CITIES

HEALTH AND

WELL-BEING

URBAN AGE HONG KONG

16-17 NOVEMBER 2011

This year’s Urban Age conference followed the new pattern of being issue-centered, rather than being primarily about a particular city or region. The topic was Health and Well-Being in Cities. Nevertheless, the specifics of Hong Kong provided a very special context in which to examine this topic: Hong Kong is an incredibly intense, dense, exciting urban environment; it is related both to situations in the wealthier countries of the more established, Western parts of the globe, as well as to the exploding urbanization of the newer—often poorer—parts of the world—and Asia, in particular.

For those of you who are not familiar with it, the Urban Age is a series of world-wide conferences, dedicated to studying the problems and issues facing cities in the 21^st century and creating dialogues designed to find solutions. (See the UA’s own very informative website: www.urban-age.net). 100 years ago, 10% of the world’s population lived in cities, while 90% lived in rural areas. We are at a moment in history when the world has recently crossed the point that more than 50% of its population now live in cities—and the United Nations predicts that by 2050 approximately 75% of the world will live in cities. This fact means that the nature of cities will have an incredibly important impact on the nature of life on this planet. The Urban Age program is centered at the London School of Economics, and funded by the Alfred Herrhausen Society (the international forum of Deutsche Bank). These conferences are designed to form the framework for the development of an ongoing dialogue between government leaders, academic experts and urban practitioners—it brings together architects, city planners, government officials, transportation experts, real estate developers, and the academics who study these areas; and to this array of urban thinkers, the Hong Kong conference added representatives from the worlds of health care, public health, and epidemiology, .

The Endless City, a book representing the integration of the findings of the first series of conferences (which began in New York [q.v., my write up] in February 2005 and which culminated in Berlin in November 2006 [with Shanghai, London, Johannesburg, and Mexico City in between], was released by Phaidon Press in 2008. It was co-authored by Ricky Burdett and Deyan Sudjic (member of the Urban Age team and author of The Edifice Complex: How the Rich and Powerful--and Their Architects--Shape the World, and many other books).

The second series of conferences began in November 2007. The first of this series was Mumbai (q.v., my write up), followed by São Paulo, and, in 2009, Istanbul (q.v., my write up), which was the final of the three meetings of this second series. Living in the Endless City, also co-authored by Ricky Burdett and Deyan Sudjic and by published Phaidon Press (2011), presents an in-depth overview of the findings from this series of conferences.

The third series of conferences began in December 2010 with the Global Metro Summit in Chicago, organized by LSE Cities in conjunction with the Brookings Institution Metro Policy Program. This conference explored approaches and perspectives to overcome the current global economic crisis as it affected cities. The Hong Kong conference on Health and Well-Being is the second in this series of issue-centered conferences.

{My personal remarks in the sections below are set off in curved brackets}

THE CONFERENCE

DAY ONE – 16 November 2011

Wolfgang Nowak (at right), Managing Director of the Deutsche Bank's Alfred Herrhausen Foundation, and our friend from the beginning of the Urban Age conferences in New York in 2005, opened the proceedings and welcomed everyone to this 10th Urban Age conference. He told the story of a young woman coming into the US from China, inadvertently carrying a lethal virus that spread and devastated the world's population—only at the end letting on that what he was describing was actually the plot of the then current film, Contagion; but he said that part of what this conference would be about was making sure that such things do not become reality.

Tony Travers (at left), another Urban Age friend from the earliest years, and Director of LSE London, noted that the conference coincided with an LSE alumni event in Hong Kong, where the institution has more than 2000 alumni. He sounded the theme that we all know that buildings and streets and the form of cities affect the nature and quality of life in cities, and that LSE Cities was dedicated to the examination of cities around the globe, and especially in the context of the economic turbulence in the global economy. In the more established cities of the world, there is an increasing level of extreme financial constraints, whereas in Asia there are more resources; but everywhere cities will continue to grow.

John Burns, Dean of the Faculty of Social Sciences, University of Hong Kong, raised the question of how to make health care available in Hong Kong—who pays, who benefits—and what is the role of government, private sector, etc.; he spoke about how questions of health and well-being must be considered in terms of density and the politics of economic development.

Our dear friend, and head of the Urban Age and LSE Cities, Ricky Burdett (at right), announced that for the first time, our proceedings were being broadcast as a live podcast (on the Urban Age website). He said that understanding the starting point for these issues required we look at London in the mid-19^th century, where, as in Paris, Madrid, and other places, there was a rapid rise in population and incredible pressure on the quality of life. Life expectancy was only 32 years. All this resonates with the problems of today. During the Broad Street cholera outbreak of 1854 in SoHo, John Snow—without any knowledge of microbial theories of disease—located, through epidemiological mappings, the single water outlet that was the source of the epidemic, marking the beginning of the modern awareness of the relationship between the built environment and public health, and heralding the modern age of public health intervention via water supply and sewage handling. (This parallels the work of Edwin Chadwick ["The Sanitary Condition of the Labouring Population," 1842] whose useful sanitation reforms also were undertaken without modern understanding of communicable disease transmission {; and the contributions of Haussmann's major sanitation and water improvements that radically bettered health conditions in 19^th century Paris}.)

Similarly, in 1889, Charles Booth in his surveys of life and labor in London became the first chronicler of inequality in London, mapping areas of poverty and wealth—making clear unequal patterns of distribution of wealth that still persist today (with wealth residing in the western sections, poverty in the eastern ones).

Ricky found a sign in London, dating from 1927, which reads, "The Health of the People Is the Highest Law." There began a series of movements designed to address these issues: Ebenezer Howard's Garden City movement, whose vision was to combine the best of rural and urban to create "slumless and smokeless cities"; and Le Corbusier, and his ill-fated alternative to Medieval Paris—the whole idea of "towers in the park" (but, Ricky queried, "where is the park?").

Essentially, the central factor in this new approach was government creating services and infrastructure to provide clean water and good sanitation resulting in a better quality of life.

THE POLITICAL OF URBAN HEALTH

Moderator Detlev Ganten, President of World Health Summit and Chairman of the Board of Charité Foundation in Berlin, noted that Sun Yat-sen, so important to the founding of modern China, had practiced medicine in Hong Kong.

Designing Health and Well-Being in Hong Kong

York Y. N. Chow, Secretary for Food and Health, Hong Kong Government, began by reminding everyone that Sun Yat-sen actually had not been allowed to practice medicine in Hong Kong due to pressure from British doctors, and therefore actually had to move to Macao to practice. He spoke of the reciprocal interaction of productivity, progress, and stability in the process of achieving health and well-being for a society. He defined well-being as requiring a system to be safe, caring, humanistic and fair; and health he said had four components—physical, mental, public health, and healthcare (the latter two specifically being the province of government). He said that Hong Kong has excellent public health (with a life-expectancy of >80 years for men and 86 for women {this averages to 82.5 years, compared with 51 years in Johannesburg or 72 in Istanbul}), having created a low-risk environment for its 7 million people. Given this intense concentration of people (plus the enormous number of people in transit through Hong Kong at all times—300,000/day from the mainland alone), the government's concentration has been on infectious disease, as with health protection initiatives following the 2004 SARS outbreak. Currently, the emphasis is shifting toward environmental interventions, preventive public health, and health education, and dealing with NCDs (Non-Communicable Diseases, like hypertension, diabetes, asthma, etc.). In 1992, they established the Hospital Authority to provide access to healthcare to all, good emergency services, high-tech services (like transplants), and training of health professionals. The care delivered in hospitals is 90% public (at an extremely good professional level, and 97% government funded! [inpatient care is uniformly HKD 100/day—even for an $800,000 kidney transplant]), and only 10% private; whereas 70% of the primary care is provided on a private basis. {It is clear that there is an extremely well-developed system of government-supported secondary and tertiary healthcare in Hong Kong; what is strikingly and dangerously lacking is primary health care. And this latter deficiency promises to be increasingly problematic as the system shifts focus from infectious diseases to the problems of NCDs.} The changes in focus, the growth of the population, and the demographic shift (in the next 12 years, the percentage of the population over age 65 is expected to double) will lead to enormous challenges to their capacity and their need for cost containment, and increasing in balance in the private/public markets. They are planning increasingly to look to the private establishment (though medial vouchers, subsidies, quasi-private insurance programs) to deal with these problems. One weapon in their arsenal is the provision of public land for the building of hospitals, private as well as public.

