Building Healthy Cities

Excerpts from a conversation with

Leonard J. Duhl, M.D.

by Joe Flower


From the Healthcare Forum Journal, May-June 1993, Vol. 36, #3.

International Copyright 1993 Joe Flower All Rights Reserved





We talked in his cramped, book-lined, ex-carport study with the laden plum tree bowing its fruit over the garden gate outside. He's small, tweedy, quiet-spoken, a university professor, a Menninger-trained psychiatrist with a warm and confidential manner. He didn't look like a world-shaker. Yet Len Duhl has had more positive effect on people than any of us could ever hope for: one basic idea in one talk eight years ago has spawned a program of grass-roots social change - the World Health Organization's "Healthy Cities" program - that is now growing in over a thousand cities around the world.

In a 40-year career in government and academia, in the Public Health Service, at NIMH, at HUD, writing speeches for Bobby Kennedy, organizing hearings on the health of cities for Senator Abraham Ribicoff, teaching at the University of California at Berkeley, consulting for WHO and UNICEF, Duhl has shaped and expounded that one idea: if you want healthy people, you have to build healthy cities, livable cities with decent housing, clean water and air, recreation programs, community organizations, and strong families. They must all knit together.

To do this, you have to change things from the ground up. He says, "The policies that run our society, and in fact run our health systems, are not health policies - they are business policies, they are profit policies, they are power policies." He has presented this view in scores of papers, in lectures at dozens of universities, in consultation with governments and international organizations around the world, and in 15 books, including his most recent, Social Entrepreneurship of Change (1990), Urban Condition II (1993), Health Planning and Social Change (1986), and City of Health - Governance of Diversity (1992).

Our talk ranged from the personality characteristics of people who effect social change to the estimated 200 million children struggling to survive on the city streets of the world. We started by talking about those experiences that brought him to his powerful point of view.




Getting involved

In the midst of my psychiatric training, during the Korean war, Uncle Sam tapped me on the shoulder. I volunteered for the Public Health Service, and got assigned to Contra Costa County, California, working for Henrick Blum, who is now my colleague at the university. Among other things, we did a massive X-ray screening survey for tuberculosis and other lung conditions. And we did a study on the people who didn't get X-rayed. The populations that needed it most didn't get X-rayed. The ones that didn't need it, because they were pretty healthy, did get themselves X-rayed.

The ones who didn't were poor; they lived in north Richmond, an unincorporated slum. The Health Department had a hard time there, but the Quakers - the Friends Service Committee - did well. They ran Neighborhood House, doing community organization and development. They facilitated a process by which people got involved, and suddenly the community started asking for services. During the two years I was there, we set up daycare programs, well-baby clinics, housing programs, community organizing chicken dinners, and a legal service, all coming from the Neighborhood House and the community organizers. The more we worked, the more positive was the response of the people to the Health Department. I found that if we just did a health program by itself, we'd get little response from this population. But if we did community organization and got everybody involved, we got a lot more response.


After I finished my psychiatric training at the Menninger Clinic, the National Institute of Mental Health asked me to do long-range planning. I didn't know what long-range planning was. I had the audacity to read the Mental Health Act, which said for the Institute, you are to be concerned with "the care, treatment and rehabilitation of the mentally ill, and the mental health of the population of the United States."

That meant, on the one hand, that I had to look at the disease model. I had to look at the onset of mental illness, its treatment, the patient's rehabilitation and return to the community, or death. And that was all one continuum. As I looked at that continuum, what I got was a real shock. I found a real differentiation by social class. Poor people ended up in mental hospitals, while well-to-do people ended up in psychiatric therapy. I also found that different cultures had different ways of treating illness. Some were religious or spiritual. Some of them never came into the psychiatric system.

On the other hand, I had to look at the mental health of the whole United States, which meant the life cycle, what we jokingly called "from conception to resurrection." I had to look at everything that impinged upon people in the life cycle, what taught people how to be healthy, what taught them how to get sick.

If you have a child who learns very early to be depressed and to withdraw into his room whenever there is a crisis, later on in life he will get depressed. If a girl is told in junior high that her first menstruation is bad, she might get sick and end up having menstrual difficulties for many years to come. These are learned strategies.

