Life can only be understood backwards; but it must be lived forwards.
—KIERKEGAARD
The best way to predict the future is to create it.
—ABRAHAM LINCOLN
IN A DISASTER, people walk. They walk because they have to. Cars are often ordered off the roads and public transportation often has to shut down, even if temporarily.
Extreme weather events are occurring more and more frequently. The threat of terrorist attacks, and terrorist attacks themselves, in the Western world have also been on the rise. Many of us remember seeing on television the long lines of yellow school buses and cars and campers trying to get out of the most heavily affected areas in New Orleans during Hurricane Katrina. More recently, during Hurricane Sandy in New York City, power outages in the most ravaged areas of the city, such as the Rockaways, had residents of old-style social housing towers trapped on high floors because they were unable or too afraid to use the completely dark stairwells without any natural light. Many New York City government employees volunteered to walk, run, or rollerblade to find those whose homes had been destroyed by the storm, or who had no electricity in their buildings, so they could provide assistance.
In a recent severe snowstorm in January 2016, with record-breaking snowfalls, New York State Governor Andrew Cuomo mandated that cars remain off the roads. Public transportation rail tracks iced over and those lines had to be shut down. My neighbors and I, however, were not stuck without food or water. Although many of us had purchased non-perishable foods and filled up our bathtubs and pots and water jugs, or loaded up on bottled water, our neighborhood was spared from any power outage or water shutoff. Television news stories showed neighborhood stores whose owners and staff lived nearby and were able to open up for people living within walking distance, and that was the case with our nearby supermarket. Children and their parents who lived within walking distance of parks, especially parks with hills, ended up enjoying the snowy days with sledding and tobogganing. In contrast, those who had no amenities within walkable distances were trapped on their properties, hoping the storm would abate before any food they had stockpiled ran out.
I had not yet moved to New York City in 2001, but we all know stories about what happened on the morning of 9/11 when the Twin Towers fell. One woman I know worked on a high floor of a high-rise building in midtown Manhattan near the Empire State Building. She told me how she and her office colleagues watched on a small TV screen in the office as the first tower fell, and then the second, bringing the realization that this was no accident. A terrorist attack was happening right in their midst, just south of where they were. People ran down the stairs of the building and out onto the streets. They tried their cellphones to call their loved ones but the phone lines were overloaded, with so many others trying to do the same. People feared what could happen if they went into the subway. Many decided they would walk home. They hoped their loved ones would and could do the same.
Disasters, both natural and human-made, illustrate for us just how important it is that our homes, schools, workplaces, and grocery stores be at walkable distances from each other. This allows us to stay alive, healthy, fit, and with our loved ones when our cars and our public transportation systems cannot be relied upon. Which inevitably happens, sooner or later.
The work to create healthy built environments continues, and its successes are outstanding, in New York City and around the world. This is excellent news when we consider what it portends for the aftermath of disasters, and for the more insidious destruction caused to millions of lives yearly from obesity, physical inactivity, and unhealthy diets.
One of the key successes of the Active Design movement has been the growth of active transportation initiatives. Even before this book was released, my friend Sam Schwartz published Street Smart: The Rise of Cities and the Fall of Cars. A former commissioner in the New York City Department of Transportation and a transportation engineer by training, Sam spent a couple of hours with me one afternoon in his sunny boardroom in downtown Manhattan discussing the most important health issues today, and what his transportation engineering firm, Sam Schwartz Engineering, is doing, with a special focus on walkability, to make a difference. It is truly remarkable that a growing number of urban planning, design, and transportation engineering firms all over the world—from the forerunner, Jan Gehl of Copenhagen, to other international giants like AECOM and Stantec—are making active transportation a key part of their work. Well, one might say, with all the problems plaguing our cities today—from global warming to terrorism threats to obesity and non-communicable disease epidemics to the need for the economic revitalization of blighted urban districts to the needs of an aging population in many of our towns and cities—how could they not?