Detler asked: Do you have the influence/power to accomplish these objectives?

Dr. Chow answered they need to encourage innovation and monitor standards in order to achieve the goals {which I took to mean the answer is "no."}

Detler: Shouldn't environmental issues be more under your control?

Dr. Chow: We monitor the environmental effects (as with asthma), and we do work with other branches, as with the very effective and radical anti-smoking legislation recently instituted.

Victor asked the question I was wanting to ask: "What is the role of primary care in Hong Kong?"

Dr. Chow: It's not very developed here. GPs have been almost exclusively private—and unregulated—in the past; but they are trying to set up registries of PCPs (Primary Care Physicians), establish clinics, and explore models for providing these services.

Rebalancing London

Stephen O'Brien, Chairman of Barts and the London National Health Service, discussed the reciprocal interaction of productivity, progress, and stability on health (which must be safe, caring, humanistic, and fair) and well-being (physical, mental); and the public health and health care components, which are the province of government {ah, would that the latter be recognized in the US!}. He spoke of the long history of lack of integration of services in London—present, but fractured. He used the example of East London, with 1/8 of the city's population, but little wealth or resources—and how there had been little change over the past 60 years. He cited the incredible statistic—often quoted by the Urban Age—that life expectancy in London decreases by a full year for each stop on travels east on the Jubilee Underground Line. TB was and is rampant in East London, and there has been little progress in 150 years—which is clearly a failure of government. The National Health Service, which is supposed to provide everyone in the UK the same quality and quantity of healthcare, fails to do so because all of its power is retained at the center, and it is isolated from the rest of government—there being no real interface between public health and local government. It had been thought that the advent of a strong Mayor of London in the structure would help integrate things; but it hasn't. He is hopeful, however, that the Olympics are having a positive effect. What is needed is a real integration of primary, secondary, and tertiary care, the commissioning of local people and services, and a patient-centered approach to healthcare—all pushing down control from the center to where it belongs on the local level.

From Secretary of Health to City Mayor: Lessons from Chile

Luis Gonzalo Navarrete Muños Mayor, La Prado, Santiago del Chile; former Vice-Secretary for Health, Chile, who is, by training, a physician, noted that Santiago's 7 million people represented 40% of Chile's population of 16.5 million. Sanitary reforms in Chile over the past 20 years have resulted in a marked decrease in the rate of infant mortality; yet economic disparity leads to segments of the society experiencing higher rates of infant mortality than before. Wealth in Santiago is concentrated in the eastern side of the city, while the western districts have high levels of poverty; and, predictably, green spaces are predominantly in the eastern parts, quality of life and education levels are higher there, and all measures of health are better in those parts. In the years of the "dictatorship," 1973-90, there was social housing built, but it tended to isolate the poorer population; in the period thereafter, 1990-2006, there basically was no plan. Mayor Navarrete Muños has been successful in instituting a series of programs to create new housing, healthcare, and public spaces designed to promote social integration and community participation. The result has been already observable improvements to measures of the health of the formerly underserved sectors of his city.

UNDERSTANDING HEALTH IN CITIES

Joan Clos (at right), Executive Director of UN HABITAT, and former Mayor of Barcelona, who chaired the session, began by noting the disparity inherent in the starting point for discussing the cities we are talking about, which have per capita incomes which vary from in excess of $60,000 to as low as $900. He thought it was important to note that social conditions of health have often necessitated and justified changes before there was science which was able to support them, as in the London cholera example already mentioned, where effective measures were taken 30 years before the development of the microbial theory of disease which actually explained them.

Cities Population Health, and Healthcare Systems: New York, London, Paris, an Hong Kong

Victor Rodwin, Director of the World Cities Project, and Professor of health and Policy Management at the Wagner School at New York University, began by recalling that while cities have often been studied as the breeding ground for disease, there are many suggestions that cities can be centers for the production of their population's health, and that cities may also serve a governmental function for strengthening the healthcare system (as in New York City). A population's healthcare is largely affected by social determinants—the physical environment, the built environment. Many behaviors influence health (smoking, obesity, lack of exercise), and poor neighborhoods disproportionately are also exposed to environmental factors. The idea of life expectancy being dependent on location within a city is not confined to London: Tokyo, New York, Paris, London, Hong Kong all claim to be healthy cities, but the reality is far from it—especially if one looks at areas like Central Harlem in New York. Victor discussed the difficulty in measuring health. He pointed out the problem inherent in using self-report as a measure by noting that while the Hong Kong objective measures of health show that health in Hong Kong is clearly better than that in New York, less than 1% of the residents of Hong Kong report that they are in good health, whereas more than 10% of New Yorkers report they are. In his work (q.v., Healthcare in World Cities), Victor has looked at New York, London, Paris, and Tokyo, and has found an enormous level of intra-city disparity: in New York alone, infant mortality rates vary between 3.9-18.3. And, in the 80s and 90s, the "Manhattanization" of the world has led to even more such disparity everywhere. Victor proposed using Avoidable Mortality (AM: deaths before the age of 75 for which there are effective healthcare interventions [things you shouldn't die from if the medical system is working properly]) and Avoidable Hospital Conditions (AHC: a good measure of the adequacy of Primary Care in a system, as it measures the rate of hospital admissions for illnesses that should have been treatable without requiring hospitalization) as metrics for accurately evaluating a city's healthcare. On AM, Paris rates the best, with Hong Kong a close second, whereas inner London the worst in the cities he's studied. Interestingly, all cities—with the exception of New York, which simply cannot—claim to have good primary care, but most cities actually do not. There are many signs that primary care is not working in Hong Kong: too many hospital admissions for asthma, Congestive Heart Failure, bacterial pneumonia, etc.

Well-Being in African Cities

Catherine Kyoburtungi, head of Health Systems and Challenges, African Population & Health Research Center, said that in sub-Saharan Africa, the percentage of people living in slums is going to double in the coming years, bringing it to a total of 20%. Cities like Nairobi already have a density of 65,000/km² in its slums, with few public health facilities (and the existing ones only open from 8-5, when people who work cannot use them), low levels of vaccination, malnutrition, high rates of infection with HIV/AIDS (41% in its female population), high infant mortality (98/thousand in its slums, 60 in Nairobi as a whole, 50 in Kenya). These problems are highly different by economic situation: for example, the teen pregnancy rate in wealthy areas is 9%, while it is four times that among the urban poor. Undetected, undiagnosed, and uncontrolled disease is rampant. The implication is that there is a critical urgency to address the needs of the urban poor in sub-Saharan Africa.

