Population Health through Inclusive Urban Planning: Healthier Communities and Sustainable Urban Development in Indian Cities

Author:Shriya Malhotra
Position:Completed an MA in Cities and Urbanization from the Graduate Program in International Affairs at the New School
Pages:51-57
SUSTAINABLE DEVELOPMENT LAW & POLICY51
“If cit ies are the ‘def ining artifa cts of civiliz ation’ a
nation may now be judged by the health of its urban majority.”
Christopher Dye1
INTRODUCTION
The definition and importance of urban public health has
evolved in recent years, both in developed and devel-
oping countrie s. Onc e domi nated by bi omedical sta-
tistics and epidemiol ogy, the public health field is shifting to
emphasize environmental and social determinants of population
health. Amartya Sen, in his keynote address to the World Health
Assembly, emphasized the importance of health as a foundation
for econom ic development and community growth. 2 This new
perspective on health, as it relates to urban populations and the
economy, is gaining momentum.
Public health, otherwise referred to as population health, is
an immediate issue facing many developing nations with grow-
ing pop ulations. For instance, “the accumulated urban growth
of [the African and Asian] regions during the whole span of his-
tory will [double] in a single generation. By 2030, the towns and
cities of the develop ing world will comprise [ei ghty] per cen t
of urb an humanity.”3 Populations in Indian cities are expand-
ing in terms of their real num bers and as a proportion o f the
national total. The I ndian government estimates that by 2050,
India’s urban population will grow to 820 million, compared to
285 million in 2001.4
Popul ation growth coupl ed with movement from ru ral
areas to urban centers in India is occurr ing for several reasons:
migration for great er income, employment op portunities, a nd
an e conomic shif t away from the former agri cultural em pha-
sis.5 This hist oric shift has been address ed through policies via
the nationally coo rdinated and municipally implemen ted Jawa-
harlal Ne hru National Urb an Renewal Missio n (“JNNURM”).
The scheme provides funds for urban renew al from the national
governm ent and currently funds urban deve lopment p rojects
in sixty-five Indian cities. But cove rage by the JNNURM is
inadequa te given that 4,378 urban agg lomerations and towns
exist in India.6 Ap art from presently being limite d to just a few
cities, the JNNURM also does not fund any heal th related proj-
ects. It i s therefore necessary to explore the us e of urban plan-
ning as a tool that can promote im proved urban publ ic health,
within a broade r context of susta inable deve lopment. Wi thin
and beyond India, inte grated urban planning could provi de
alternative development strategie s in the diversi ty of contexts,
experiences, and degrees of urbaniz ation that exist in de velop-
ing countries .
Before e xamining the t heoretical li nks between urb an
planning, popula tion health, and sus tainable development, it is
important to define the terms used in this article. Urban planning
is t he design and organizat ion of urban spaces and activ ities,
i.e. ho w cities and towns function , based on the environment,
zoning, infrastructure, and services.7 Integrated urban planning
is increasingly recognize d as a means t o promot e resil ience
for populat ion health which includes: targeting the location o f
pharmacie s, clinic s, hospi tals, em ergency ambulance routes;
promoting safety and reduced occupational hazards in the city;
preventing noise pollution for mental health benefits; promoting
healthy building s and habitats that are hygienic and clean; and
maintaining green spaces and urban biodiversity.
Public health is the science and art of dealing with the health
of populations and communities by preventing disease, prolong-
ing life, and promoting health through community planning and
by educating the population.8 It entails protecting and improving
the health of a community through a combination of primary
preventive methods such as health education and health services.
Public health differs from medical health because of its focus on
community health, rather than on individual well-being.
Sustainable urban development entails sustainable services
delivery, planning, environment al, and socioeconomic policies.
In the In dian conte xt, susta inable ur ban devel opment mea ns
several things: sustainable provision of basic urban services,
governance, and inclusive development that targets the needs of
vulnerable populations.9 With decentralized governa nce and a
shift towards prioritizing the needs of urban populations becom-
ing a reality in th e Indian political arena, now is the time to
explore alternative strategies that reinforce sustainable develop-
ment policies.10
These components are all interrelated, which means urban
public health should be examined within the web of legal pro-
cesses, governance, and policies that support a broader notion of
sustainable urban development. The health of a city is reflected
population health through incluSive urban
planning:
healthier communitieS anD SuStainable urban Development in inDian citieS
by Shriya Malhotra*
* Shriya Malhotra completed an MA in Cities and Urbanization from the Gradu-
ate Program in International Affairs at the New School. Her research interests
span the role of IT, art, design, and visual and spatial analysis to address urban
public he alth challenges. She is currently a research associ ate at the Center
for Research on Sustainable Urban Development and Transport Systems at The
Energy and Resources Institute (“TERI”). The opinions expressed in this paper
are those of the author and do not necessarily represent the views of TERI.