I now also regularly attend full-house public events where active transportation is the main subject. What started as a focus just for professionals and a few members of the public at our Fit City conferences has now become a topic that energizes many who work in the transportation and planning worlds, and inspires an increasing number of public events and book readings.
On March 9, 2016, I was at just such an event. Janette Sadik-Khan, former New York City Transportation commissioner, was going to be discussing her work on creating an “urban revolution” on and through city streets. To get to the event, I walked past many of the lasting infrastructure interventions the New York City Department of Transportation (DOT) had instituted during Janette’s time: striped crossings on narrowed streets, additional pedestrian spaces created with paint and plant potters, bicycle lanes painted in green, a large bicycle-share station with its bright-blue Citi Bikes. I arrived early, and good thing, too. There were probably a couple of hundred seats at the Barnes and Noble in Union Square, and I just managed to nab one before it was too late. Part of the reason for the excited crowd was that Janette was going to be on stage in conversation with David Byrne, the iconic singer, bike advocate…and designer of some city bicycle racks that were cool and quintessentially New York, like the one shaped like a red high-heeled shoe in front of the Bergdorf Goodman department store.
That night, Janette said many of the things that I have said in this book. She described her work as a daily fight to give people more choices, and pointed out that New York City created a model that any city can follow.
Successes in fighting the obesity epidemic are already being achieved by cities that have spent the last decade (or even less) in policy and practice efforts to improve their physical and food environments, so that more options and choices are made available to their residents and visitors for physical activity and healthy eating. After more than three decades of unrelenting rise, childhood obesity trends are now reversing in U.S. cities like New York, Philadelphia, and San Diego. After a mere decade of concerted efforts by public health professionals working in partnership with other government departments, professionals from other sectors, non-government organizations, community advocates, and individuals with the power to change the daily environments in which we work, go to school, play, and perhaps pray, we are starting to beat this modern-day public health epidemic. In New York City, physical inactivity in adults has also gone down in recent years, after a decade of no significant change. Adult obesity in New York State has also shown a recent reversal.
The successes that are being achieved in transforming our physical environment, however, are shadowed by insufficient progress on these issues in the developing world, particularly and most crucially in the increasingly developed and urban areas that are aspiring to become great cities in Latin America, Africa, China, India, and other Asian countries. Unfortunately, all too often these rapidly growing cities are modeling themselves on an outdated idea of Western cities; by replicating the car-dependent model, they find themselves increasingly plagued by traffic congestion and traffic-related deaths, air pollution, obesity, and non-communicable diseases. Active transportation policies and practices still need a great deal of work in these regions.
Additionally, although many cities in the developed world have begun to address active and sustainable transportation choices, the car is still the predominant mode of transportation, particularly in many cities in North America and Australia. And many cities still need to do much more on the issue of supporting choices for activity in buildings, and using government policy to address healthy food access and unhealthy food exposure. Although health departments across North America are increasingly working with corner store owners and operators to increase healthy options, too few cities are working on policies to improve zoning and tax incentives in order to ensure meaningful access to supermarkets, farmers’ markets, and community gardens in food desert neighborhoods. More cities need to follow the lead of Detroit, with its policy banning fast food restaurants around schools, and use city zoning policies to decrease our children’s unhealthy food exposure when parents are not around to help them make good choices. Like New York, other cities can also look at what policies governing food, physical activity, and screen time in daycares can be developed, implemented, and enforced. These settings-based building-scale and food issues have generally received less attention currently in the design and planning of cities than active transportation issues.
Though the progress has been encouraging, we still have a long way to go to bring obesity rates in both children and adults back to pre-1960s levels. Fortunately, since the release of the Active Design Guidelines, a whole set of second-phase—and even third-phase—initiatives in the movement for physical environmental change are afoot.