Urban Governance for Heath Equity

Jason Coburn, Assoc. Professor of City and Regional Planning, UC Berkeley, raised the question of what we can do to promote health equity. He asserted that "place" matters—and that intra-city differences were more important than inter-city ones; and that institutions matter. Urban living can be good for health, but inequity needs to be dealt with, and it is getting worse. Increased poverty means increased disease, and we cannot focus on just one disease: there is a serious assault on people's health, and patterns of racial segregation have a particularly damaging effect. There is a structural racism that is at the heart of all this. Urban planning matters, but it does not have a very good history of success. One of the most crucial factors is the presence or absence of community institutions that determines whether family dynamics succeed or fail in specific areas. He raised the question of whether in the case of Nairobi (where 60% of the population is unemployed) and elsewhere, shouldn't we be focusing on the effect of unemployment.

MEASURING QUALITY OF LIFE

Christine K. W. Loh, Chief Executive of the Civic Exchange of Hong Kong, chaired the session.

Social Equity and the Quality of Life

Richard Sennett (at left) posited that quality of life was heavily dependent on people's ability to deal with complexity and difference: it suffers when people can only deal with others who are like themselves. Healthy cities can deal with differences—they tolerate ambiguity and can contain frustration. Social competence, not "happiness," needs to be the measure. Isolated social islands (as in the case of gated communities) do not encourage this. There needs to be a focus on "mixture": mixed use, social integration. {Richard's theme here parallels many discussions he and I have had over the years on the analogies between healthy individual functioning and healthy city functioning—with narcissistic pathology and the xenophobia associated with it being the central issues in this case. Healthy cities—like healthy people—can deal with complexity and differences [otherness] in ways that promotes interaction and increases tolerance of stress and frustration.}

The Infrastructure of Urban Well-Being in an Unequal Urban World

Joan Clos agreed with Richard, and stressed the relation of much of this to consumerism. He said that by definition cities are, as in the old saw, places "where you find what you are not looking for." It is essential that people don't just communicate with others like themselves—and that this is often a problem in forms of electronic interaction as on Facebook and Twitter.

Quality of Life in Chinese Cities

Xuejin Zuo, Director of the Institute of Economics, Shanghai Academy of Social Sciences, said that since the reforms of the 70s, the bigger cities in China (like Shanghai and Beijing) have done well economically, although smaller cities have been unsuccessful at creating job opportunities, as they have lacked the economy of scale open to the larger cities. There are 220 million migrants or itinerants in Chinese cities, who, without official registration, lack access to public services like healthcare, social insurance, or other protection. This has led to a whole shadow organization of society in Chinese cities. {It appeared to many of us that Hong Kong had a similar "shadow organization" on its poorest levels—with the existence of "cage dwellers" and those other people living in illegal, undocumented residence structures largely being denied by official sources—although it is avowed that these people are documented citizens of the SAR.} Professor Zuo spoke of the need to make cities more inclusive in the future.

Measuring Happiness in Hong Kong

Lok Sang Ho,Professor of Economics, Lignan Univ., Hong Kong, began by agreeing with Richard Sennett that interconnectedness was an important factor in happiness; but he paid no apparent heed to Richard's sage warning that "happiness" may not be the appropriate—or even the significant—measure. Professors Ho's "happiness study," based completely on direct self-report {an approach already flagged as extremely problematic in such research}, generated findings that were highly suspect: his study found that level of education was negatively correlated with happiness {ignorance is bliss, perhaps?}, and that religious people are invariably happier than non-religious people.

Economic Development and Well-Being: Trends and Transitions in Asia

Athar Hussein, Director of the Asia Research Center, LSE, was wonderful in terms of his presentation's profound depth, seriousness, and importance. He began by noting that urbanization in Asia was larger in scale, faster in pace, and taking place under more severe environmental restraints—and that its character has a direct effect on what cities look like. One doesn't find the historical layering one finds in European cities. He said that the pattern of this urbanization is being set by China and India (which contain 40% of the world's population, and 60% of Asia's). In China, with a stated urbanization rate of 50% (which Athar claims is probably an underestimate), the pattern has been a move from farming, to industry, and now to services; meanwhile India (with an urbanization rate of 30%), the move has been directly from farming to services. Historically, poverty had been rural, but poverty is urbanizing, and rural poverty is becoming urban poverty (or low income). Poverty is more obviously visible in cities, with problems of access to housing, services, etc.. Economic growth in China and India is accelerating, and inequality is increasing more rapidly, too. This is all exacerbated by the appearance of giant cities: there are 19 or 20 Asian cities with core populations in excess of 10 million. The governance of cities coincides with city jurisdictions, but this doesn't fit with new patterns of urban growth, which is organized along different principles. Democratic representation has traditionally been based on place of residence, but this may be importantly unrelated to where one works, or where much of one's life is spent.

Subjective Well-Being and the City

Phillip Morrison, Professor of Human Geography, Victoria Univ. of Wellington, New Zealand, said that his city of Wellington had a density only 100^th that of Hong Kong. He differentiated between the city on the ground (its physical existence, place; the objective, external aspects of city) and the city of the mind (what people think; the subjective, internal aspects). He agreed one must consider the aspects of satisfaction and quality of life, as well as happiness.

Richard commented that getting Blacks and Latinos into the work force is the real issue; and there are cultural patterns that work against it (like the fact that Black ghetto dwellers do not naturally understand making eye contact as an important social connecting, but rather avoid it as an aggressive sign of confrontation, which makes job interviews go less well than they could). We are not paying enough attention to building self-confidence in terms of personal identity, giving people a sense of symbols needed to function with one another.

Athar said we need to eliminate district rules (the hukou system) that have created an underclass of 220 million in Chinese cities.

Professor Ho claimed that the national government does provide services to these migrants, but that local governments lack the resources to do so, and therefore resist it; thus there is a need to promote national funding of local services. He also said ere was a need to with the exploitation of farmers whose land was being taken—that fair prices must be established for land taken from farmers.

SPACE AND DESIGN

Edgar Pieterse (at right), Director of the African Center for Cities, Cape Town, who chaired this session, began by raising the question of how to deal with these issues when the resources are not available. He noted that the response to the Bubonic Plague in London was an example of how health resources shaped city space—but was also the first example of racial segregation of London. He also raised questions about the phenomenon where people know what they should do to lead a healthy life, but do not do what they know they should—a profound human paradox, and not simply a question of appropriate education and knowledge. He urged caution in approaches to reorganizing space and the relationship between people and space, as the schemes professionals consider "good places" do not always do what they are supposed to do—they do not always conform to expectations as planned. He posed the question of what we can do to influence things, while still respecting the spontaneity that is so essential to the life and growth of cities.

Linking the Physical to the Social

Ricky Burdett noted that current growth in Africa and Asia is not being accompanied with the creation of jobs—and certainly not with industrialization. He said that Hong Kong represents the one type of urban form we've examined, with high environmental density. There exists the other pattern, like Mexico City, with endless sprawl. He raised the question of how we need to approach the delivery of services differently across these forms, and how the pace of change affects all this (Lagos and Mumbai are growing at ~50 people/hour). The LSE Cities team has undertaken to re-map patterns of health, wealth, education, etc., in these areas. There are issues we need to understand: life expectancy is rising, with the exception of Africa (in Hong Kong it is 82+ years, in Johannesburg, 51); child mortality is significantly down in Hong Kong. It has long been documented that education, health, and wealth are highly correlated at the upper ends of these scales; poverty, low life expectancy, and high infant mortality all are also highly correlated. In general, growing up in a city is better for one's health than growing up outside one. Hong Kong has a density 3-4 times that of New York, but has a high level of convenience. 97% of daily trips are made by walking or using public transportation (Manhattan has similar numbers, but for different social reasons). In London, £9.3 billion is being spent in the poor areas of east London, as opposed to in the wealthier western areas.