FALL 2010 52
in the health of its environment and inhabitants. Urban public
health requires involving multiple stakeholders, and establishing
benchmarks that will direct urban planning in the w ay that i s
most beneficial to populations and their health. Viewing sustain-
able development in terms of health impacts is a more tangible
way of addres sing urban issues for poli cy makers and urban
communities.
Despite havi ng beneficial policies in place, Indi a’s decen-
tralizi ng st ate governments face issue s of enfo rcement and
delegation of power, which in turn result in ineffective imple-
mentation of urban public health policies.11 With infrastructure
projects driving the growth of ci ties, sustainable development
policies could address and improve the health and well-being of
urban inh abitants. Spatial planning is direc tly linked to public
health practicalities such as sanitation and solid waste manage-
ment while transportation options and physical activities high-
light the link between location and health. These polic ies have
not yet been effec tively imple-
mente d in urban slums, for
instance, which are comprised
of poorer populations who gen-
erall y face sev eral disa bling
public health issues.12 Environ-
mental and social determinants
of health are at the forefr ont
when i t comes to c ities and
spatial inequalit ies rel ating to
health.
On its path towa rds sus-
tain able deve lopment, Indi a
faces several legal and pol icy
challenges. The “urban” dimen-
sion of hea lth and sustainable
livi ng is now m ore i mpor-
tant than ever before because
fifty per cent of the world’s population now resides in cities.13
Although cities occupy a small portion of a country’s landmass,
they consume large quantities of energy, which result in higher
concentrations of pollution that adversely affect public health.14
Often the spatial organization of many of these modern cities
offers little consideration of human behavior and does not pro-
mote act ive and healthy lifestyles. Ur ban transformation is an
opportunity to create in creased awareness of the link between
individual, community, and population health. At the same time,
the shift highlights the importance of environmental and socio-
economic determinants to human well-being. This article will
examine the historic trajectory of cities and their development
impact on population heal th. It will then briefly discuss urban
development i n New Delhi wit h a focus on examples that lin k
planning and population health.
A HISTORY OF URBAN PLANNING AND PUBLIC
HEALTH IN THE DEVELOPED WORLD
In terms of legal, policy, and r elated processes, exploring
and understanding the relationship between urban planning and
public he alth is crucial in promoting strategies for sustainable
development. Challenges facing s everal developi ng countries
highlight the con cern of repeating the mistakes of dev eloped
countries, which have resulted in environmental and ecological
degradation.15 Developin g world cities in particular are adding
populations exponentially;16 apart from the scale of their popu-
lations, these cities face similar health issues seen in eighteenth
and nineteenth century Europe .17 For example , chole ra out-
breaks, chronic dysentery, as well as acute health issues related
to water quali ty and the spr ead of infectious diseases due to
population density and overcrowding often result from a lack in
infrastructure, services, and sanitary habitats.18
The field of public he alth emerged from t he West in the
post-Victorian era dominated by the concept of hygiene; it later
evolved in to being dominated by the medical field.19 Evidence
of the relationship between urban planning and public health in
Europe dates back to the eighteenth and nineteenth cen turies
during the construc tion of urban
centers th at eventually became
citi es.2 0 John Sno w’s c hol-
era ma p is an example of how
important targeting and under-
standing of urban infrastructure
is to promoting public health.21
Similarly, Charles Booth’s pov-
erty map revealed the spa tial
segreg ation of poorer ho use-
holds.2 2 As a resul t of these
simple visual and spatial anal-
yses of urb an epidemics and
poverty, the next generation of
city plan ning more appropr i-
ately targeted infrastructure and
services in the city.23
Epidemics in early twenti-
eth century cities spread rapidly and it is believed that the spatial
layouts of these industrial cities were responsible for the conges-
tion and poor health of urban co mmunities.24 As a reaction to
the problems arising from overcrowding in high-density build-
ings and mixed land use envir onments, pos t-industrial world
cities so ught to encourage a more expansive urban p opulation
model.25 T he development of U.S. cities and the ph enomenon
of suburbs changed land use from a congested urban framework
towards a less dense “sprawl with satellites” urban model. This
has been problematic when mimicked in developing countries,
because postindustrial public health challenges continue to exist
and persist.