I found myself asking, where do we learn them? We learn them in the family, from peers, from the local community, the schools, the work situation and on and on. As I started to look at every one of these institutions cutting across both the disease cycle and the life cycle, I said, "these institutions make up the urban world."

The Urban Condition

In 1962 we had a conference at the annual meeting of the American Orthopsychiatric Association. That meeting brought together a lot of people from different disciplines to present issues about the city. What we came up with was the book The Urban Condition, which was basically the first book that looked at health and cities in a systemic and ecological way. We felt that the only way to deal with physical or mental health was not by looking narrowly at psychotherapy, or treatment by drugs or medication. Most of the time these were symptomatic responses. We had to look at what created the illnesses and perpetuated them. If you could begin to change policies in other areas, you could have healthier people.

It amazed me to discover, when I first got into planning, that planning for the separate areas were done independently of each other. Resources were allocated in a political process based upon power that had very little to do with human needs.

During 1963 and '64, my office concocted a plan to pull all the resources together from multiple points of view. We proposed to the President's commission setting up HUD that they should develop a set of "Demonstration Cities" in which we could show that by doing planning and policy holistically, we would do better. President Johnson said, "I've had enough demonstrations. Let's call it Model Cities." So they did. That was the origin of the Model Cities program.

We found that just as the poverty program didn't achieve what some of us wanted it to achieve, in reallocating resources to the poor. Neither did the Model Cities program, because, in the words of the eminent late Mayor Daley of Chicago, "Why should I pay for undermining my own political strength?" If you put in all sorts of different groups in the process, and especially if you also put in the groups which included the consumers, you screwed the process up politically from the big-city politician's point of view. As a power base, it wouldn't work for him. The politicians fought this process.

I got very depressed about the unwillingness of the society to do much. By 1968 I had come to Berkeley to teach city planning and public health. I didn't know that there was another phase of this to come, or that it would take 17 years to get to it.

Healthy Cities

In 1985, Trevor Hancock, a very bright, alert, Canadian physician, held a conference in Toronto called "Beyond Health Care," on the tenth anniversary of the publication of the Lalonde Report. That report had essentially said that, in Canada, "We have to put less money into medical care, and more money into personal services and the environment." It had developed out of work that was done in Quebec, which was a result of consultations with my old boss Henrick Blum.

At the 1985 meeting, Hancock brought in everybody but the medical care people and said, "What can we do about health?" I gave a paper called, "Healthy Cities." I said that the new direction for health has to be looking at the city as a whole - we had to look at health promotion and the prevention of illness.

Ilona Kickbusch, a young woman from WHO, picked it up and proposed the idea to WHO's European division in Copenhagen. Within two weeks I was whisked to Copenhagen, where I spoke before their staff.

The response was depressing at first. One staff person said, "Heck, if you want to put a sewer in, you just bulldoze it through." But then Dr. Astvall, the executive director of the office, said, "This will be our program for the next five years." With that everybody got interested. Since then it has become the major program in Europe.

Kickbusch, with her tremendous energy, got it going. She started to visit everybody in Europe. She got permission from the federal ministries to go directly to cities, and slowly picked out two cities in each country to work with. Hancock, myself, and John Ashton from Liverpool, as well as a few others, became the consultants to Europe, shuttling to the Continent eight times a year from 1986 through '88.

Slowly the program took off. The WHO program is now officially set up in some 36 cities in Europe alone. There are sister cities in all of Eastern Europe, so that Stockholm and Helsinki are helping St. Petersburg, and Vienna is helping Prague. Many countries have spun off their own national networks, separate from WHO. As an example, there are 70 cities involved in just the province of Valencia in Spain.

Meanwhile, Trevor got some money to wander Canada. One of my students, Real Lacombe, left here and went back to Quebec. Now he's got about 69 or 70 cities going in Quebec. The Quebec and French cities adopted all of the Francophone cities of Africa.

Australia, New Zealand, and finally the United States, picked it up. Joe Hafey from the Western Consortion of Public Health went to Europe, spent six weeks there looking at the program, and now we have a program started in California. A group of nurses started a Healthy City in Indiana and got money from the Kellogg Foundation. More recently, Boston took off. The U.S. program is coordinated by the National Civic League and the U.S. Public Health Service.