Anthony G. O. Yeh, Head of the Department of Urban Planning and Design, Univ. of Hong Kong, said that there will be another 200 million people moving to cities in China in the next 20 years. The average density of the seven million people in Hong Kong is only 1,100/km², but in its core it is 6,400/km², and the peak density (at the block level) is as high as 400,000/km². The extremely high price of land in Hong Kong contributes to its density. He was the first correctly to mention that while in the 60s and 70s there were many studies examining the relationship between density and pathology {following the famous but usually over-simplified and often mis-characterized rat studies of John Calhoun}, but subsequently it has been shown that there is no real, direct relationship between the two, especially when other factors are controlled for. What is really necessary to look at is the question of "crowding—the psychological feeling of not having adequate space {again, while not ever mentioned directly, this correction of Calhoun's work derives directly from the work of Jonathan Freedman}. Hong Kong is beginning to have crowding issues, with much housing having only 200 ft² to house a family of four. Planning is urgently necessary. In Hong Kong, buildings over 60 stories are considered tall, whereas in Singapore the standard is only 50 stories. Dealing with crowding in Hong Kong is a serious issue, and the government is attempting to plan to mitigate the city's amazing density in several ways: design, layout, open spaces, traffic control, and community facilities—they are building more flyovers, "travelators" (as the escalators are called that move pedestrians and shoppers up the hills to the Mid-Levels), converting more private space to public space (e.g., the ground floor of Norman Foster's HSBC building, which is totally open as a public space). Nevertheless, they badly need professional housing management and education.

Age and Public Space in Hong Kong

Jackie Y. C. Kwok, Assoc. Professor, School of Design, Hong Kong Polytechnic Univ., spoke about a paradigm shift. He described projects near dense, public housing at the city's periphery, which actually had been designed by older residents of the community, and which were having a positive effect on community life and spirit. Nevertheless, these projects are illegal, not having ever been officially sanctioned, and therefore are under constant threat of being removed.

Planning Ahead of Urbanization: Lessons from Mozambique

Jørgen Eskemose Andersen, Head of the Department of Human Settlements, Royal Danish Academy of Fine Arts, Copenhagen, said he had spent 30 years in Africa, 10 in Mozambique, where citizens feel a high sense of security and of investment in their homes; but that the urban poor there still have enormous problems with inadequate infrastructure—water and sewage, in particular. His community there is mostly women, the men off working in Zanzibar, and now in S. Africa. It is not a "slum," although UN indicators would label it so: “slum” is an unnecessary stigmatization of a place like this, with its home builders and home makers. There is a participatory upgrading of these informal settlements: simple plot layouts, done under local control; improved sanitation, with the introduction of concrete-slab pit latrines; road design. Their biggest problem is finding ways to purchase and get title to the land they've built on.

Professor Yeh raised the issue that one cannot do informal development with hundreds of thousands of people, and that land ownership was, indeed, an important issue.

Paul Yip noted that half the households in Hong Kong are living in spaces less than 500 ft², which negatively affects social engagement, as well as physical health. They have reached the state where they have to do something.

Ricky, building on what Richard had said earlier, said we have to provide spaces where complex interactions can happen—places where people can blow off steam. We need green spaces, and he noted the absence of them in smaller communities. "Planners don't go down to smaller scale"; we need to be able to use the space outside. He raised the idea of the need for resilience of space, regardless of scale.

Dieter Läpple (at left) said we need to consider the complex relation between people, buildings and environment—density of interaction, and the social relationships behind it. The issue is how to live together in and transform density into social relationships. Density reinforces all the problems, but informal activity shows us that behind density is a mode of living. It is not just the absence of the state; it is the development of a vernacular state.

Question: given these places are 20-30 km from the centers of cities, what are the lessons that we as planners can learn from informal organization?

Siddharth Agarwal said that this informal organization applies to a large part of the developing world. Can there be a presence of the informal as part of the overall development? Isn't this the human dimension of urban design?

Edgar had one observation: we need to give greater substance to the spectrum of regulation. Does it have to be top down (from the state)? Or can it work with a city as it is energizing it? Furthermore, he asked, how are we to deal with differences of great wealth and great poverty?

DESIGNING FOR DENSITY

David P. Y. Lung, Dean of the Faculty of Architecture, Univ. of Hong Kong, who had led the wonderful Urban Age tour of the city before the conference, began this session he was chairing by relating that in 2003, someone ate the wrong thing, got a virus, pushed an elevator button, the virus spread to others who pushed that button. It was a dense neighborhood, with small air-wells between residences, and it spread rapidly. Eventually, several blocks had to be quarantined.

Hyper-Density as Practice

Reinier de Graaf, Partner at OMA, Rotterdam, said Hong Kong was the default example of high density. It has been booming since the neo-liberal revolution of the 70s and 80s (Thatcher and Reagan), but its growth has been especially sharp since the Chinese economy began booming; and that all of this is very linked to urbanization. Real estate has become a big part of Chinese propaganda. Disparity of wealth has increased: in 1978, 10% had 40% of the wealth, in 2006, 10% had 88% of the wealth. In places like Dubai, the people who rule are also the real estate developers. There are mega-cities that have greater wealth than many countries; and some businesses are actually wealthier than some mega-cities.

Integrating Design and Well-Being

Elizabeth Burton, Director of Wellbeing in Sustainable Environments Research Unit, Univ. of Warwick, understood the social aspects and sustainability of compact cities—the importance of walkability, mixed use, and availability of shopping. I liked her quote, "It's not the density per se that matters, but the form in which it is delivered." Her research apparently indicates an inverted U relationship between density and quality of life, with both low and high density being good. {it was not really clear what exactly this meant, however. Her notion of optimal urban form was quite odd, favoring front yards as promoting urban interaction and community spirit, in a way that flies in the face of most thinking about urban design and the advantages of public realm. And her notion that a grid plan is important because it is better for those suffering from dementia seemed as unrealistic as it was bizarre.}

Unsettling High Density Development in Hong Kong

Wing Shing Tang, Professor, Department of Geography, Univ. of Hong Kong, said that the social is being ignored in the whole situation: where is social justice? We haven't heard about it in the conference so far. Poverty and the Gini coefficient have steadily increased over the past four decades. {The Gini coefficient is an index which measures “the degree of inequality in the distribution of family income in a country. The index is calculated from the Lorenz curve, in which cumulative family income is plotted against the number of families arranged from the poorest to the richest. The index is the ratio of (a) the area between a country's Lorenz curve and the 45 degree helping line to (b) the entire triangular area under the 45 degree line. The more nearly equal a country's income distribution, the closer its Lorenz curve to the 45 degree line and the lower its Gini index, e.g., a Scandinavian country with an index of 25. The more unequal a country's income distribution, the farther its Lorenz curve from the 45 degree line and the higher its Gini index, e.g., a Sub-Saharan country with an index of 50. If income were distributed with perfect equality, the Lorenz curve would coincide with the 45 degree line and the index would be zero; if income were distributed with perfect inequality, the Lorenz curve would coincide with the horizontal axis and the right vertical axis and the index would be 100.” [Quoted from the CIA World Factbook]} People in Hong Kong are living in cage dwellings and partition flats, paying higher rents than in regular apartments. His conclusion is that high density development increases injustice.

Density and Crime

Wing Maas, Partner MVRVD, Rotterdam, claimed that density and crime are actually inversely related, except in Asia.

David Lung said that Hong Kong looks the way it does by necessity—land prices, etc. Hong Kong has learned from the West in the 50s and 60s; now will the West learn from Hong Kong? He pointed out that Hong Kong is actually successful. The question is how do we move forward.

Sophie Body-Gendrot asked how we apply ail this to what we've seen in Hong Kong.