I first met Yianice Hernandez when she was director of research for Green Communities at Enterprise Community Partners, a non-profit organization started by an American developer and his wife, Jim and Patty Rouse, in 1982. The vision of the organization is to give everyone a decent, affordable home, and its key goal is to improve the quality of affordable housing in the United States, integrating environmentally sustainable “green” features into new developments. Shampa Chanda and Bea De la Torre, assistant commissioners in the New York City Department of Housing Preservation and Development (HPD) and key contacts for the work related to the Active Design Guidelines and their implementation, had recommended to me that I meet with Enterprise: “We already require all HPD-funded affordable housing projects to use Enterprise Green Communities criteria, so you should see how you can get them to integrate more health and Active Design criteria.”
One factor for success in cross-sector collaboration is listening to advice. I never tell my colleagues, who are experts in their own sectors, what I think they have to do. What I can do, however, is share with them what I know of the data and evidence concerning public health issues, including what has worked elsewhere and what studies have shown will lead to improvement in health outcomes. I also share whatever I discover that might be of benefit to their work. Strategies that can improve maintenance and decrease maintenance costs of the buildings and housing developments? Check. Strategies that can improve affordable housing residents’ access to necessary items like food, and especially healthy food? Check. I may even help them with creating public engagement initiatives, using health as a shared value among the public to lead the conversations for environmental change. Then, I wait. I may prod with emails and with questions at every meeting about what we could possibly and feasibly do within their departments and fields. But I always wait for their answers. And so, when I’m asked by other jurisdictions whether I faced opposition from other sectors to my work in New York, I am able to answer, definitively, “No.” You don’t tend to see opposition from others to the ideas that are their own.
The other critical factor for success is this: once I get advice, I always follow up.
I asked HPD for introductions to their Enterprise Green Communities contacts and searched for information on their website. Now my staff and I were on the lookout for people from that organization when we attended meetings on housing issues, and we sent emails to housing developers who might have contacts there. And we found Yianice Hernandez.
Now, I had to get Enterprise Green Communities on board.
Yianice and I met in her office in Manhattan, a bright, airy space with simple, contemporary furnishings that reminded me of the U.S. Green Building Council (USGBC) headquarters in Washington, D.C. With long, dark hair down to her mid-back and Woody Allen–style glasses, Yianice looked like a cross between a trendy singer and an academic. She explained that Enterprise Green Communities was an organization working to unconventionally integrate environmental issues into the social cause of housing those in need, with typically very limited budgets. And yes, they were indeed in the process of updating their Enterprise Green Communities Criteria and would welcome more health-related criteria for supporting and promoting the health and well-being of affordable housing residents.
Another key strategy for partnering successfully is sharing the workload. The last thing a potential partner wants to hear is that your request will turn into a burden for their already over-busy staff and organization. But if your requests for help come with an offer of staffing resources and extra capacity? That is a much better prospect. Yianice was delighted to hear that I could also offer her practical staff support. We had recently engaged Angela Aloia, a Presidential Fellow for the U.S. Department of Housing and Urban Development, to work with our team, and Angela could engage in the necessary but painstaking work of integrating the Active Design Guidelines strategies into the appropriate sections of the Enterprise Green Communities criteria for new construction of affordable housing. I am happy to report that our partnership was very successful and the new, merged criteria were released.
Incentives for Certification
It’s May 2015. I am in Washington, D.C., and it is a beautiful sunny Saturday. I have arrived a day and a half early, taking advantage of a ride-sharing opportunity, for the WELL Building Standard Advisory Meeting that will be taking place on May 11 and 12 at the USGBC headquarters. This meeting will be another second-phase initiative following on the growing awareness of and interest in health among architects and building professionals who were exposed to these ideas through the Active Design Guidelines, the LEED Innovation Credit for Physical Activity, and other first-phase initiatives.