During the twent ieth century in t he United States, urban
sprawl and the emergence of “s uburbia” beg an to define cit -
ies. This coupled with car-centric mobility that discouraged
physical activities like walking and biking, have contributed to
obesity rates of epidemic pro portions.26 Becaus e suburbs and
modern life are constructed a round the use of vehicles, people
incorporate less physical movement into their daily lives.27 The
American obesit y “epidemic” is dir ectly linked to two modern
The “urban” dimension
of health and sustainable
living is now more
important than before
because fifty percent of
the world’s population
now resides in cities.
SUSTAINABLE DEVELOPMENT LAW & POLICY53
urban phenomena—a la ck of walking28 and the indus trializa-
tion of foods.29 There are several cities like New York, specifi-
cally Manhattan, where residents have been found to have lower
heart disease rates and lower levels of obesity, because the urban
environment encourages individuals to walk.30 Since 2007, the
mayor of New York City, Michael Bloomberg, has implemented
a multi-pronged health plan targeting improvements in nutrition,
pedestrian facilities, and increasing b icycling routes, to better
the environment and human health.31 New York City is a good
example of urban planning int erventions that work to promote
population health.
It is evident from c ities in Europe an d the United State s
that devel opment and natural environments requir e simultane-
ous planning and management for public health. However, their
models f or planning can not be mimicked as Indian cities face
several additio nal ch allenges of
different scales than these cities
did or do. Nevertheless, experi-
ences within and among cities
need to be shared for a sustain-
able urban future. Exploring the
links between urban planning
and population health to inform
appropria te polic ies may help
inform the current lapses seen
in the health and well-being of
Indian communities and India’s
urban populace.
Ur ba n su st ain abi li ty
includ es looking beyond the
built and natural environment,
and towards related issu es of
governance and services, while
measuring outputs in terms of
health . The trajec tory so far
in India ’s development have resulted in numerous imbal ances
which policies have sought to keep up w ith: rura l vs. urban
emphasis; private vs. public coverage; preventative vs. curative;
along with multiple existing health care systems that fail to link
individual behaviors and community health to basic hygiene
and sanitat ion. In doing so, emphasis must be on urb an health
centers an d specific health vulnerabilities, whic h vary by geo-
graphic location, population density, and many other factors.
Developing world cities sho uld take note of the deci sions
made in post-industrial developed cities. The resulting sprawl
and commercializat ion of cities32 on their path t o econom ic
liberalizatio n in the developed world s hould not be emulate d
for sust ainable urban d evelopment in d eveloping world cities.
Regrettably, development to date in major Indian cities like New
Delhi seems to reflect this post-industrial trend. An emphasis
on population health oriented planning processes that balance s
human and env ironmental priorities a ppears to be lacking in
policy and needs to be established. A balanced ecosystem or bio-
sphere approach may hold the key to examining the link between
urban planning and population health. Smaller cities like Surat in
Gujarat appear to have several examples that would benefit sus-
tainable urban development while targeting health—given their
focus on public health and urban renewal in the last few years.33
Clearly, the trend is changing for the better—however without
appropriately prioritizing and targeting population health needs
in an inclusive manner, Indian cities will face several obstacles
on their path towards sustainability. Th e focus needs to be o n
addressing urban public health requirements and orienting poli-
cies towards i mproved health impacts, services, and infrastruc-
ture for urban communities.
PUBLIC HEALTH SNAPSHOT OF INDIA
“The onl y way to cope with the developing world’s over-
whelming pr oblems is to build effective p ublic health systems .
Such device s monitor the health and well-bei ng of its c itizens,
identify p roblems in the environ-
ment and among the me mbers
of its comm unity, and estab-
lish public he alth practice s to
address these problems, includ-
ing the p roblems of whe ther
proper health care is accessible
to all, rich or poor .” Laurie
Garret34
Publ ic he alth as a fo r-
mal concept and, with rece nt
advan ces in te chnologie s, is
relati vely new in India with
publi c health serv ices bein g
establi shed to monitor epide-
miol ogy and env ironmen tal
risk fact ors for health in the
last decade.35 The integra tion
of wes tern medi cal su pport
and other technologies used for
population health analysis and diagnosis are just entering India,
and may run parallel to urban planning processes.36 It is undeni-
able that to address global public health issues, one needs basic
public health parameters that transcend borders. But first, cities
need to a ddress the immediate health risks and concerns pos ed
by the city to their populations— recurring epidemi c outbreaks
along with unsafe buildings and infrastructures that lack ade-
quate lighting, recurring epidemic outbreaks and footpaths.