David Lung said that in the 60s and 70s there were all kinds of studies on the local culture.

Reinier de Graaf said that the important relationship is between crime and real estate; that to discuss petty crime is trivial.

Winy Maas said things are based more on fear than anything else.

BEYOND INEQUITY: THE EMERGING LOGIC OF EXPULSION

Saskia Sassen (at right), Robert S. Lynd Professor of Sociology at Columbia Univ., gave the evening keynote. Noting that there had been much talk about inequity, she said there was a need to find narratives which capture the particular reality which began in the 80s. She believes that there are a whole range of conditions that go beyond inequity: that behind them is a systemic dynamic of expulsion. Formerly, the goal had been to bring in people, to create a middle class. She proceeded to claim that the rise of finance was the culprit. What is happening so brutally in the US is also happening more subtly in Europe. An increasing share of national income is going to the top 10%—currently 47%, leading to the expulsion of the middle class. In her view, what is dangerous about finance is that it is about "not money"—finance involves selling money it does not have, which is the opposite of banking. From 2001 to 2008, the amount of Credit Default Swaps rose from .9 trillion to 62 trillion. {I am afraid Saskia is using here an odd sense of "finance": it is as if she is totally equating the arcane—and, admittedly often dangerous (especially because of their lack of transparency)—instruments like CDSs with the whole of finance. The idea that any modern economy—or municipality—can do without finance is not conceivable.}

DAY TWO – 17 November 2011

PLANNING FOR CITY CHANGE

Responding to Global Challenges in Hong Kong

Carrie Lam, Secretary for Development, Hong Kong Government, said that the population of Hong Kong had grown a million people a decade since the 30s, but that their projections say this rate will moderate, and they plan to take advantage of this lessened population pressure—a luxury many other cities do not share. Their GDP per capita is 246,700 HKD; commerce is very important—their container ship business, while slightly down, still makes them the #3 in the world. Only one quarter of Hong Kong's land is built on; 66.8% is wooded, wetland, or park (46% being actual parkland); and 6.1% is agriculture. Their answer to density is to have gone vertical, and the number of skyscrapers in Hong Kong now surpasses that of New York. There has been a heavy investment in public transit, and car use is controlled (there is a fuel tax, a first registration tax for cars, and they have limited parking), with the result that 90% of daily trips are done on public transit. They are proud of their "connectivity," by which they mean their system over overpass/underpass pedestrian walkways. {Although I recognize that this may be an advantage during the intense heat and humidity of Hong Kong's summer months, the fact that it is actually impossible in the newer, central areas of the city to cross streets at street level seems like a tremendous negative to me. Throughout these areas one is forced into what tend to be extended mazes of shopping malls in order to get across any street. In fact, it is easier to get around these areas completely either above or below street level than it is to go out onto the street at any point—which to me is a major negative. The older, less central areas, by contrast, actually have the kind of life at street level I so love as part of a city.} Secretary Lam also catalogued the city's many problems: segregated neighborhoods, monopolistic shopping centers, urban decay, newer towns that are 90% public housing high-rises, overwhelming economic pressures, wall-like buildings, and more. Power generation produces 60% of the city's greenhouse gasses, and 90% of the power consumption is attributable to buildings (and that, largely due to air conditioning); and roadside pollution is very bad, as well. There is a high degree of social disintegration: there is an increasing disparity between the rich and the poor; the urban redevelopment designed to remove people from sub-standard housing has not always has such good results. She described what the CEO of Hong Kong SAR, Donald Tsang, terms "Progressive Development," which is aimed at overall progress, not just economic development: sustainable, balanced development; not just green buildings, but green neighborhoods; providing incentives (in the form of FAR bonuses) for green features (including a mandate that any new car parking facility provide charging facilities for electric cars); and a requirement that a rigorous BEAM assessment be done before the granting of any incentives. The principles are threefold: sustainability (with new building guidelines being in place since this April), livability (e.g., the new Kowloon East development), humanity. They are using economic incentives to preserve historic buildings, giving incentives to private developers to do so, rather than actually buying the buildings themselves. She described one project where they stopped the demolition of an important building by declaring it a "proposed monument," then negotiated a land swap with the developer, who paid to restore the historic building (which is now a museum, open to the public) and built on the swapped land in a way that created a 58 million HKD land premium benefit for the government. In the Kowloon 2 project, the relocated old Kai Tak airport and surrounding former industrial sites (all the manufacturing has relocated to the mainland) is being redeveloped using incentives to convert industrial buildings; but there have been extensive Early Social Impact Studies, urban forums held to discuss plans, relocation choices offered (with a flat-for-flat option, as well as a cash option)—and the whole thing is proceeding in a demand led way. The Secretary concluded by quoting Jane Jacobs: "Cities are an immense laboratory of trial and error..."

Ricky warned that we have to beware of "convenient development," a system that invariably generates segregation by stacking all those who are relocated vertically—losing the horizontal life of which Jane Jacobs was so much the admirer and advocate. Our research shows many residents of Hong Kong very much feel this pressure. At what point would the government respond by releasing more land? {she had spoken of how fiercely they hold onto undeveloped land, and how there was now a freeze on harbor reclamation [much of Hong Kong, and especially the waterfront property of Hong Kong Island], is built on land fill and reclaimed from Victoria Harbor.}

Carrie Lam replied that it is not a question of when, but of how. We are selling off some for preservation trades. But what we have lost are streets and a sense of human scale.

Can the London 2012 Olympics Make East London Healthier

Ricky gave this talk prepared by Andy Altman, Chief Executive, Olympic Park Legacy Company, London, who was unable to attend at the last minute. There has been a critical lack of infrastructure in East London, with bad levels of education and poor health. The London 2012 Olympics is modeling itself on Barcelona, where the Olympics left tremendous positive infrastructure improvements, rather than on Los Angeles, where it did not. £9.3 billion of public money came with winning the bid for the games, and they have begun by depolluting the toxic soil of the chosen site and putting underground the high-tension electrical lines that crossed the site. Their intention is to build up and re-stitch the community, to cement the existing tissue of the surrounding communities, and to deliver social and environmental benefits. The new park th at will be created in itself will be a major benefit; and sports and healthy life style need to be parts of the development plan. Some of the buildings will remain (e.g., the velodrome which will provide the area with an ongoing cycling venue, and the swimming complex, designed by Zahah Hadid). 50% of the housing created will, by law, have to be affordable units—and they will not be placed in the "bad bits," as often is the case, but rather will be integrated into the overall mix. The whole project, of course, exists within the wider context, which is political—and includes the reality of the increasing disparity of wealth and poverty. But we are working to support the development of a healthier lifestyle and more functional community integration.

Housing China's Urban Dwellers: Shaping Cities in the 21st Century

Shi Wang, Chairman, China Vanke Co., which is described as the largest real estate development company in the world, presented a project they did some 20 years ago in Shanghai called City Garden. Although it was 20 km from the center of the city, and directly in the path of the flight pattern from the airport, the project was enormously successful. By 2008, however, the development was in bad disrepair. Mr. Wang said that Vanke, although they had no ongoing responsibility or obligation in the community, decided to invest 25 million RMB to rehabilitate the place. They did so solely to enhance the "reputation" of the company. The repairs were enormously successful, and the community was very pleased and grateful. He said that there was 2.1 billion m² of residential space in Chine in great need of renovation.

Sophie asked about job creation in the Olympics project.

Ricky said that the shopping mall in the area had already seen an increase of thousands of part time jobs, and that the media center which was out for bid would produce many full-time jobs; and that the football stadium, which eventually would go out for bid to a professional club, would also create many jobs.

