Cost Index (MKECI).

 

The MKECI enables a house design to be thoroughly and accurately assessed in term of overall energy performance, at the design stage.

 

The MKECI is assessed using a computer model which evaluates all the energy demands for the house under standard occupancy assumptions. The computer programme does not actually predict what energy will be used in the house since this will depend critically upon how it is eventually used; in exactly the same way mpg figures for cars are given for certain driving conditions (such as a constant 56 mph) which are never realised in practice.

 

Nevertheless the test results, in both the house and the unrealistic driving test, are a useful indicator of performance.

 

Hesperian

 

Hesperian22 has produced a sample list of audit questions. “To Help Determine Community Health Needs and at the Same Time Get People Thinking”

 

FELT NEEDS

 

What things in your people’s daily lives (living conditions, ways of doing things, beliefs, etc.) do they feel help them to be healthy?

 

Some questions include:

 

What do people feel to be their major problems, concerns, and needs—not only those related to health, but in general?

 

Do people work together to meet common needs? Do they share or help each other when needs are great?

 

What can be done to make your village a better, healthier place to live? Where might you and your people begin? “

 

Atul Gawande The Checklist Manifesto23

 

Reveals the surprising power of the ordinary checklist now being used in medicine, aviation, the armed services, homeland security, investment banking, skyscraper construction, and businesses of all kinds.

 

The modern world has given us stupendous know-how. Yet avoidable failures continue to plague us in health care, government, the law, the financial industry—in almost every realm of organized activity. And the reason is simple: the volume and complexity of knowledge today has exceeded our ability as individuals to properly deliver it to people—consistently, correctly, safely.

 

We train longer, specialize more, use ever-advancing technologies, and still we fail. Atul Gawande makes a compelling argument that we can do better, using the simplest of methods: the checklist.

 

Much of the groundwork has been done, is it now a matter of formalizing the pathways, the training and implementing seriously?

 

A strategy for the prevention of the effects of a sedentary lifestyle

 

The following is adapted from an essay I wrote for a Coursera course on Global health.

 

Rajna Golubic24 has written:

 

“Lack of physical activity detrimentally increases several risk factors for chronic disease and death, including raised blood levels of lipids, glucose, as well as high blood pressure.

 

Inactive people are more likely to develop obesity, diabetes, cardiovascular disease (heart disease and stroke), osteoporosis and some cancers (breast and bowel), all of which pose major public health problems.

Interestingly, evidence emerges concerning the link between low activity and a greater risk of dementia, depression and impaired physical function in the elderly.

 

Convincing research suggests that sedentary behaviour has harmful health effects independent of physical activity, meaning that high levels of activity don’t cancel out the effects of sitting down for extended periods of time.”

 

The risk factor of sedentary lifestyles is important in my context because I am personally at risk and the Lancet has stated that:

 

“Because much of the world’s population is inactive, this link presents a major public health issue.”25

 

And

 

“Physical inactivity is the fourth leading cause of death worldwide.”26

 

The strategy requires defining where it is required and who it is aimed at. I am proposing an almost complete redesign of all aspects of our environments. This will of itself cause huge resistance, but our existing ways of being are only habits, and by experimenting with different environments, appropriate ways may easily become normal.

 

“Physical activity can be pursued in four ‘domains’ of daily life including leisure time, work, transport and at home.”24

 

Arguably, physical activity has become endangered in urban situations and survives primarily in the leisure domain.  A key purpose of my strategy is for activity to be normal across all domains and throughout life.

 

Homo Sapiens is a very mobile probably aquatic primate27, what should all our environments look, smell, hear, taste and feel like? Are there opportunities for swimming, rowing, cycling, walking, running, climbing, play and fun for adults, not only children, everywhere and everywhen?

 

“We are monkeys” 2829

 

“Laughing is probably one of the most important social behaviours we have.”30

 

The main stakeholders are planners, architects, health, government, business, artists, comedians, and people. Volkswagen’s Fun Theory is an example.31

Wherever and whenever someone goes, interesting fun things should happen, people should have choices to climb over or under things, hear echoes, have magical experiences – a fountain in Montlucon France asks you to wet the noses of lions and make a wish!

 

Buses, trains, offices, all should be made fun and exciting. Dancing and celebration would be far more common. 32

 

The urban landscape would also have plenty of opportunities for napping.

 

“Take regular naps. People who nap at least five times a week for half an hour have 35% reduced chance of cardiovascular disease. Stress hormones also decrease when you’re napping.”33

 

The environment would of course use the best examples of inclusive design.

 

This strategy does require a complete redesign of how we work, including asking fundamental questions about ergonomics – are chairs for example actually a major health risk? 34 Should we be squatting?

 

The delivery mechanism for this policy would be contagion, well placed examples allowing others to copy and riff on and develop the ideas.