The WELL Building Standard is a new building certification system for health and wellness created by the International WELL Building Institute, a public benefit company that has said it will reinvest over half of its profits in public benefit initiatives. It has made it its mission to improve health and well-being through the built environment, focusing first on the creation of healthier buildings. Like the Leadership in Energy and Environmental Design (LEED) green building certification system of the USGBC, WELL certification comes at a cost to the developer and building owner of tens of thousands of dollars. WELL is a market-driven tool, created by a former Wall Street banker who wanted to do some good using a business model. Although the USGBC is set up as a non-profit organization, while the International WELL Building Institute is a public benefits corporation, both use and rely on market principles. Companies pay a lot of money for certification, and that money in turn supports the certifying organizations’ staff. While many residents of new affordable-housing buildings are chosen through a local government lottery process for the limited number of available spots, other clients are buying or renting units at market-value prices. The certifications buy bragging rights for building owners and developers when it comes to the environmental friendliness or healthiness of their buildings, which helps them attract higher-paying residents.
The WELL Building Standard meeting started early on a beautiful sunny day in Washington, and I was glad to have walked to the USGBC headquarters, close to the hotel where I was staying along with the other expert reviewers from across the United States. In a sunlit conference room, the dozen or so experts would be put to two days of intensive work with the WELL leadership and staff. WELL staff provided an overall orientation to the WELL Building Standard at morning sessions, and the experts all participated actively as we laboriously plowed through each section of the standard, focused on Indoor Air Quality, Mental Well-being, Fitness, and Nutrition, among others. Air quality experts and psychologists offered their input on the sections on indoor air quality and mental health factors and interventions. There were worksite-wellness providers present. There were design firms present. I was there to provide a lens on obesity and on its related chronic diseases, looking at physical activity and access to healthier foods and beverages. Joyce Lee, who had relocated to Philadelphia, was also present.
About two months after this meeting, I received an email from Sarah Welton. Sarah had approached me some time back when she was finishing up her master’s degree to ask if I could spare some time to discuss career options with her. A fit triathlete, Sarah planned to work on healthier real estate developments, and after graduation she was hired by the WELL Building Institute. Sarah asked if I could assist WELL in a more intensive review of the section that she was charged with, Fitness, particularly by giving input into the research that would inform that section. I agreed, and reviewed for Sarah the research she had found, which she then used to create a document supporting the relevant criteria. Where there were gaps, I was able to help her add to her research data, and I put my experience to work, suggesting changes to the language in the hopes that reframing and rewording might increase the work’s appeal and salience to its broad target audience.
It has been over three years since I completed that review, and now that WELL has decided to move into community-level factors and pilot a set of criteria for rating communities, my expertise might be helpful once again. And so I came to work again with WELL, this time with Sarah’s colleague, Vienna McLeod, on the WELL Community Standard.
In order to be approved for construction in New York City, affordable housing developments with supports and funding from the Department of Housing Preservation and Development must now be Enterprise Green Communities certified. Although there are myriad mandatory and optional strategies to achieve certification, those mandatory strategies and a threshold of optional strategies must be integrated.
Outside of affordable housing, healthy building certification systems, while not mandatory, are gradually evolving. WELL now serves market-driven needs and desires in this realm, and a program called FitWel was previously initiated.
In 2012, while Joyce Lee was still at the City of New York, and while I was still the director of the New York City Department of Health and Mental Hygiene’s Built Environment and Active Design Program, we both received an invitation to travel to Washington, D.C. After undertaking the myriad bureaucratic steps to get travel approvals from City administration, Joyce and I found ourselves sitting around a conference table with six or seven others in the windowless conference room of a large hotel. The meeting was being led by the U.S. General Services Administration (GSA). The U.S. Centers for Disease Control and Prevention (CDC) had also been invited. Joyce and I had been invited because of our work in New York in leading the development of the LEED Innovation Credit for Physical Activity (which had, in its latest iteration at the time, become the LEED pilot credit Design for Active Occupants, integrating physical activity and health strategies into the LEED green building rating system). We had also co-led with interested developers the development of a LEED Innovation Credit for Urban Agriculture, and I had worked on an Innovation Credit for Healthy Food and Beverage Access for our new health department headquarters.