Tony Travers said that there had been a significant short-term boost: that unemployment was down in Hackney, although there had not been too much effect close to the site itself. They predict a 10-20,000 increase in jobs eventually.

Bruce Ramer disagreed about the LA Olympics: it had been entirely privately supported, had been profitable, and the residue was a substantial programmatic legacy for the city.

Ricky said that the real goal for London was to leverage the public money in order to rebalance the city.

Someone raised the question whether non-permanent resident status (of the "floating population") prevents the providing of housing.

Mr. Wang said that Hukou system has no effect for this year; but that one must have Hukou status to purchase an apartment in a city.

Someone asked what the social profile was in Mr. Wang's project. He said that as a developer, he prefers to bring down walls. City Garden is an open city, without quotas—a mixed use community.

Victor Rodwin said that it was interesting that Ricky had made reference to health data, and he asked to whom it applied.

Ricky said it applied to those outside the site—the five surrounding boroughs. From the end of next year, the Olympic Village itself will house ~3,000 families (~12,000 people)—half of the units will be public low-cost housing, half will be for sale (and they are assuming gentrification).

Tony noted that the area has a substantial public health problem: high levels of smoking, other harmful behaviors. The Olympics is a once in a life time chance to institute some meaningful change.

Steven O'Brien said that attention must be paid to the legacy, the period from 2012-2024, and, in particular, to families. But that he is optimistic.

Richard asked Mr. Wang whether Vanke retained any financial interests in its developments, any management responsibility {although, from the content of the presentation, it was distressingly clear that they did not—which was why they had described renovations as a favor, and just for their "image"}. The answer was that the company can only buy an extended lease to the land, do the construction, and cannot maintain any economic interest. The projects were turn key.

Ricky pointed out that only the government will own long-term interest forever.

A question was asked, given the demand for housing, what do you think the Chinese government will do?

Mr. Wang answered that the central government controls it.

MOBILITY AND URBAN WELL-BEING

Transportation Equity: Istanbul, Sao Paolo, and Mumbai

Philippe Rode (at left), Executive Director of LSE Cities and Urban Age, reported on their work on transportation equity. São Paulo, Istanbul, and Mumbai have, respectively: 19.2, 12.7, and 19.3 million people; $12,000, 12,900, 1,900 GDP per capita; and Gini inequality coefficients of 0.6, 0.43, and 0.35. He showed a frightening, but fascinating graph of education levels in the three cities plotted against distance from the city centers: the highest levels of education correlated with short distance from the center in each of the three cities; unlike São Paulo and Istanbul, Mumbai does offer access to the center even to people of lower education and income. In Mumbai, more than 6 million people a day ride the rail roads. São Paulo has the highest level of inequity and has the most regressive relationship with respect to access to services. São Paulo has "peripheralized" its urban poor, whereas in Istanbul and Mumbai the poor are still better integrated into the urban fabric—although this is changing for the worse. In São Paulo, the poor travel the farthest even for non-work-related trips. Mumbai is an "accessibility machine," but it compromises personal living space. São Paulo has the least accessibility and the highest level of inequality. Istanbul is somewhere in between, with high density, and a high level of mixed use.

Planning for Quality Living in Hong Kong

Jimmy C. F. Leung, Director of the Planning Department, Hong Kong Government, said that over the years, much of the land area of Hong Kong Island has been reclaimed. In the 90s, they realized that rail needed to be the backbone of the system: 75% of their commerce and office space is within 500m of stations, as is 44% of the housing. 89% of the incredible number of 12 million daily trips take place using public transportation; 80,000 people a day use the Mid-levels escalators. They provide incentives to build foot bridges that are open to the public 24 hours a day. Hong Kong is the third largest financial center in the world, after London and New York. They have a major plan, he 2030 Study which aims at integrated land use in an integrated environmental framework.

Ricky asked, in terms of Philipp's presentation, what is your sense of how Hong Kong would look in terms of income groups?

Director Leung said that in the new towns, all are poor. All full-time students, and now some working people (below certain income levels) receive housing subsidies; and there are discounts on transportation for seniors and the disabled.

Ricky asked what the relation of all this was to people's health; is there any testing?

The Director that there is a culture of communal and family gatherings, and said that perhaps the best example takes place on Sundays in restaurants and tea houses, where family groups gather and spend hours together.

Road Traffic Accidents in Indian Cities

Geetam Tiwari, Professor for Transport Planning, Indian Institute of Technology, New Delhi, reported that road accidents have a huge impact on society: 12 million people around the world are killed annually, and the rate is higher in low-income countries. In India, between 1960 and 2010, road accidents increased at the rate of 5% per year up to the mid-80s, but that subsequently they have risen at the rate of 8%, and since the 90s there has been a great increase in the number of fatalities—and it is wise to assume that these figures are grossly under-reported. These accidents result in an annual loss of 3% of GDP, as the most productive age groups are disproportionately affected. The majority of casualties are pedestrians: 30% in London, 45% in New York. The longer pedestrians are expected to wait, the more they run across instead of waiting, and the more accidents. Rumble strips in road ways have the maximum effect in reducing accidents, since they reduce vehicle speeds. Interestingly, increased investment in traffic infrastructure has had the effect of increasing fatal crashes—especially pedestrian fatalities—since it makes possible higher traffic speeds. Geetam concludes that road crashes actually has to do with design—and that appropriate design can have a major positive impact.

Ricky pointed to the sobering statistic that the number of deaths involved translates to one jumbo jet aircraft crash per day!

There was a discussion that ensued that explored the fact that some of the best functioning communities are not the result of planning at all, but rather informal, or at least, spontaneous development. {I attempted to point out that much depends on what is mean by planning: any planning that simply imposes on cities a paradigm of assumed structure almost invariably is destructive to the very communities and communal dynamisms that are so essential to the best aspects of city life, but that well-conceived, public realm planning can facilitate these more spontaneous and natural forces and be supportive of communities, while at the same time encouraging patterns of growth and development that will enhance quality of life. I also suggested that we keep in mind for the afternoon's sessions the fact that healthy community life actually has major positive effects on health, both individual and public. (A rare sighting of the Parrot actually making a public comment at this session is included at right)}

URBAN DENSITY AND HEALTH

Urban Density, Overcrowding and Health

Gora Mboup, Chief of the Global Urban Observatory, UN Human Settlements Programme, Nairobi, said it was important to distinguish between density (which is defined simply as people/unit area) and overcrowding. In the first stage of urban development, high density was associated with problems of health. In Africa, however, there is no relationship. He felts that the Shelter Deprivation Index, which takes into account water, sanitation, and housing—was a much more meaningful measure. Multiple deprivation has a much higher influence on health—and, in particular, exposes children to morbidity. Overcrowding by itself is just not that much of a factor in Africa, except in Uganda. He suggested that there were ways of positively taking advantage of high density: planning can be done which influences increased social integration, connected and compacted cities can improve access to basic services.

Investigating Health and Well-Being in Cape Town

Warren Smit, of the Healthy Cities Lab, African Centre for Cities, Cape Town, said that in Cape Town, low-density is the issue. They have a population of 3.7 million, high poverty, increasing Gini coefficient; 280,000 people live in informal settlements; there is a density of only ~3,000/km², with the poor consigned to the periphery, and no public transportation. They are reeling under the increased pressure of disease—HIV/AIDS, TB, NCDs, injuries, and psychological problems; and conditions are 5 times worse in poor areas. The informal settlements are dense, and they are inhabited mostly by migrants. Health in Cape Town has fallen off the urban agenda. Low-income residents are spatially marginalized, cut off from communities, jobs, and services.