The importance of an integrated and holistic public health
system for India should not be underestimated. An expanded
definition of pub lic health would o vercome sever al obstacles
faced in Indian cities by linking concepts that are often consid-
ered distinc t. One concept is individual and population health.
Individua l beha viors u ltimately drive and affect community
health, as do es the built environment. The presence of walking
trails, bike paths, local food systems, and trees, for instance, can
promote well-being and better health outputs.
Population health relates to the environm ental, economic,
and social determ inants of health—for instan ce, being sur-
rounded by unhyg ienic conditions. The mitig ation of these
Challenges facing several
developing countries
highlight the concern of
repeating the mistakes
of developed countries,
which have resulted
in environmental and
ecological degradation.
FALL 2010 54
public health risks requires shifting away from a western medi-
cal science approach of curing and more towards primary pre-
ventative health measures. I n the Indian env ironment, pub lic
health must incorpo rate alternativ e systems of health such a s
knowledg e ste mming from Ayurveda,37 Homeopat hy,38 and
other traditional science systems. Health education with literacy
and non-literacy components aimed at both those who are liter-
ate and illiterate can help to strengthen primary prevention.
To help facilitate primary prevention, India’s public health
program req uires a holistic approach from various dimensions
including nutrition, a change in disease burden, and the effect of
urban environmental health factors. It also needs to incorporate
indigenous and traditional sources of knowledge to inform well
being of urban population s. Although life expectancy in India
has been increasing, so have incidences of cardiovascular dis-
ease—thirty-eight million people were affected in 2005, and the
number is estimated to rise to sixty-four million by 2015.39 The
benefits of urban and “modern” livi ng have come with its own
lifestyle and environmental challenges to health. An aging popu-
lation, combined with lifestyle related risks factors, has resulted
in higher rates of diabetes in developing countries as compared
to developed nations.40 The burden of disease has been shifting
with rising economic growth in India, resulting in malnutrition
and obesity rates increasing at the same time.41
Other environmental health factors such as air pollution and
water quality continue to be a problem in the urban environment,
affecting both urban services and the heal th of urb an popula-
tions. Numerous water borne epidemic s persist, such as ch ol-
era, tuberculos is, and dysentery, and seasonal diseases such as
malaria and dengue.42 Although dengue fatality rates have been
declining in most countries because of better access to health
care and timely case management, dengue outbreaks continue to
rise in India.43 Reasons for persisting issues like the plague and
water borne diseases include water and sanit ation. Almost all
of these issues are poverty related or stem from unclean wate r
and sanitat ion facilities. In India, the lack of sanitary drinking
water and adequate solid waste management both contribute to
the problem.44
These environment al condi tions ar e often predicat ed by
one’s socio-economic status, which determines the quality of
health of c ommunities and individuals. Thus, a person’s health
is contingent on where sh e or he lives. For exam ple, in the
southern coastal Indian s tate of Kerala, which has seen high
investments in health and education since the 1970s, t he mor-
tality age is hi gher than i n other par ts of the country.45 How-
ever, it is with in the citi es that the spatial d isparities come to
the forefront. Sites where marginalized and vulnerable popula-
tions reside are also often sites with poorer environmental health
and population health, often as a result of living environs. Slum
dwellers in cities face a drastically different quality of life than
rich urban inhabitants. Gated communities in New Delhi have
access to expensive, modern hospitals with emergency treatment
and medical ser vices while services for the urban poor or slum
dwellers are comparatively rare.46
India is also witnessing a shift from extremely high occur-
rences of communicable diseases such as HIV/AIDS, tubercu-
losis, malaria, and influenza47 to non-communicable diseases48
pertaining to nutrition. A lack of proper nutrition al knowledge
affects health, as does the avai lability of accessible cl inics and
health services. India demonstr ates a troubling c ase of rising
obesity as well as malnourishment.49 Childhood malnutrition is
linked with maternal mortality, which in turn, is linked to urban
poverty.
However, many appear to see addressing population health
dilemmas as separate from protecting the environment and cre-
ating habitats. This is unnecessary since addressi ng the need s
of urban ecosystems holistically is a more appropriate approach
for envi ronmental policy makers and de velopment specialists.
In the last few years , Indian policymakers have devise d sev-
eral policies, which can shift the trajectory of its cities towards
sustainability.
