From hygiene to care: a genealogy of urban health
There have been times in history when staying in the city or fleeing it meant the difference between life and death: consider the plague of Justinian or the Black Death of 1348, or the role of the city as stronghold in the periods of intense warfare that marked the Middle Ages, or the urban expansion of our own times in countries where rural populations have migrated to the cities in their efforts to escape famine. These are extreme instances, but despite their exceptional nature they have much to teach us. In this article we’ll concentrate on the role of health in modern urbanism, or the development of our cities since about 1850.
In Europe, many of our urban environments took form in response to the health and hygiene crises of the second half of the 19th century. In England, Charles Dickens described the industrial towns as “pigsties” where the foul air was unbreathable and the risk of disease ever-present. The same could be said for Paris, Berlin, Barcelona and elsewhere. It was the fight against cholera that finally prompted European legislators to introduce regulations on the disposal of sewage and the collection of household waste. These moves transformed our approach to urban infrastructure.
It’s a fascinating story of the role played by science in the building of our cities, and the influence of new models in the circulation of the knowledge that informed public policy. And above all it teaches us much about the origins of cities as we now known them. The first stage of urban transformation was driven by public health concerns and the need to improve hygiene. It changed the appearance of the cities of Europe, and soon enough of America too. And it produced the two major urban forms of the 20th century: the new town and suburbia. Both of these models have survived down to the present day, each in its own way attempting to answer three very different questions: How do we tackle the health risks posed by cities? How do we provide healthcare in cities? And how do we care for city-dwellers?
Although the modern city first took shape in 1870s Europe, it wasn’t until about 1930 that it was conceptually formulated by the architects of the CIAM or international congresses of modern architecture, one of whose leading figures was Le Corbusier, architect of the “ville radieuse”. Often misunderstood in its intentions, the modern movement has been widely inspirational in its functional aesthetic and its approach to architectural ensembles. From the outset, one of the key principles of the movement was the desire to provide a healthy framework for living by building cities with plenty of air, daylight, and open spaces. Although this initial concern gradually lost ground to radical functionalism and a narrow, overly-prescriptive conception of “health”, it has been decisive in the formation of modern approaches to urban expansion.
More or less concurrently with the CIAM (late 1920s), another model, also taking its cue from the hygiene-driven transformations of the 19th century, began to emerge: suburbia. One of the earliest models for suburbia was Broadacre City, conceived by Frank Lloyd Wright. The American architect envisioned vast tracts of low-density housing where each family was allotted a plot of 4000 m2 (about the size of a football pitch) to build a home and grow vegetables. Although the Broadacre City project was never built, it was hugely influential as a model for the residential suburb - still the world’s principal form of urban development. Like the new town, suburbia has been widely condemned for its reliance on the car (something Wright fully acknowledged). In essence, though, it’s conceived as a response to the health risks posed by city life, with lower construction density, more nature, and local services and facilities: a sustainable city ante litteram, if you like.
Both models sought to offer urban forms that are not harmful to health (or at least place health at the centre of their concerns, even if they’re unable to deliver a fully convincing solution) - or even make it better. This was a key preoccupation for engineers and urban planners before the Second World War and in the decade of reconstruction that followed it.
By the 1950s, planners found themselves faced with a new problem created by the emergence of social welfare systems in the developed countries: how best to offer healthcare services in the city. Or, to put it another way, how to make the city a place that looks after people. Before then, the accepted procedure had been to keep the sick at arm’s length, or even intern them. With growing opposition to institutional healthcare, however, came the need to re-think and re-design the places where care is provided - beginning with hospitals, which began to lose their citadel-like detachment, becoming opener and more accessible to their urban surroundings (even if one consequence of this openness was a new form of separatism driven by growing specialization in medicine). The new orientation was accompanied by changing conceptions of what “health” actually meant. Rather than simply the absence of illness, health was increasingly defined in terms of global well-being, spiritual as well as physical. It was this outlook that drove the emergence in the 1960s and 70s of what we call “community health”, and the new emphasis of the role of the city in looking after its inhabitants. But few projects were ever implemented, and these were quickly abandoned. By the end of the 1970s, the divorce between urban planning and the healthcare sector was all but complete, and health no longer figured among the concerns of urban planners.
Not until the early 1990s, with the emergence of the climate crisis, did health regain its place on the urban policy agenda - and even then in a very limited sense. Cities were now identified as partly to blame for the deterioration of the environment, and a new, ecological approach to urban design emerged. This new approach acknowledged the impact of cities on the environment - and of the environment on the health of the individual. The World Health Organization published an official definition of “healthy city”, while eco-district projects and Agenda 21 initiatives sought to reconcile urban development with environmental health. Many of these schemes were successful, but there were disagreements and disappointments too.