Density and Equality of Public Health Services in Shanghai

Yuan Ren, Professor in the School of Social Development and Public Policy, Fudan Univ., Shanghai, said that changing spatial structure creates a relationship between healthcare and density, with a huge difference between the city core and outer areas, in which the former have far more and better facilities (by a factor of 2 or 3x). This not only lowers access for those in newer communities, it reduces the motivation to go to them. The inequality in healthcare enlarges social inequality in general, and leads to increasing polarization. Migrants have even less access, which is leading to great social discontent.

Jean Woo, who had moderated this panel, said that cities need adequate health services if they are going to work.

Richard Sennett pointed to the HIV/AIDS crisis in cities. He mentioned the Clinton Health Initiative, with its stress on local organizations in dealing with this crisis. Things are not effective on a national level, only on a local one.

Gora said that these were national problems, but that we cannot overlook the local level.

Catherine Kyuobutungi maintained that a system that functions will deal with these things; other systems won't. The same is true with all healthcare providers.

Warren Smit reminded people these things are the worst in slums, where unstable conditions facilitate the spread of disease.

Athar said that access to public space is important. Health is a matter of both communicable and NCD—better sanitation, clean water supply, etc., will deal with the first, but not the second.

Mazda Adli asked whether we know by area how density is tolerated.

Gora quoted an old Senegal saying: "If there is peace in the house, it's not overcrowded; if there is strife in the house, it is overcrowded." It does not have to do with numerical density.

Tony said that the quality of government is going to be important. Health service depends on the capacity to deal reasonably with issues and mount reasonable support. There is a need for some legitimacy of action for governments to deliver services while still determining what is to be done. He then raised the all-important question of dealing with these issues in a top down versus bottom up fashion, about which all too little had been said so far.

Victor asked whether we know anything about health outcomes in Shanghai.

Jørgen pointed to the differences between situations of ownership and renting.

Gora answered that, in general, rentals are far more secure; but, that in studying Addis Ababa and certain other areas, there was no real relationship.

Warren Smit said that some surveys find that renters are worse off.

URBAN DENSITY AND HEALTH (continued)

Social Isolation and Suicide

Paul S. F. Yip, Professor of Social Work and Social Administration, Univ. of Hong Kong, who is also a physician, spoke of the relationship between social isolation and suicide. He said that 40% of the general population of China accounts for 60% of the suicides; and that the suicide rate in China was 13.5/100,000, as compared with 11 in the US and 8 in the UK. From 1981 to 1991 to 2001, suicide has gone from the 8^th to 5^th to 4^th leading cause of death in China. In the over 60 age group, the main factors involved are psychological illness, recent life events, chronic pain, and lack of social support. Suicide is highest in Hong Kong, especially in areas of lower median income and bad unemployment rates. Disconnection in community: physical isolation leads to social isolation. They need to enhance the understanding of the disadvantaged. There is a need for sustainable mental health and general well-being. They need to use space wisely. He suggested that neighborhoods should consider using school playgrounds in off-hours for community programs. To strengthen social support, there needs to be a partnership with family and community. Perhaps it will be more effective to "move the bell curve" and create a better general level of health and mental health than it would be to try to deal directly with the unhealthy tail of that curve.

Changing Urban Lifestyles and Health in Singapore

Kee Seng Chia, Dean, School of Public Health, National Univ. of Singapore, said that the city's population had experienced a drastic rise due to immigration—ethnically, primarily Chinese, although also many Malay and Indian. From 1964-94, their fertility rate had dramatically declined. They have a serious problem with NCDs—diabetes, ischemic heart disease, and stroke (all related to Type II Diabetes)—which are up 11.3% in 2010, in which obesity is the biggest single factor. The change in BMI (Body Mass Index, a proxy measure of body fat based on weight and height) has not been anywhere that dramatic; but this is not a good measure in Asians. A BMI of 30 is usual in the general population, but for Asians it ought to be more like 7! He maintained that, "Asians are obese; they just are hiding it very well.” In Singapore, they have programs in place that should be healthy; but eating is the national pastime—and they rarely walk (usually blaming the humidity). Their urbanized lifestyle he terms "obese-o-genic," with its low level of physical activity. There is a conflict between their health messages and the easy availability of unhealthy food. There is a general lack of awareness of the problem

Neighborhoods Matter: Exploring Spatial Patterns in Older People’s Health in Hong Kong

Jean Woo, Director, Division of Geriatric Medicine, Chinese Univ. of Hong Kong, is a wonderful physician who first continued the theme of the importance of how meaningfully to collect the evidence. She noted that the number moving from rural areas to cities was increasing, as was the number of elderly. (She also noted the interesting finding that the number of hemorrhagic strokes has been holding steady, while the number of ischemic strokes was improving over time.) She said there was a need for an integrated framework that combined personal factors (lifestyle, social-economic status, psychological factors) and environmental ones. We need to be able to assess the impact of different factors on health, because we have to create ways of designing environments, programs, and neighborhoods that will promote health. They have found that where you live matters directly as well as indirectly: walkability (e.g., obstructions and safety of crossings) of neighborhoods affects health; neighborhood design has an important impact on health. {Jean and I agreed on the importance of primary care, and the staggering problem of its inadequacy in the Hong Kong picture. We also had a discussion about the psychological importance of neighborhood and community organization and solidness and the enormous role these factors play in the health of a city. We both had deep concerns that some of Hong Kong’s efforts to “modernize” (e.g., the move toward removing the street markets at the foot of the city’s residential pencil towers) would have extremely deleterious effects on community life and consequently would undermine some of the strength and viability of the city.}

Stress and the City

Mazda Adli, Executive Director of World Health Summit, and Director of the Mood Research Group at Charité Univ., Berlin, claimed that our brains were not optimally designed for urban living. Stress has an impact on our lives—it is an unspecific response of the organism to challenge. He claimed that in cities there was a 50% increased likelihood of schizophrenia and a 39% increase in mood disorders. {I am afraid I have serious doubts about the meaningfulness of these findings, and I have questions about how the data was collected and interpreted.} Mazda did acknowledge that there are correlations, not causality statements: it does not mean that urban living causes these problems. He found that social stress is the biggest stressor, that the stresses of density and isolation were stronger factors than alcohol or diabetes. {His foray into explaining the neurophysiology of stress (the interactive role of the amygdala and of cingulate activation), while interesting, did nothing to establish his conclusion that decreasing density was an appropriate course of action for promoting mental health.} Many of his conclusions did seem well-founded–he correctly understood that increased social contact and decreased isolation were important to both stress management and health in general. {I believe that, despite Mazda’s sophistication in many areas of studying stress and its neurophysiology, he lacks adequate acquaintance with some of the long-established social-psychological truths which are so important in understanding the meaning of these findings and the interpreting of them in ways meaningful to understanding how they relate to larger group, and societal interaction—and, most importantly, to how they function on the level of cities.}

Victor said there were two themes that act across policy intervention: do we target high risk areas or try to change the whole way of living (like Professor Yip’s “iceberg”/bell curve shift)

Paul Yip said that if he had only $1, he’d spend it on primary care.

Jean Woo agreed that the primary care approach to intervening was crucial; it is something all governments know, but which governments don’t do.

Stephen O’Brien asked whether anyone had any thoughts about what they should do about the rapid rise of drug and alcohol addiction they were experiencing in East London. {No one answered his question in the discussion, but it the answer most certainly lies in the kind of neighborhood building and support for community integrity that was understood as being so important to much of the whole question of health in cities.}

Richard Sennett opined that when we feel stress, we are paying attention—which may have some positive implications and value.

