Monday, 21 July 2008

Imagining the Medical City?

This Is Not a Gateway’s (http://thisisnotagateway.squarespace.com) recent salon discussion was implied, at least, to be a look at how medical understanding could influence the design of cities in the ‘developing’ world. Perhaps inevitably, given the western backgrounds of all the participants, the focus in actual fact was on the influence of medical thinking, hospital design and governance on the design of western cities, and most specifically, London.

Chris Sharp’s loose analogy of the city as a human body (roads and tube lines as blood vessels connecting various important vital urban organs, for example), was a useful way of putting the debate in context. Practitioners from various backgrounds traced the rise of improved services in the city, specifically water and sanitation, and events such as Dr John Snow’s local interviews and subsequent mapping of London’s 1854 cholera epidemic, which helped to show that this was a water-borne disease emanating from a contaminated source on what is now Broadwick Street, Soho. The idea of the salon was, then, to trace how advances in medical thinking have influenced the shape of the city (and the design of hospital buildings) since the Great Stink of London, 150 years ago, and to generate debate on future directions.

We were led through the history of medical thinking and its links to city planning and development, from drainage dating from 3,300 BC to the various utopian townplanning experiments of the 20th Century. The Great Fire of London heralded the first of the London Building Acts, which were designed to regulate against environmental hazards, through determining the materiality, height and density of urban development. Later Bazelgette’s sewers separated people from the pathogens they themselves produce, thus creating a less hazardous, and more pleasant, environment.

Now that more of the world’s population live in urban environments than in rural communities for the first time, what does historical experience tell us about how the development of cities should be managed? In the London context it might mean that there will be ever greater strains on services, and hence the health of the city’s citizens, as an increasingly dense population is squeezed into an area that cannot be radically increased because of the sanctity of the greenbelt. But urbanisation and density don’t have to mean more unhealthy cities. They may generate environmental hazards, but clustering closer together can also help to improve productivity, create wealth and make water and sanitation service provision more viable. Other services of benefit to the health of the community too, including public transport and provision of sports and arts facilities, are often dependent on sufficient density to create sufficient demand. It is the poor management of the downside to density – crime, grime, production of waste – that leads to the declining health of the city and its inhabitants.

The debate at TINAG was perhaps a little too clouded by long discussions on the nature (or not) of Utopia, surely a debate that should long since have been relegated to the dustbin of 1960s thinking. There is no utopia in any city and nor can it be created. Likewise, the gnashing of teeth over governance issues within the NHS and health thinking within government is no doubt valid, but perhaps out of step with the stated emphasis of TINAG to look for grassroots solutions to the testing issues raised by urbanisation.

In practical terms perhaps there could have been more emphasis on community based planning and development initiatives that have proved major successes in improving the environment – and limiting the exposure of people to environmental hazards, including faecal and other pollutants – such as the well known Orangi Pilot Project, in Karachi, Pakistan. The project included a planning approach which supported the local community in organising at the ‘lane’ (street) level and implementing its own low cost sanitation system. The model has been extended to other projects including housing, education provision and heritage conservation.
(www.oppinstitutions.org/
(http://eau.sagepub.com/cgi/reprint/7/2/227)

Perhaps the most eye-opening of the TINAG presentations was that made by Elizabeth Fonseca, an American Environmental Quality Officer working for LB Hammersmith & Fulham. She highlighted the poverty of the British approach to land quality issues, with a complex regulatory system, a lack of resources and problematic cross-council powers of enforcement that lead to unsustainable and downright cheap approaches to improving land quality. 

Only a fraction of the ground contaminants recognised in the USA or Australia are recognised in the UK, and the approach tends to be to do the minimum necessary to get through the planning system. Rarely are the available technologies used to achieve long-term remediation; instead, contaminated soil is simply dumped in landfill. When the precautionary principle to public health is marginalized in favour of ease of development, surely we are just storing up the next Great Stink?

Author: Lewis Eldridge

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