In 2008, India launch ed t he N ational Urban Sanitation
Policy (“NUS P”) through the Ministry of Urban Development
with a goal of urban sanit ation in India.50 So far, it has ranked
the major Indian cities acc ording to parameters in cluding the
absence of visible outdoor defecation, measured ratios of human
excreta generated with that whic h is saf ely collected, and the
proportion of treated wastewater that is recycled.51 It will now
be up to state and city government agencies to prioritize, coordi-
nate, and improve sanitation in these cities. The goal is to make
all Indi an cities sani tized by provi ding technical and financial
assistance to the cities in order to promote “healthy and clean”
cities.52 This could be crucial in the context of the National Mis-
sion on Sustainable Habitats (“NMSH”), which was approved in
2010 by India’s Prime Minister Council on Cli mate Change.53
It will soon be up to Indian cities to effectively implement these
nationally funded priorities to improve their cities with a view to
the wellbeing of the people living in them.
Effec tive urba n and e nvironmen tal plann ing requ ires
addressing human and environmental health in a manne r that
does not pr omote one at the expe nse of the other. The need
for integrated approaches regarding the creation of sustainable
cities and services is evident i n problems, such as spra wl and
inadequate environmental planning. The idea of sustainability is
not static and means different things depending on the context,
which is evidenced in the case of Indian cities.
CASE STUDY OF PLANNING AND POPULATION
HEALTH IN NEW DELHI
India ha s witnessed ra pid economic g rowth and huge
influxes of money as a result of liberal policies and its impact
has been manifes ted in India’s ca pital city, New D elhi. New
Delhi and the Nation al C apital Region (“NCR”) have bur -
geoned, e ngulfing the surr ounding agricultural land to accom -
modate urban populations. Land use patterns in the city changed
drastically between 1998 and 2001, with agricultural lands con-
verted into residential and commercial spaces.54 Designation of
special economic zones ( “SEZs”) and dist ribution of fina ncial
incentives have been used to establish businesse s across the
SUSTAINABLE DEVELOPMENT LAW & POLICY55
city with high-rises erected in the subur bs, though not on the
same scale as in the developed world.55 In addition, lands have
been purchased in adjoining states to accommodate the growing
population.56 Transp ortation systems have also been changing
with the addition of flyovers (bridges). With the advent of these
developments however, there has also been an influx of automo-
biles and increased levels of air pollution, as w ell as increased
consumption and waste generation because of modern lifestyles.
Alternatively, issues of resource scarcity are likely to arise
in the high rise, commercialized suburb of Gurgaon. The twenty-
four hour energy guzzling malls will eventually result in wate r
and electrical s hortages in this a rid region unless sustainable
policies and practices are implemented. Similarly, the NCR has
expanded into the state of Uttar Pradesh and its agricultural land
in Noida.57 Noida’s rich, fertile fields, which were once sources
of food for the cit y’s inhabitants are now being developed for
residential use.58 There seems to be little awareness that adding
populations to these satellite suburbs, with their already inad-
equate infrastructure, will prove unsustainable and problematic
in the long run. The first step mus t be to man age and plan the
seemingly unlimited urban expansion or at least tailor the expan-
sion in a sustainable way to reduce negative health impacts on
the popul ation. The fact that New Delhi’s forests and wildlife
are const antly being displa ced has pitted several animals such
as monkeys against the city’s residents.59 This ap tly illustrates
problems that underlie rapid and unplanned development.
New Del hi’s NCR fac es logistical and management chal-
lenges a s it struggles with effectiv ely implementing city level
policies since there are several agencies that are competing for
jurisdiction, yet lack effective coordination amongst themselves.
This is however beginning to change.
The decentralized public health delivery services need to be
strengthened. In April 2010 , New Delhi’s government cabinet
agreed to introduce Public Health Standards for Primary Urban
Health Cente rs (“PUHC”) in the city.60 For every 50,000 peo-
ple, one health care unit would be identified, strengthened, and
upgraded to a PUHC.61 How ever, data gathering and sharing
must also be strengthened. Detailed maps identifying dispens-
ing a reas, pharmacies, clinics, an d hospitals would be benefi-
cial. No effective ambula nce routes exist , so in the case of an
emergency the reaction time is inadequate. Municipal oversight
of constructed are as is also necessary to ensure that stagnant
water does not pool and become a breeding ground for mos-
quitoes. Access to clean water facilities, while necessary, must
also ensure that wastewater remains treated and separate fro m
drinking water to prevent cholera and dysentery outbreaks. Lim-
iting air pollution emissions and noise pollution is also a part of
the equation, because they can negativel y affect mental health.