MAPPING INEQUALITIES

The Social Determinants of Health and Health Equity in Cities

Sharon Friel, the Chair of the Global Action for Health Network, and Professor at the National Centre for Epidemiology and Public Health at the Australian National Univ. in Canberra, gave the afternoon keynote address. She said that it was all about, “Having freedom to live a life we have reason to value.” It is economic and social policies that drive health inequity, and government seems inadequate to address health inequity. She stressed the need to understand the political economy of health. Whereas life expectancy at birth is 75 years in the U.S., and 76 years in the UK—and even 61 years in India—it is only 54 years in the working class neighborhoods of Glasgow. Her conclusion is that social injustice is killing people on a grand scale. The social determinants of health include power, money, resources, empowerment. It is very much a question of who has the power: participatory government holds sway when communities assert what they need, when democratic (indigenous) control matters—and these things have a positive effect on health. Suicide rates decline with increased community control. {Sharon, whom I liked very much and enjoyed speaking with, was right in line with a theme that has been present in Urban Age discussions from the very beginning: the belief that people being stakeholders in society—participatory members of their communities—is the essential element in increased healthy functioning, whether the metric is health, behavior, mood, social control, whatever.} Sharon maintained that we must embrace complexity and systematic approaches. And we have to get meaningful data, because without it we cannot have a plan to meaningful action.

Urban Africa: A Fragmented Landscape

Edgar Pieterse, Director of the African Center for Cities, Cape Town, said that from 1990-2010, Kinshasa’s population doubled, with a move from 31-38% living in slums. West and East Africa’s populations will double in 20 years, and will remain markedly poor. 62% of the people in sub-Saharan Africa live in slums, and there is a generally poor level of health—and this is very different from the situation in Asia. There are structural obstacles for Africa: governments are opposed to the idea that they need to confront what is going on; there are small economies, with minimal resources; regulations deliberately penalize informality; affiliation is discriminated against; the entry into global markets is done with little leverage; costs are born by the large number of poor people. The urbanism of the region is extremely splintered: there is a neglect of slums, while attention is paid to the elite urbanism (which takes place in gated communities). Despite the prospects for growth, there are no mechanisms for dealing with this disparity. What is needed is resonant design, utilizing both top down and bottom up approaches.

Poverty and Inequality in Hong Kong

Lai Shan Sye, representative from SoCO (Society for Community Organization), who substituted for SoCO’s Director, Hei Wah Ho, had been one of the leaders of the Urban Age tour of illegal housing in Honk Kong the day before the conference. She said that there were 320,000 people in Hong Kong living illegally in cage dwellings or cubicles. These people are Hong Kong residents, almost all single, living in 1.5 m² of bed space, paying rents that are higher than rents for regular apartments. The reason is partly due to a decline in the supply of public housing (which has gone from 50,000 in ’01 to 15,000 in ’11).

Health Inequalities I India’s Cities

Siddharth R. Agarwal, Director, Urban Health Resource Centre,New Delhi, said that in India, affluent and deprived areas are closely juxtaposed. 50% of Mumbai’s population lives on 6% of its land. In Delhi, people consume 225 liters of water per capita per day, while in its slums, the consumption is only 50 l; in Delhi, 40% of its poor have no toilets. There are 100 million designated poor, living on $1.25/day. 30-35% of the slums in India are not registered; and this makes a huge difference, because those on the official lists have much better access to health care (as well as other services). Many cities suffer even more because of lack of infrastructure. Organization of slum groups enhances the access to health care by “making the miserable visible.”

Philipp Rode asked whether there was any evidence we’ve tackled healthcare inequity in the absence of dealing with income inequity.

Sharon said the income inequity is not the only thing in this—the relationship is not a linear one.

Tony Travers noted that Glagow has been so good at rebuilding itself, that he wondered if the life expectancy disparities have improved.

Sharon answered, no. No one has figured out why Glasgow is the way it is—historical factors, cumulative social disadvantage

Dieter said that there is strong connection between health and inequity, and he asked whether there are any successful examples of breaking the relationship between social inequity and health inequity

Edgar said that part of the Latin American story is a long tradition of social movements, in which communities drive the vision—20-25 years of social struggle. If we look historically, when movements of the poor achieve a degree of consolidation, there is a real influence they manage to exert. These conditions simply do not exist in Africa countries.

Victor asked why is it that Africa is more splintered, more fragmented.

Edgar referred to Simon Marvin’s work and the idea that infrastructure is tied to the capacity to pay, and he described the “partial coverage” investment structure in Africa. To really understand inequity in Africa, we need to use multiple deprivation indices. He re-emphasized the importance of bottom-up approaches, because it is necessary for people to define for themselves what needs to be done.

Catherine Kyobutungi noted that some of the structural issues have to do with governments refusing to admit that the problems exist.

Edgar said that there is a major omission: there are shifts happening. Slums are the centers for the seeds of political opposition. There is a fear on the official end that this represents the seeds of their own demise—land re-distribution, and other things that will upset the existing order.

Ricky said that it is a question of “invisibility versus research”

Tony said that governments need to “boost” cities—to show them in their best light instead of just emphasizing their problems. This always threatens power elites everywhere. In the future the question will be how big a role the redistribution of resources will play in all this.

Challenges of Inclusion

Richard Sennett attempted to draw together some of these themes. First, Hong Kong in relation to other Urban Age cities: Hong Kong with its rapid evolution, great wealth, and peculiar combination of problems really represents a unique case. With respect to the question of “what’s urban about inequity?”: the urban effects on things like asthma represent a new form of inequity; there is inequity of access, leading to resources becoming increasingly difficult to obtain as one descends the social ladder. Saskia’s ideas about expulsion relate to making some people increasingly “invisible.” The possibilities for upward social mobility are decreasing—they are far less than they were 100 years ago. As for the question of social isolation: quality of life in cities depends on dealing with this issue, which he asserted is spoken to by his notion of “social competence.” As for the question of the role of design: there is a seeming contradiction in the idea of designing informal space (and he here discussed the example of the British pub); there is the idea of the design of the fabric of cities—e.g., the vertical city, with spaces in between buildings that allow people to be sociable with strangers (but here the problem of the privileged status given to the vertical buildings over that of the street space may be a real issue); as for the important distinction between density and overcrowding, density is a social phenomenon, crowding is not. And his personal comment about medicine providing a model for urban planning: when William Harvey discovered the principle of circulation of the blood, he provided a model for urban design—cities, like the body, need circulation, and this has all but disappeared, only to be replaced by something more mechanized (and here he used Corbusier as an example).

EVENING KEYNOTE

Governing the Healthy City

Christine K. Loh, Chief Executive, Civic Exchange, Hong Kong, said that if we‘re talking about governing a healthy city, the process has to be people-based. In discussions of political economy and urban form, it is unavoidable to talk about the politics. Hong Kong is very wealthy: we have a $9 billion annual surplus, which is expected to continue for the next 5 years. Most of it is based on the fact that whenever there is a sale of land or a change of land use, there is a land premium which must be paid to the government—and land transactions take place at an incredibly high rate in Hong Kong. Nevertheless, the money does not go into the general government account, but rather to a special segregated account which can only be used “to pour concrete.” Hong Kong does make other investments, but they pale in comparison to the money spent on building. Can we imagine prosperity? It could come from some other kind of investment. As for what is in the minds of the elite who are actually making the decisions about what is good for the community, there is always the fact that it is difficult for the elite to consider sharing wealth. Our economy is up 55%, but income has remained unchanged. The issue is how to create conversations “on the ground,” how to cure the “blindness,” and how to move to a conversation based on the evidence.

CLOSING REMARKS

Wolfgang Nowak exhorted everyone that we all should become advocates for the invisible. “We always have to work to make the world a better place, even knowing that it will never be the case.”

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