The most recent example has nothing to do with the Healthy Cities program. In Atlanta, Jimmy Carter has been trying to improve the quality of life of the city. He doesn't call it health, he calls it "Habitat." Other programs such as "Headstart," new government, new businesses, and "New Enterprise Banking" are other Healthy City type programs. It is happening not only in health, but in field after field.

Things fall apart

The important question is: Why is it happening now? We have been operating, until recently, in a model based on top-down, hierarchical control. But suddenly several things have happened: One, communication has increased tremendously, so everyone knows what is happening. That probably is the major reason why the Communist bloc in Eastern Europe fell apart. Two, communication is complemented by transportation, and at the moment there are no real boundaries that exist any place in the world.

There has been a revolution in this country since 1954. The "Brown vs. the Board of Education" court case was the turning point. People who had been oppressed can now speak up for themselves. Since that time, everybody speaks up to the point where we all consider ourselves victims. We are all complaining. We are all saying that we have to get into the act. We all want to participate. We are all rejecting the "top down" model of control.

Every country in the world is breaking up. The most powerful institutions emerging around the world are cities. At the same time, the rural world is breaking up - everybody is moving into the city. I include suburbs as part of the city; it's an urbanization process. Some places are moving as rapidly as Sao Paolo, which is growing at the rate of 450 thousand people per year, and Mexico City, at 575 thousand per year. There are mega-cities that are growing to 20 and 30 million. What's more frightening is that cities that used to be five and 10 thousand are now 200, 500 and 800 thousand. There are 400 hundred cities with populations of over 1 million in China. They take up rural land and are large polluters of the environment.

The bulk of cities in the developed world up to now were planned. Now, the bulk of cities are unplanned. They are the informal sector, they are the squatters, they are the poor, the favelas of Latin America and the horrible slums of Asia and Africa. We now see UNICEF reporting 40 thousand kids dying every year of diarrhea. We are finding 200 million kids living on the streets.

I'm spending a lot of time with UNICEF about street kids. There are programs that are good enough to reach maybe 50 thousand. A "great" statistician screamed at me and said I was off by 100 percent, so I said OK there are good programs that reach 100 thousand - out of 200 million. The kids have no place to go but the streets and the army. The families break up. Illness rates are immense. Infant mortality rates are as high as 50, 70 and 90 per thousand. The death rates are high in these places, from the diseases of civilization: murder, suicide, alcoholism, drugs.

How it works

The first thing that happens when the Healthy Cities program develops in a new place is that some persons assume the responsibility of bringing together all segments of the community to deal with the issues: the business community, the government, the voluntary sector and the citizens themselves. Most often there is approval by a city council. Secondly, people with all kinds of expertise get involved, in what WHO likes to call "multisectorality" and "multildisciplinarity." This, in itself, is chaotic because not only do you have confusion, you have different languages. The languages of medicine and psychiatry are different from the languages of education and economics. So people spend a lot of time getting to know each other.

Then there are "vision workshops" in which people are asked, "What kind of city do you really want?" My personal surprise is that the clearer I am about what a Healthy City program is, the less likely a community is to develop it. The fuzzier I am in what a Healthy City is, "A Healthy City is what you want to make it," the greater the odds are that they will start.

The various participants define the program. All I say is that you have to start someplace. You have to begin to look at it in an ecological and systemic way. You have to involve people. You have to start thinking of values of equity and participation. Beyond that, you can start wherever you want.

Some cities start on the environment, on pollution, on smoking, seat belts and the quality of life index. Some have government operations, some have newspapers, big organizations, housing. Barcelona linked it to the Olympics. Glasgow linked it to developing itself as the cultural capital of Europe. It is being done every way.

In Europe, WHO facilitates. In California it is the Healthy City office in the State Health Department. We put no money in it, unlike the Model Cities program or OEO. We bring people together. As part of the larger process, we are bringing people from all over the world to San Francisco for the First International Healthy Cities meeting in December 1993 - 1500 people. The idea is to get people to start to talk with each other. What we have learned at the smaller multinational and national meetings is that most of the time people like to do show and tell. They learn from each other. They say, "Oh gee, you got a bank in your town? How did you get started?" They get the information and they take off. The next thing you know, a bunch of women get together, they make a bank, they give out loans of $250. In the southern hemisphere $250 can start a health clinic, or rebuild a house.

Our success is our process: getting people to talk to each other about what it is they are doing. It is a new kind of government, in a way, the governance of diversity.