These are just a few examples of how urban planning and popu-
lation health are linked. Although progress of effectively inst i-
tuting measures that might address public health is being seen in
cities like Surat in Gujarat, this is still not the case in New Delhi.
Unfortunately, a “master plan” system that promotes sus-
tainability, as currently exists, is difficult to implement in a city
with s uch a long and complex history as New Delhi. With so
many structures built, demolished, and rebuilt, the city is com-
prised of innumerable layers of diff erent age s and qualities,
which pose as ob stacles to holistic approaches and revital iza-
tion projects. The risk is that s hortsighted plann ing decisions
will compromise sustainability by negatively affecting the needs
and re quirements of current as well as future generations and
their health. Thus, planning requires unique and thoughtful inno-
vation. There n eeds to be aware ness regardin g the impact of
construction on public health, su ch as construction that fosters
the use of automobiles, which are detrimen tal to public health
because of their emissions and the sedentary lifestyle they pro-
mote. Access to fresh and local foods will also become an issue
as the city continues to expand haphazardly, engulfing surround-
ing agricultural lands, thus requiring transportation of food from
longer distances with additional preservatives.
The public health cha llenges faced in Indian cities are
innumerable and complex—but po licy makers are aw are and
beginni ng to add ress these issues. Ultimate ly, however the
responsibility and effective implementa tion lies with the cities
themselves. This is why inclusion and participation, especially
in the Indian context, are crucial—but i s also a p ractical chal-
lenge given their numbers.
SUSTAINABLE URBAN DEVELOPMENT:
INCLUSIVE PUBLIC HEALTH
Slums or i nformal ur ban poor settlements fall along the
blurry divide between urban planning and public health lapses.
Basic urban services are serious ly lac king f or New Delh i’s
urban poor and slum-dwellers, in terms of access to power, clean
water, health facilities, sanitary environments, and sewage man-
agement. They face multiple challenges as a result of the various
facets and cyclical nature of poverty.
The slum population of N ew Delhi accounts for almost
twenty percent of the total urban population.62 The la ck of a
hygienic and sanitary living space, as well as services and infra-
structure, poses sev eral issues for slum dwellers. Un-sanitary
and un-hygienic conditions can li mit slum dwellers opportuni-
ties a nd highlights the multidimensio nal nature of urban p ov-
erty. Environmental risk and health factors are high, as are the
social determin ants ne gatively affecting health. As a r esult,
slum-dw ellers face perpet ual health costs and pr oductivity
inhibitors. They have no proper place to live; the informality and
often illegality of their living areas presents a challenge to policy
and lawmakers.
Although the “informality” of slums poses a problem to
legislati on and policy enforce ment, fo rmalizing these living
areas is not always the best solution. The first step should be to
ensure their consistent access to several (quality) basic services
including water and other basic necessities. The needs of slum
dwellers are often ignored or over-shadowed by disparate popu-
lations and their requirements. However, recognition that both
populations share the same living area may be a great motivation
for disparate populati ons to a ddress the needs of slum dwell-
ers. Health and opportunity costs borne by families are examples
of hidden disease burdens, particularly i n developing countries
FALL 2010 56
such as India that lack specialized health services for poor popu-
lations.63 Participation by poorer populations is required to guide
the trajectory of the city. One solution is to strengthen rural and
urban linkages so that populations migrate less. Another neces-
sary measure is access to resources including basic necessities so
that slum dwellers are not quite as vulnerable. Helping the poor
invest in health and education is another. Urba nites could also
learn about sustainabl e urban living by studying thes e slums.
Slum dwellers use minimal resources, recycle out of necessity,
and have a minimal impact on the environment.64
These current challenges in Indian cities can be addressed
through integrated urban planning. Reducing air emissions pro-
motes better lung function and general health, while better plan-
ning of land use can prevent malaria and dengue. For example,
the negative publicity surrounding the Commonwealth Games65
illustrates the city’s lapses in planning for population health and
a lack of coordination or priority for popular inclusivity or par-
ticipation.66 While the Games will result in an advanced metro
system and several infrastructure upgrades, in the long run, they
have come at the expense of the poor, rural laborers, and slum
dwellers whose habitats have been shifted or hidden.67 An esti-
mated 2,500,000 poor residents in the city were displaced as a
result of these games.68 Concurrently, the city faced a recurrent
dengue epidemic.69 To prevent further such occurrences, zon-
ing and planning distinctions need to be in place to allow slum
dwellers to participate in the urban renewal processes while main-
taining facets of history, culture, and the environment. Inclusive
planning is a crucial component of sustainable urban development
and perhaps the opportunities presented by global games could
focus on improving and strengthening local public health systems.
