Blog | Healthy City Design Congress 2024 Recap: Can we align health, equity, and sustainability? Evidence, economics, and engagement

Opening the session “Neighborhoods as a foundation for a just, green and healthy City”, Isadora Spillman-Schappell, Cities Programme Manager at the UCL Institute for Innovation and Public Purpose, called for a new type of economics based on the common good to address global polycrises. Next, Ricky Burdett, co-chair of the Council on Urban Initiatives and Director of LSE Cities, discussed how housing and health should be addressed together through an integrated approach. This integration can be broken down into two parts: the process aspect, including voices, ambition, and alignment, and the technical aspect, through designing and weaving elements of the city together.

Dan Hill, Director of the Melbourne School of Design, opened the panel discussion by sharing the history of Sweden’s streets. The rise of the automobile has profoundly influenced urban form, sparking debates on the right to space. Recently, Sweden’s innovation agency launched a mission to ensure that every street in Sweden is healthy, safe, and full of life by 2030. Together with politicians, civil servants, and children, the agency developed a new value model for its streets. Dan also shared examples of creative spatial adaptations, such as cases that have met demographic shifts with both innovative planned design features and organic community responses. From Swiss villages to Japanese towns, these cases maintained low building height yet fostered conviviality by freeing up their streets for human needs.

Sunand Prasad, Principal at Perkins & Will, reminded us that today, we have the intellectual and scientific understanding of how to build low carbon and healthy homes, citing the numerous existing guidelines.

Beyond health and sustainability objectives, Sunand underscored the challenge of achieving equity. While Liverpool is home to the UK’s first social housing, he noted how the initiative “was done out of enlightened self-interest” to prevent the illness and squalor from poor residential neighbourhoods from spreading to the rich. He compares this to today’s climate crisis, expressing his concern that “there is no such self-interest argument” from the powerful. So how do we develop one, or circumvent the need for one?

Yonette Thomas, CEO of Urban Health 360, provided an epidemiological perspective on healthy neighbourhoods, detailing a compendium of social and environmental exposures and subsequent health impacts. She extended the discussion, urging us to consider healthy homes and neighbourhoods in the broader context of the Sustainable Development Goals and human security. She emphasized the importance of considering infrastructure when building or retrofitting homes, including sustainable energy sources, food security, and digital access. These components are essential to ensuring that transitions and improvements benefit all.

This panel touched three key topics that echoed throughout the congress: evidence, economics, and engagement.

What is the role of evidence?

Inconsistencies in how evidence is perceived and used often hinder efforts to promote health through the built environment. A paradox exists: while we have an immense body of evidence, decision-makers frequently cite a “lack of evidence” as a reason not to pursue new initiatives, even as policies are regularly implemented with little to no proof of effectiveness. Researchers continue to address knowledge gaps, yet it remains challenging to produce the type of evidence that is context-specific and actionable. This broader issue of knowledge translation was highlighted at Healthy City Design, where multiple attendees stressed how we already have ample evidence linking urban form to health outcomes, as demonstrated by several toolkits, sourcebooks, and standards. However, that presenters shared novel research ranging from modeling health impacts to characterizing user experiences indicates that there is more to unpack for implementation. As Sunand noted, "the devil is in the design.” The impacts of individual projects depend on their implementation in harmony with surrounding environments and community needs.

Requiring highly certain evidence before taking action may stall the transformational investments needed for healthy and sustainable cities. Instead, we need an evidence-informed, learning-by-doing approach, with built-in mechanisms for iteration and analytical tools that embrace uncertainty. New arrangements, such as embedding researchers in councils and increasing cross-departmental collaboration, may help strengthen the links between research and action, with attention to fostering a culture of experimentation. We must build new methods that embrace uncertainty while leveraging existing evidence to achieve ambitious goals for society.

Who is leading the economics?

The need for and perceived validity of evidence often depends on the audience or actor. While decision-makers across public, private, and the third sectors increasingly consider social and environmental factors (e.g. the Sustainable Development Goals, wellbeing, distributional impacts), fixed budgets and short-term impacts to the funder often override these broader criteria. For example, local governments and private investors frequently demand site-specific projected return on investment to justify spending. This approach often overlooks spillovers and immeasurable future impacts. By focussing primarily on developing economic justifications to convince public sector leaders and attract private-sector investment, too often we reinforce a culture of neoliberal value modeling and budgetary limitations rather than bold investments for the common good.

A common good approach does not preclude economic considerations, but places public value at the forefront. For example, highlighting economic benefits, such as rapid cost savings from improved indoor air quality that reduces illness, can improve awareness of co-benefits and catalyse action. At the same time, we must develop mechanisms to shape markets to prioritize common good outcomes, such as health and wellbeing, as goals in themselves.

In the housing context, the affordability crisis and failure to provide housing as a human right beg the need for entrepreneurial states – governments that can shape housing markets to deliver common good outcomes. Just as attendees shared the understanding that cities should be designed to promote health, we ought to ask how markets can be designed to promote health. This will require reassessing relationships with public health and planning practitioners and developers. How can the different levels of government shape development to promote the building blocks of health such as housing while staying within carbon budgets? While we have examples of integrated design, the tools need to be adapted to local contexts.

The dominance of private investment in housing markets surfaced in several sessions, though how could governments shape and incentivize private actors to build quality affordable housing was less clear. Programmes such as UCL’s Institute for Health Equity and conference knowledge partner TRUUD (Tackling Root Causes Upstream of Unhealthy Urban Development) Consortium are exploring this, investigating how to influence real estate investment decisions to promote health. Beyond incentives or regulation, we need more consideration on how to build the partnerships needed to tackle housing issues. Successful partnerships not only require shared goals, but also shared commitment, risks, and rewards. This requires going beyond discussion of a public-private binary to consider the role of social developers, philanthropies, and pension funds. How do we effectively engage these actors and empower excluded voices?

How might we promote meaningful engagement and co-creation?

Co-creation and participation are pillars of the economics of the common good. Yet time and time again, efforts fail to deliver the outcomes asked or promised by communities. Furthermore, as Sunand explained, even “well-evidenced" initiatives such as low-traffic neighbourhoods can experience backlash. What evidence was missing and how can we address these deep-rooted differences? Sunand pointed to Ireland’s abortion referendum as an example of patient social movements. Yonnette agreed that deep engagement in these discussions requires persistence, sharing that “history, like context, matters.” Dan suggested that models such as citizen assemblies may support democratic decisions.

We saw new models of community engagement, from integrating community voice into health impact assessments to having designated neighbourhood managers. Attendees questioned the limitations of consultation and engagement when power could be reallocated directly to community, such as through creative community-led initiatives (such as Repowering London, Nature Vibezzz, and many more). This is growing in recognition among government officials:

Genuine co-creation can help realise the equitable design of our cities, making them appropriate for children, for people with disabilities, for gender minorities, for newcomers, for all.

Together, these themes reflect three vital elements needed to address health upstream, set forth by the UK’s Chief Medical Officer, Chris Whitty: political will, evidence, and a long-term view. Many ideas were shared throughout this conference which can help bolster these elements and direct future work to create healthier cities, neighborhoods, and communities.

Authored by:

Cassandra Mah, Cities and Innovation Associate, UCL Institute for Innovation and Public Purpose.

Isadora Spillman-Schappell, Cities Programme Manager, UCL Institute for Innovation and Public Purpose and CUI secretariat member