The health care industry

The health care industry has to be a partner in the process, but not in charge. There has been a history of hospitals getting involved. Michael Reese Hospital in Chicago got involved in the first urban renewal development back in the '50s. The University of Chicago got involved in its neighborhood. There is a whole set of examples of people, institutions and corporations, like Coca Cola and Johnson & Johnson saying, "In order to survive, I'd better do something about my neighborhood." That's one way - getting involved in the community because the chaos is invading my turf.

I am also interested in those areas where nobody's turf is invaded. How do you fix up the parts of Oakland that nobody cares about because there is no business and industry there? There are black churches. They don't own the turf, but they can start organizing.

The concept is universally applicable, but the way it is applied is dependent upon the local scene. Sometimes it's around a health system or a health department. Sometimes it's social service or a business. In Los Angeles, Peter Ueberroth is trying to put the post-riot area of Los Angeles together the way he put together the L.A. Olympics. At the same time there are a lot of people struggling on the community level. The Healthy Boston project is using the hospitals and medical schools as the core, because that is the big industry in town. Some cities will do it around suicide, or murder in the streets, or drug busts.

In Cali, Columbia, they started by providing building materials for poor folks in the favelas. Now providing building materials for the favelas is the largest business in town. They have a thing that looks like the Price Club where you can buy food cheaply. The man who started all this, a graduate of the School Of Public Health at Harvard named Rodrigo Guerrero, is now the mayor of the city.

One example of the way health care can get involved is the City of Hope hospital in Duarte, a little town in California. Terry Fitzgerald, who is running the Healthy Cities project there, decided to do a "wellness" book so that people would know where to get help to stay well. We were doing something here for Berkeley through the state Department of Mental Health. We produced a book and we started to test it out in Duarte. The City of Hope got involved up to their neck because they said, "This is our town, and health care is a big business in town." The hospital, as part of the larger process, becomes involved in, and learns things, about its own town.

Kaiser in Watts had a similar experience. Ophelia Long, who ran it, was concerned that the nurses may get raped when they get off work - the neighborhood is awful. So she set up patrols. She started child guidance clinics, family help centers and bus services. She did an anti-graffiti program. She involved everybody in town. The surprise was that the hospital discovered there was a net gain for them - they didn't lose nurses, and patients could come safely.

Long took this idea and went to Oakland Highland Hospital here in the Bay Area, which had lost its accreditation and had lousy morale. Once again, she got everybody to participate. Within six months, she had the hospital turned around, and got it re-accredited. The people who worked in the hospital painted it. She went out to the black churches and said, "How come there's no ministry help here? How come there are no volunteers here?" Now she's got black ministers in there, volunteer help, and a counseling service.

Governance of diversity

In the '60s there was a famous debacle at Lincoln Hospital in the South Bronx. There were riots at the hospital and demands for more pay. The volunteers wanted to be paid, they were stealing things. I went there. I remember a psychiatrist who said, "I have fought my whole life as a psychiatrist to become accepted by the medical community. I'm now chief of staff of this hospital." He carried a stethoscope around his neck to show he was a real doctor. He said, "Now I got to go talk to those people?" The old model said, "We can ignore those people." Then suddenly it became clear, "I can't even practice medicine anymore unless I am involved with all the people in the community, because we are in fact in a community and they are as much part of the hospital as we are." This was very shocking to the medical profession. It still is.

When Bob Montgomery, at Alta Bates in Berkeley, wanted to put up a parking lot, he discovered the community was against him. He spent about two years negotiating with Berkeley citizens.

About 10 years ago there was an editorial in the New England Journal of Medicine that said, "If a patient comes in with a set of questions, the patient must be neurotic." Now they are coming in with a thousand questions, and they are saying, "Hold it. Before you do this I want an outside consultation. Do you have an ombudsman in this hospital?" As with all institutions, we have to ask "Who runs this place?" What has happened is that the old "top down" control has disappeared. The whole world is breaking up into parts. That is why I use the word "governance of diversity." We now have to learn how to govern diverse institutions.

Family therapy was the first medical model that dealt with this in a coherent way. Family therapists have learned that families are systems.