SOME RECOMMENDATIONS:
LEGAL AND POLICY INTERVENTIONS
Cities ought to be app roached as complex urban ecosys-
tems comprised of interrelated built and natural environments,
with direct links between policies and urban participants. How-
ever, citi es also need to strengthen and target the provision of
services such as health and education, which are the bas is of
human develo pment according to Amartya Sen, through infra-
structure , legal , and policy process es. He alth an d educa tion
combine to form the basis of public health and therefore need to
be prioritized. Th ey need to look towards addressing the plight
of mi grants, because they too are a part of urban space s, and
towards inclusive policies that address the needs of other vulner-
able populations. Environmental and ecological concerns ought
to be balanced with human requirements through a holistic, mul-
tidimensional approach that looks at the relatedness of these dif-
ferent factors. Indian cities do not need to follow the developed
world’s urban ways and should instead seek to forge a new path
of development that other countries will want to replicate.
Linking individual behaviors with community and popula-
tion health is a crucial first step. Communicable diseases turn into
epidemics when populations are uninformed or unable to achieve
the benefits of hygiene, clean water sources, and preventative
health services, including disease tes ting and immunization.70
With increasing longevity and recognition of urban environmental
health factors, the prevention of lifestyle diseases requires more
attention. Health awareness and education should therefore figure
prominently in policy-making at the city level.71
Urban public health and individual health determinants are
interrelate d. Inadeq uate child nourishme nt negativ ely affect s
adult health and often stems fr om nutritionally deprived moth-
ers.72 Immunization programs redu ce inequality in c hildhood
mortality and maternal nutrition can reduce inequalities in other
aspects of health and wellness. Free checkups from easily acces-
sible clinics are also important. Nutrition information and educa-
tion needs to be addressed in India—a governmental body akin
to the U.S. Food and Drug Administration (“FDA”) would help
ensure standards are set and met, while addressing the growing
dual burdens of nutrition and disease.
Social determinants of health must also be addressed, par-
ticularly in India, wi th a large p opulation of ever increasing
urban poor.7 3 Population health rela tes to poverty and urba n
planning. The poor generally live in t he least environment ally
healthy environments and are often found inside informal settle-
ments or dirty, overlooked urban spaces.
Environ mental determin ants of human and commu nity
health need to be prioritized and do not have to be seen as sepa-
rate or a s a zero-sum game. Both are mutually beneficial if the
approach is lo ng-term orie nted, target ing the needs o f future
generatio ns wit h a holistic ecosys tem or biosph ere or iented
approach, which does not compromise the needs of one for
another. Clean water is essential for healthy living, but is reliant
on infrastructure and policies that enable access in urban areas.
Unsafe water, poor sanitation, and hygiene are major contribu-
tors to high mortality in many developing countries.74
Primary preventative strategies lik e health education an d
awareness, nu trition, vaccines, and sanitary water ar e all basic
strategies in facing the challenges of implementat ion, and ar e
required for effective interventions in urban poor populations.75
This is in addition to focusing on how planning and services can
be reoriented for human needs that also consider the importance
of health. Thus, it highlights a crucial link between health an d
education services for development as well as opportunities for
providing them—which perhaps exist more in cities.
city-level policy anD planning recommenDationS
• Encou rage a nd pro mote h ealthier human behaviors and
mental health through the planning and construction of cit-
ies by ensuring adequate green spac es, walk and bicyc le
paths, access to clean water, local food systems, public rest-
rooms, recycling, and composting.
• Ensure lega l and policy provisions that provide services—
such as he alth servi ces access —for poor and vulnerable
populations while also allowi ng them to have a vo ice to
contribute to sustainable and environmental practices.
• Overlay present and future maps that integrate land use and
urban t ransportation policies with a public health outlook
to design services and infrastructures that meet anticipated
population density and growth in different parts of the city.
SUSTAINABLE DEVELOPMENT LAW & POLICY57
• Per iodically re-exa mine an d refoc us the rela tionship
between rural and urban areas to ensure they are evolving in
a sustainable manner
Bottom up change should be supported by focusing and pri-
oritizing health at the neighborhood or community level with an
emphasis on local foods, ac cess to resources, and other neces-
sities. This might i nclude wor king with specific settlements,
slums, and communities. Participatory maps, spatial representa-
tion, analysis of health, and environmental concerns could high-
light policy lapses, areas requiring resource allocation, as well as
different population and environmental health determinants that
result in disparity within cities. This also supports engaging and
educating populations to create livable urban environments and
strengthen their communities.
