1. THE FUTURE OF HEALTHY CITIES - and the WORLDLeonard J. Duhl, M.D.Professor of Public Health and Urban Planning, University of California, Berkeley, Ca, USA, 94720- 7360, len-duhl@socrates.berkely.edu

2. Healthy Cities has come a long way since Toronto IN 1984, and even longer from its first conceptualization in the early 1960’s. What is important, is that with the world changing, new paradigms had to emerge, and the way we look at health, in the Healthy Cities program, is that shift.First, it’s important to remember how long it takes for change. In the Old Testament, when the Jews left Egypt for the Promised Land, it took forty years. They wandered in the desert, tried to return, worship idols, and gradually the old died off. Only, two got to their goal.

3. What exactly is that paradigm shift? On one hand, it is the redefining health, from medical care, to the quality of life, and the totality of concepts of health promotion. But it is much more. It is focusing upon the problem and not upon the institutions and professions that provide services.In the first redefining health is hard for people to understand. After all, we have trained people over many years to the importance of medical care, hospitals and more. Science, and treatment are the focus of research, each offering a relatively simple solution.. It is a linear model where if you can destroy the cause, all will be well. As the issues of medicine become more complex this linearity won’t work.

4. Looking at any disease we find biological, social, economic, cultural issues. We discover that psychological states can change the immune system. Hunger changes our ability to grow and respond. Poverty change the ability to access care. We see that water leads to deserts, and then to hunger. Now, with our understanding of genetics, we find that each of us is unique, with uniqueness leading to different means of response.Let us look at our communities, and ask how much we know? Most people know their home area, where they work and play, and rarely see the places they pass through. Thus, most are ignorant of the whole community, and define the community as my turf. This understandable self-interest has an “I” quality.

5. We do not know our communities, in this way. We stay in our silos and happily think we know it all. I have suggested that this century is an anthropological one, of different worlds, colors, smells, values, and much more.However, community means we, us, and ours. There are places, with large extended families, or where the sense of commune-ity has a long hundreds of year’s history as in Northeast Italy.There is an important issue when we look at a problem. We have to know it totally and fully – from the molecule to the world. This takes mapping, which is the process of laying our ALL the relevant issues, people and places that impinge on the problem.

6. As the world gets globalized, and corporations sell the market economy as the paradigm, greed, selfishness and self-interest predominates. All this attacks the idea of community, and pushed the global corporation as the true community to govern.Communities mean children. Sadly, in many places children are superfluous, unneeded and unwanted. They are raped and pillages. They are killed by each other. They have little hope, unless they are well off. Our social environments kill them, and then the pollution does the rest. In Sao Paulo, I saw industry pollute so much that children are born encephalic.

7. All of this, plus increasing costs have forced us to re-think what we are doing. Let’s look at some examples:For example in Capela de Socorro, in Sao Paulo, Brazil, the mayor has used the Healthy City model as the model for community governance*. He has realized to achieve health; there is need for sewers, water, curbs, schools, recreation centers, life long education, and more, each requiring active participation of the people. And, we have learned that active participation, in itself, leads to health.

8. Governance of our diverse population is becoming increasingly difficult. In a way, everyone is right for each looks at the world and their problems from their own vantage point. They see clearly that their goals and values are correct, and deny anyone else’s interpretation. How to deal with this requires understanding social change, and the processes necessary to find resolution. To often impatience leads to use of force, police or military action. As an example, when shanty ton inhabitants organize and ask for services, whether medical or water and sewage, they are labeled illegals. To be so defined, they are defying the law, and most often the solution is bulldozers. This ignores the problem, and focuses on the irritation, leading to a swift cure, removal.

9. There are many such examples. However, I will leave this for the moment and return to the complexities of the world. Most often, I discuss with my students the problems of the World Bank, the International Monetary Fund, the international banks, multi-national corporations, and other aid givers. Focused on a paradigm that makes profit and money the core value, we have been loosing social, educational, housing and health services all over the developing world. Do we have to diagnose the problem as greed? In California we experienced the result of Enron’s manipulating prices of energy, in such a way are to treble gas and electricity prices, leaving a state deficit, which results in cuts for social and health services.

10. As I travel the world, I have learned something very important. Those places where change is taking place are local. Those on higher levels have no idea of what is happening. Locally we see social entrepreneurs*, mostly women, developing activities, with participation and collaboration, many times ignoring national or state rules. These programs, many of which are Healthy Cities activities, are in the forefront of the future. They range from the Grameen Bank in Bangladesh, Saravodaya in Sri Lanka, and to cities like Porto Alegra In Brazil, and many more.

11. Here the great wok of Paulo Friere* must be mentioned. He over many years, has changed the way education is done, especially in Brazil. He starts where people are, and people learn how read, write, do arithmetic and more, dealing with issues that are central to them. They learn to organize, and ultimately to advocate for themselves. This is the origin of the strength of the Workers Party, now the dominant party in Brazil, and especially Porto Alegra.

12. The emphasis on active participation is clearly seen in Porto Alegra, where participatory governance has been working for more than sixteen years. Here 36,000 people vote on the budget. Here they are solving traffic problems, and the delivery of health care. For example, one hospital is responsible for 100,000 persons in a favella, a shantytown. The get full medical care, mixed with the services of a Healthy Cities like program. And. its cost by most standards is very low.

13. On a city level, Helen Davies, appointed by the Mayor of London, is involved in pulling together all the resources of the city, public and private, to deal with the complex issues of health. She has the power to have all agencies work together on problems, rather than each working separately runs the largest The London Health Commission works in partnership with agencies across the capital to reduce health inequalities and improve the health and well being of all Londoners. The LHC recognizes that this requires coordinated action to improve the determinants of health across London.

14. Set up by the Mayor of London in October 2000, the Commission was created from a partnership of organizations that first came together in May 1999 to develop a strategy to improve the health of Londoners. The Health Commission is run by an Executive Group made up of the Chair, who is appointed by the Mayor of London, the Deputy Chair and representatives from its key partner organizations. The Executive Group oversees the organization’s work program, reporting regularly to Commission members.

15. Members of the Commission are drawn from across London and all sectors and represent a wide range of interests. The Commission meets approximately four times a year The Commission itself has no statutory powers, functions or funding. Instead, its work program is delivered through resources and expertise provided by its members and key partner agencies.

16. In partnership with health, employment and regeneration stakeholders across the capital, London Works for Better Health aims to:- develop and implement strategies to improve health and reduce health inequalities through employment and enterprise; - promote and support healthy and sustainable employment practices; - encourage partnership-working in planning and delivery of health and employment initiatives*.

17. Let’s now look at Panyang, MalaysiaWhat do people want?- they want jobs and not slogans, health care for my family not policy discussions, housing that they ca afford, food they can buy, and security in a crazy world- each time we ask communities around the world what they want, there is 90% agreement open space (parks), cleanliness, water nearby (streams, rivers, lakes and open water), low-rise housing, small health clinics and schools, jobs nearby that they like to do, a sense that they can improve their lives, public transport )very few see cars in their future), security (rarely a jail is asked for), and more in a similar vein.

18. The existing values and paradigms are causing great difficulty. The gap between rich and poor is growing in many countries, those in the developing world and in the US and China. The poor are superfluous, but they are the majority. Most importantly something can be done about it. Not, however, without resistance.