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How to Create Healthy Environments in Cities

Khreis, Haneen; van Nunen, Erik; Mueller, Natalie; Zandieh, Razieh; Nieuwenhuijsen, Mark J.

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doi: 10.1097/EDE.0000000000000550
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  • ISEE

The city is now regarded as the primary form of settlement, accommodating over half the world’s population and almost 75% of the European population.1–3 Urbanization is continuing at rapid rates worldwide4 and the world is currently witnessing its largest surge of urban growth in human history.5 Cities have long been known to be society’s predominant engine of innovation and wealth creation, yet they are also society’s main source of crime, pollution, and disease.6

In recent years, evidence has been emerging that urban and transport planning indicators such as roadway density and green space could explain large proportions of the variability in urban environmental exposures, such as air pollution and noise. This suggests that these indicators, and the decisions and practices behind them, are potentially responsible for a large burden of associated adverse health impacts.7

This insight also provides a window of opportunity: if current urban and transport planning practices are responsible for a substantial but modifiable burden of disease, then improved practices within both fields could lead to new solutions for creating healthier and more sustainable communities.1 In their current form in many cities, urban and transport planning practices are not only causing a self-reinforcing cycle of urban sprawl and motor vehicle-reliant travel but also, importantly, continue to discount the numerous health impacts associated with them.

New paradigms, such as sustainable cities, resilient cities, active cities, healthy cities, and smart cities, are increasingly being envisioned and advocated across the different disciplines. In many cases, however, these continue to be developed without much integration across the disciplines, potentially missing conflicting effects of practices and policies that may be good from one perspective but particularly ineffective from another. Furthermore, the lack of multidisciplinary teams within the different stages of the planning and the decision-making of such initiatives leaves room for different interpretations, by the different stakeholders.

At the 2nd Early Career Researchers Conference on Environmental Epidemiology (, we brought together different disciplines and organized two sessions around “healthy city environments.” Four researchers from four disciplines—urban planning (Razieh Zandieh), transport planning (Haneen Khreis), environment (Erik van Nunen), and public health (Natalie Mueller)—came together to explore the current health-related issues in city environments from the different perspectives, and to engage a wider audience in a discussion of potential future initiatives.

The four presentations and the discussion around them focused on the following points:

  • Cities are currently hotspots for a number of adverse lifestyles and environmental exposures deleterious to health including an associated sedentary lifestyle, exposure to air pollution, heat islands, lack of green space, noise, and waste. However, the awareness and response of policy makers and the public to these factors and their impacts are generally reactive rather than proactive. Air pollution, for example, is a widely debated issue, because in many European cities there is an ongoing challenge to reduce exposure levels and comply with regional or international limit values. Nevertheless, other exposures within cities are equally important in terms of their associated health burden, but are as yet receiving less attention in the eyes of policy makers and the public.
  • The current realities of many of our cities reveal that the three pillars of our sustainability models—the economy, the environment, and the society (including public health)—are not equally considered. Key initiatives such as the Knowledgebase on Sustainable Urban Land use and Transport ( provide numerous options for sustainable transport policy measures for cities across Europe. However, this web-based tool seems to emphasize economic and environmental sustainability, while important public health indicators are yet lacking.
  • A recent health impact analysis of urban and transport planning-related exposures showed that contemporary physical inactivity and increased exposure to air pollution, noise, heat, and a lack of green spaces in a Southern European city were strongly associated with all-cause mortality.8 Other examples from other cities and regions reinforce these links and make a stronger case for the importance of (1) promoting physical activity, (2) reducing motorized traffic, and (2) provisioning urban greening to provide opportunities for physical activity, as well as mitigation of air pollution, heat, and noise levels.
  • Urban and transport planning practices such as providing mixed land-use (e.g., green spaces and gym), street furniture, safe urban environments, pedestrian, and cyclist-friendly amenities could promote positive physical activity patterns and build them into daily routines.9,10 These practices can help to overcome contemporary physical inactivity, a major health problem in current cities and a particularly important issue at times when people are generally busy to be physically active in their leisure time.11,12
  • The role of transport planning in providing opportunities for physical activity is similarly crucial. Getting people to use public transport, walk, and/or cycle to their destinations would not only make them physically more active and thus healthier but would also have positive environmental impacts, such as reducing their carbon footprint, local air pollution, and noise levels. However, current urban configurations and poor accessibility to key destinations in many cities reinforces the need for, and the convenience of, motorized travel, thus imposing conflicts and/or constraints on how much can be achieved by transport engineers and planners.
  • Reducing motorized traffic, especially in inner cities, has recently been recognized as a favorable policy by cities like Oslo and Hamburg, who announced their intentions to become car free.13 Such visions are appealing and can lead to considerable improvements in environmental quality and health in inner cities. Challenges to these visions’ transferability, however, include overcoming the invested economic interests and powers and the public perceptions and habits. Furthermore, as with low-emission zones that ban certain vehicles from travelling across designated areas, people living outside the boundaries of the low-emission zone, or the car-free zone in this example, may suffer from a new set of augmented exposures resulting from road users avoiding the car-free zones to reach their destinations.
  • A particular point resulting from the discussion was that the benefits of getting out of the car and shifting to use more public and active transport need to be better explained, quantified, and monetized for policy makers so that the real value of “radical” car-free or large-scale active transport scheme investments can be better realized. Costing aspects are important, as the cost–benefit trade-off is what many policy makers accept as a rational basis for good decision-making.
  • Providing green environments can be one way forward to providing opportunities for physical activity and active transport mode shifts while mitigating air pollution, heat, and noise levels. Such provisions need to be carefully planned considering where they are situated so that urban sprawl is not reinforced and cities are not fragmented further. In its own right, providing “access” to green space is not enough; “surrounding greenness” in terms of street trees, sidewalk vegetation, and building-envelope greening has been proposed as more important for providing health benefits.14 Providing surrounding greenness could potentially be a cost-effective policy that can be implemented in a wider range of areas within cities.15 Car-free cities also offer complementary opportunities for getting rid of car parks and road space, freeing up considerable public space that can be used for vegetation, parks, and open spaces with recreational purposes.16
  • According to a poll taken during the discussion, cities with sufficient green space are currently probably more desirable and feasible than car-free cities, given the largest use and people’s convenience in the latter and the lower sacrifices required from the public in the former. However, attention again needs to be given to where green space is being situated and in what neighborhoods within cities. As awareness of the numerous benefits of green space increases and captures more attention, the (monetary) value of real estate in the vicinity of green space will also increase. This can feasibly introduce an additional way by which wealthy neighborhoods deviate and become more fragmented from poorer areas, and this should be addressed when planning green spaces with the aim of reducing such inequalities.
  • Public needs and convenience are tightly linked to public acceptability, calling for more public participation in the planning and policy-making process, which needs to become more transparent to those affected first-hand. Public acceptability and citizens’ movements are core to successful implementation and radical change.
  • The role of epidemiology was not explicitly discussed during the sessions, but it can make a substantial contribution to resolving open scientific questions and provide more robust policy advice. Epidemiologists should further strengthen the evidence linking urban and transport planning indicators such as road network and walkability scores and related exposures such as air pollution and noise with health. Collaborating with researchers from other disciplines, epidemiologists should also better evaluate and build new evidence of the effectiveness and feasibility of healthy urban and transport interventions as they happen. The current evidence base for the effectiveness of interventions in terms of improving public health is still weak, and more progress in this area can enhance the overall plausibility of findings showing a link between the built environment and health, and more importantly reduce “uncertainties” in policy advice. This information is also essential for future health impact assessments.
  • Researchers within the different disciplines need to translate their knowledge and understanding into action and actively work together to ensure that the health of the population is at the top of the list of competing priorities for regulatory policy decision-making. They also need to find ways to transfer their understanding and their implications to the public, so that they better realize what their current lifestyles and potential changes mean to them personally and to their communities in the long term.
  • A stronger link between urban and transport planning, environment, and public health is urgently needed.


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