What if we can plan cities to reduce health inequalities?

Today, many governments, municipalities and organizations have set ambitious targets connected to the UN Sustainable Development Goals (SDGs), recognizing that we urgently need to make cities more sustainable and equal. So, to hold them accountable, how about we use health equality in the built environment as an indicator? 

Health equality is a very powerful litmus test for sustainability, not only because it is measurable, but also because when you create the conditions for wellbeing, you create places that perform well on many other levels. If people can meet their day-to-day needs by walking or cycling, and it’s safe for everyone to do so, this not only promotes active lifestyles and social interaction, but reduces carbon emissions and air pollution from cars. Green space in a city supports physical and mental health, but also climate change adaptation by offering protection from flooding and extreme temperatures. What is good for health equality is good for pretty much everything else.  

Looking at urban development over recent decades, it’s clear that reducing inequality in health has not been a top priority. The gap in health outcomes and life expectancy between different groups is widening, and both are strongly linked to geography. In Sweden, where I live, reducing inequality is the one area of the SDGs where we are failing to make progress – and we are actually moving backwards. Rising inequality in health means that if you live in one part of Stockholm, you can expect to live several years longer than if you live in another part of the city. It’s a similar picture in many other major cities around the world. 

Urban planning has been guilty of building large swaths of suburban homes and massive high-rise housing estates that concentrate socioeconomic groups in particular areas. It has ploughed highways through residential communities, creating noise and pollution and preventing people from accessing amenities in nearby neighbourhoods. This makes it harder to deliver a full range of services and to create well-functioning transportation networks, and it contributes to loneliness and poor social cohesion. 

But as urban planners, we also have the ability to resolve the physical issues that contribute to health inequality, not only the distribution of green space, but also healthcare services and pharmacies. We can see how access to healthcare – how long it takes to get to the hospital, how easy it is to pick up your medication – affects outcomes, and Covid has only emphasized how important this is. More equal cities will also be more resilient to future pandemics: researchers in Philadelphia found that the location of vaccination centres and the availability of transportation was a significant barrier to vaccine take-up, which disproportionately affected Black and Latino communities. 

Some of the things that we can do to tackle health inequality are self-evident: it’s easy to see that walkable neighbourhoods, green space and active transportation support healthier lifestyles. Others are less obvious, such as not creating large monocultures of housing types or building physical barriers that segregate communities. None of these ideas is really new: aren’t these the same things we talk about when we talk about quality of life, or climate neutrality, or child and age-friendly cities? 

Over the next decade, we need to make rapid progress on sustainability, on health and on equality. So when governments say they are prioritizing these things, maybe we should ask to see the stubs in their chequebook. We could ask, how big are your schoolyards and playgrounds? How easy is it for people to find green space or outdoor recreation? How many people are living in overcrowded conditions or reliant on emissions-generating transport to get to where they need to be?

This is not about planning cities or doing business in a completely different way, it’s about tweaking current models and integrating a new mindset. There is a growing wave of good examples around the world, from highways retrofitted as parks, to social value used as a selection criteria in public procurement, to collective housing models that bring together older people and kindergartens or students. We need to use these to demonstrate what we can do to help, simply by thinking about health a little differently. 

Health equality is not yet top of the agenda for every society, but it is only a matter of time before it will have to be. It will become impossible to create thriving economies or businesses without it, and in the years to come, the winners will be the governments and corporations who succeed in delivering on this priority first.