City planning should not be primarily for the construction of
buildings and the use of automobiles, but for the populations and
communities inhabiting urban spaces. Indian policy makers need
to reorient their approaches that look between and amongst build-
ings and focus on the requirements of urban communities. Poli-
cies and legal provisions must address and reinforce the multiple
dimensions of urban public health by involving the public, ensur-
ing engagement and participation, and promoting flexible yet real-
istic incentive and disincentive systems. India needs to target the
creation of “energetic cities” i.e. the promotion of active living
and healthy lifestyles as well as urban environments that promote
low waste and energy use, and can generate their own energy.
CONCLUSION
“City planners must weave a complex, ever-changing array
of elements into a working whole: that is the perennial challenge
of city planning.”76
City performance can be me asured vi a five dimensions:
“vitality, sense, fit, a ccess, and cont rol,” combined with “effi-
ciency and justice” to guide them:77
[A] vital city successfully fulfill s the biological nee ds
of its inhabitants, and provides a safe environment for
their activities . A sensible city is organized so that its
residents c an perceive and understand the city’s form
and function. A city with a good fit provides the build-
ings, spaces, and networks required for its residents to
pursue their projects successfully.78
These suggestion s echo in both developed and developing
countries. Livable, sensibly planned cities in which people par-
ticipate to address their own well being are a test of humanity’s
ability to formulate and manage the future.
Urban plann ing directs how communities interact through
the designation of land use and transportation. It also determines
the layout for buildings, green spaces, clinics, and the location of
different health serv ices—as well as determinants. Urban plan-
ning therefore promo tes or hinders populat ion and individual
health. The proxi mity of urban com munities to trees or even
highways can affect health. Looking at sustainable development
through the lens of health closes the gap by linking the health of
individuals, populations, and the infrastructure together.
As mentioned above, the health of the environment and of
its constituent communities does not have to be a zero-sum game.
Countries need to explore how the built and natural environments
can promote symbiotic relationships with human communities.
Health outcomes are an appropriate measure of urban quality of life.
Adding sustainable urban development to the equation of integrated
urban planning and public health systems is important to ensure that
the wellbeing of future generations is adequately met.
Indian cities have some ground to cover before the built envi-
ronment and urban ecosystems begin to promote improved health
for its urban constituents. Steps to ensure improved health in the
future are contingent on effective planning and decision coordina-
tion made now. Examining the intersections of planning and public
health in urban spaces is a crucial step towards doing so. Outlin-
ing responsibilities and integrating resilience and flexibility into all
aspects of the city is crucial. Decentralized governance operating
through various local bodies, with specifically allocated responsi-
bility and transparency allowing for the setting of legal standards
while ensuring that policies are targeted at the correct provisions,
will be crucial for ensuring our sustainable urban future.
City planners, policy makers, and inhabitants need to work
together to integrat e their requirements w ith the environment
and en able vulnerable populations to participate in the design
and development of the city. The true test of a city is the health
and th e wellbeing of its i nhabitants. Indian cities need to rise
to meet the challenge of not only setting sustainabi lity bench-
marks but also providing strategies and examples for other cities
throughout the world to follow. This is possible by reorienting
sustainable development to prioritize the health impacts on cit-
ies. Despite these challenges, Indian citi es seem to be on the
right track , if policies are any indicat ion. Moving from theory
to practice however remains to b e seen. Policy makers need to
focus on involving communities to create their own unique and
alternative pathway s to sustainable developm ent that promotes
their health and wellbeing, without comp romising that of the
natural environment.
1 Christopher Dye, Health and Urban Living, 319 Sci. 766, 768 (2008).
2 See generally Amartya Sen, Health in Development, 77 bull. worlD
health org. 619 (1999), http://www.who.int/bulletin/archives/77(8)619.pdf
(proposing that one of the key roles of development is to liberate us from the
cycle of suffering from avoidable illnesses and “escapable mortality”).
Endnotes: Population Health through Inclusive Urban Planning:
Healthier Communities and Sustainable Urban Development
in Indian Cities
3 U.n. population FunD, State oF worlD population 2007: unleaShing the
potential oF urban growth, at 1, u.n Doc. E/31,000/2007, U.N. Sales No.
E.07.III.H.1 (2007) [hereinafter worlD population 2007], http://www.unfpa.
org/swp/2007/presskit/pdf/sowp2007_eng.pdf.
Endnotes: Population Health continued on page 73