The medical profession made the assumption that "the disease" was the problem. We do not want the patient to be the problem, because the patient will ask questions. Now we discovered, this doesn't work. Healing is not working with patients in isolation. It involves the family. And it is more than the family, it is the community in which you live, and the situations in which you work.

This is a revolution in our thinking, a paradigm shift that says unless we think systemically, ecologically, multidisciplinarily, multisectorily, we are not dealing with the core questions.

But that's not "the way things are done." Not only is planning done segmentally, so is the research, the research literature, the training in the university - and then we wonder why nobody can get along together.

We have to figure out how all these fragments fit together holistically. That is what Healthy Cities is all about. We now have 1000 cities involved in the process around the world, in every stage of development.

I am not asking the health people to take on the world. If you are in the health business, stay in the health business. But let's start looking at the health business realistically. The health industry is spending most of its time, and that includes our national leadership, asking what kind of health insurance plan we should have. Even if we have a perfect health insurance plan the health of people in the United States won't get better. The deliverers of service are being blamed for the ill health of the United States even though they might run a perfect program. In fact, there are places where there are great health systems. But we doctors have too long claimed credit for the health of the nation. So as long as there is a fragmented society with low priorities for people who are on the outside, the health professions are going to be blamed.

The data show that improvements in the health of people around the world came from the rising standard of living, especially the education of women. What do we do in the health business? We have to start asking, "How much money do I put into medical care, in rehab work, in health promotion and prevention, in cooperating with the neighborhood around me, the community, the schools? What is the right balance for my community and for my institution? Who do I collaborate with?"

You may be an excellent deliverer of health care, but if you only deliver health care and don't do any prevention you may be in trouble. If you don't do something about your neighborhood, your nurses may get raped, and you may have a community that overloads your emergency room because there are no other services available in the community. Patients go where there are services.

The city has to do something. You have to stir the city up to do it, and you have to collaborate with them.

Social entrepreneurs

There is, as I put it in a book title, a "social entrepreneurship of change." If you go out and look at these cities where things are happening, you'll always find one person making it work. Terry Fitzgerald, in Duarte, found herself suddenly meeting people she had never met before; the environmentalists, the sanitation, water, and sewage people, the health department, the hospital, schools and businesses. She became the local social entrepreneur.

A priest in Milan had been given 18 acres of land to build a hospital. He said, "I could build a hospital, or I could turn this land into a new town in town." He developed it, and it became the fanciest part of Milan. He makes enough money from that development to run four hospitals that are totally free and are the best hospitals in the country.

Dixie Lee Petry, in Knoxville, was worried about her children in school. She started off by developing a toy program. She then discovered that the kids were hungry, so she started a food program for kids and for their families. She involved the supermarkets and the restaurants in town. She got the city to create a food policy so that nobody will go hungry. Then she started a low-cost housing program in the city.

What it takes

These entrepreneurs are interesting to me because they have done "lateral transfers" in their own development. They look at new worlds with different eyes. They are not stuck in a rigid civil-service mentality of saying, "This is the way we do things."

I am an example of these "lateral transfers." I started out in psychiatry. Then I shifted to public health. Then I finished psychiatry and moved to long-range planning. Then I shifted again and helped develop the Peace Corps. Then I shifted into Model Cities, Housing and Urban Development, and the poverty program. I then became a professor at Berkeley in city planning, public health and psychiatry. Then I went back into working with cities.

When you do a lateral transfer, you shift from field to field, but you bring your core competencies with you. An old friend of mine, a professor at MIT named Don Schon, talks about the "transfer of metaphor" from one field to another.

Risk taking is probably the most important thing in change. In order to take risks, you have to be secure. You have to know that you can come back to your own base. Innovators have to have enough security to be willing to take risks. That's why it's hard to expect the very poor to take risks. You need social entrepreneurs. They are no longer teachers or bosses, but coaches. They are coaches, not of a football or baseball team, but of a basketball team. Basketball is free floating - whoever has the ball is the captain for that moment; he determines who he is going to throw it to. In football you know the complete plan for each play in the game. It's the difference between an orchestra playing Mozart and a jazz group. The jazz group always plays together, but they have no score, or only a minimal score. You have to be willing to take risks, to try new things, to connect to others, to be in different worlds.

If you can change the process, things will change. Process changes take a long time. Some institutions have to die, and new institutions created, new tools, new ways of dealing with others.

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