 

References

 

  1. Life Between Buildings | Island Press. at <http://islandpress.org/book/life-between-buildings&gt;
  2. Perri, 6. Holistic Government. Demos (1997). at <http://www.demos.co.uk/files/holisticgovernment.pdf?1240939425&gt;
  3. Mini-Holland. Waltham Forest Council. (2013).
  4. Hass-Klau, C. An Illustrated Guide to Traffic Calming: Amazon.co.uk: C Hass-Klau: Books. (1990). at <https://www.amazon.co.uk/gp/product/B00800P16U/ref=od_aui_detailpages00?ie=UTF8&psc=1&gt;
  5. William H. Whyte – Project for Public Spaces. at <http://www.pps.org/reference/wwhyte/&gt;
  6. Bosselmann, P. Urban transformation : understanding city design and form. (Island Press, 2008).
  7. The Blackwell City Reader – Gary Bridge, Sophie Watson – Google Books. at <https://books.google.co.uk/books?hl=en&lr=&id=P2aC62fqCyQC&oi=fnd&pg=PA273&ots=QH564h9rBu&sig=KHVLW4MOaoKKrrxAR-4Ut6lxpRk#v=onepage&q&f=false&gt;
  8. Greater London National Park City. at <http://www.nationalparkcity.london/&gt;
  9. Chain, G. Green Chain – Tel: 020 8921 5028.
  10. Oecd & Ocde. Improving Transport Accessibility for All. (2006).
  11. Palazzo, D. & Steiner, F. R. Urban ecological design : a process for regenerative places. (Island Press, 2011).
  12. Health, G. B. D. of. Healthy Lives, Healthy People: Our Strategy for Public Health in England. (The Stationery Office, 2010). at <https://books.google.com/books?hl=en&lr=&id=fQf4tRfWPd0C&pgis=1&gt;
  13. WHO. Declaration of Alma-Ata. (1978). at <http://www.who.int/publications/almaata_declaration_en.pdf&gt;
  14. Smith, K. Bio « Keri Smith. at <http://www.kerismith.com/bio&gt;
  15. McCormick, K. Kes McCormick | The International Institute for Industrial Environmental Economics (IIIEE). at <http://www.iiiee.lu.se/kes-mccormick&gt;
  16. Search, F. Future Search Network. (2015). at <http://www.futuresearch.net/&gt;
  17. Chambers, R. 0305750X(94)E0029-W The Origins and Practice of Participatory Rural Appraisal*. World Dev. 22, 953–969 (1994).
  18. Rowan, J., Heron, J., May, J. & Stevens, R. Festschrift for John Rowan.
  19. Leadbetter, C. For, With, By and To – Charles Leadbeater. (2010). at <http://charlesleadbeater.net/2010/05/for-with-by-and-to/&gt;
  20. Hillman, M. Cities, transport and the health of the citizen | Dr Mayer Hillman. at <https://mayerhillman.com/1992/11/30/cities-transport-and-the-health-of-the-citizen/&gt;
  21. Lang, T. & Rayner, G. Ecological public health: the 21st century’s big idea? An essay by Tim Lang and Geof Rayner. BMJ 345, e5466 (2012).
  22. Hesperian Health Guides | Knowledge for Action – Action for Health. at <http://hesperian.org/&gt;
  23. Gawande, A. The Checklist Manifesto | Atul Gawande. at <http://atulgawande.com/book/the-checklist-manifesto/&gt;
  24. Golubic, R. The Health Threats of a Sedentary Lifestyle | Gates Cambridge Scholars. Huffington Post (2013). at <http://www.huffingtonpost.co.uk/gates-cambridge-scholars/sedentary-lifestyle-health-threats_b_2939088.html&gt;
  25. The Lancet. Literature and medicine: why do we care? Lancet 385, 90 (2015).
  26. Kohl, H. W. et al. The pandemic of physical inactivity: global action for public health. Lancet (London, England) 380, 294–305 (2012).
  27. Attenborough, D. BBC Radio 4 – The Waterside Ape, 14/09/2016. at <http://www.bbc.co.uk/programmes/b07v0hhm&gt;
  28. Al- Khalili, J. & Scott, S. BBC Radio 4 – The Life Scientific, Sophie Scott. at <http://www.bbc.co.uk/programmes/b03bdpl5&gt;
  29. Konradsen, F. An Introduction to Global Health – University of Copenhagen | Coursera. at <https://www.coursera.org/learn/global-health-introduction&gt;
  30. Scott, S. K., Lavan, N., Chen, S. & McGettigan, C. The social life of laughter. Trends Cogn. Sci. 18, 618–620 (2014).
  31. Piano stairs – TheFunTheory.com – Rolighetsteorin.se – YouTube. at <https://www.youtube.com/watch?v=2lXh2n0aPyw&gt;
  32. Ehrenreich, B. Barbara Ehrenreich – Dancing in the Streets A History of Collective Joy. Holt (2007). at <http://barbaraehrenreich.com/website/dancinginthestreets.htm&gt;
  33. PSC Blue Zones. at <http://www.bibalex.org/psc/en/home/sciplanetdetails.aspx?id=105&gt;
  34. Bakrania, K. Research suggests exercise counteracts sitting time — University of Leicester. (2016). at <http://www2.le.ac.uk/news/blog/2016-archive/april/research-suggests-exercise-counteracts-sitting-time&gt;

 

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