We were told that the GSA wanted to do more to make federal government buildings and office facilities that it built and managed healthier for government staff. There was an opportunity to affect the lives of hundreds of thousands of federal government employees who spent at least some, if not most, of their time in these buildings and facilities. Leadership and staff of GSA had thought that perhaps a healthy-building certification system could be created to systematically track—and push—each building manager’s implementation of health-promoting strategies. They wanted the CDC’s help, and mine, to identify the evidence-based health strategies. And they wanted Joyce’s and my experience in developing new healthy-building credits for LEED to inform their process. Since there was, at the start of the FitWel process, also a lack of building certification systems with a focus on health as the primary outcome, with WELL having not yet entered the market, our working group also envisioned that the FitWel process could begin with government buildings but eventually be extended to buildings outside the government sector. When I left the New York City health department in 2015, FitWel was in the process of being piloted in GSA, CDC, and City of New York government buildings. With the development of WELL as a market-driven tool released to the private sector, and with the 2015 Enterprise Green Communities criteria available for Affordable Housing and now intentionally integrating a comprehensive overlay of health criteria including Active Design criteria, the role of FitWel has become less clear. At the time of the writing of this book, WELL reported having 2,146 projects impacting 383 million square feet of real estate in 51 countries, while FitWel reported having 210 projects certified or pending certification.
Work to improve our physical environments for the prevention of obesity and non-communicable disease is taking place also, increasingly, on the international front. And it is much needed.
Working on the Built Environment Around the World
It is pouring rain, a heavy, tropical rain, and all of us in the van are wondering whether we can make a dash to the St. George University building for our workshop without getting soaked. Tall palm trees lining the driveway where we are parked sway in the warm, wet winds. We decide to wait it out, since we’re a bit early, but I’m uncomfortably aware that I’m the keynote speaker and I can’t be late.
Seeing that the rain is not going to relent, the driver of the van gets out and makes his way around to our sliding back door with a large, sturdy, bright-blue umbrella and escorts us to the building entrance one at a time.
The CARPHA Conference in Grenada is the first Caribbean conference on the built environment and health. CARPHA, the Caribbean Public Health Agency, is an agency backed by its member nations that provides them with supports on public health issues. For the Health and Built Environment workshop, we have convened in a large conference room that takes up the whole of the small, one-story building, and when I enter I’m greeted by colleagues from the Public Health Agency of Canada, who were also asked to attend. Tables have been lined up into a large rectangle in the back two-thirds of the space, and this is where we will be spending our days discussing just what can be done on the different Caribbean islands to improve their built environment for health, with a focus on the epidemics of obesity and their related non-communicable diseases, also a problem in this region. The audience will be local planning and health officials from all over the Caribbean.
I decide to improvise a bit as I start my keynote presentation, throwing in examples from my recent experience of the built environment in Grenada. I explain that I was barely able to cross the street from the hotel to the bus stop to catch my shuttle. There was no traffic light to produce a red for the cars and a green for pedestrians, and though there was a marked crosswalk and a pedestrian crossing light that was supposed to flash to alert the cars to stop, it didn’t work. I stood at the edge of the sidewalk for at least ten minutes, making myself and my intention to cross the street as visible as possible, but it was morning rush hour and there were so many cars that I didn’t dare try to cross the twenty feet of space. A woman who was trying to catch a local bus at the bus stop bravely made a dash for it, and finally, fearing I would miss my shuttle, I took a deep breath and did the same, running to beat the oncoming traffic from both directions—not an easy feat in a skirt and high-heeled shoes.
I go on to offer my observations about the sidewalks, which are so narrow that people are forced to walk single file. On the busy, narrow road from the hotel to the university, the sidewalks sometimes end abruptly, so that people have no choice but to step onto the road among the speeding cars. It is no wonder, I say, that everyone who can afford to owns one or two cars. It is no wonder that the rate of injuries from motor vehicle and pedestrian collisions is high. It is no wonder that this workshop is so desperately needed here, as elsewhere, in the quickly urbanizing world around us.
Rio de Janeiro is a beautiful city. With a topography of mountains and ocean and beaches in between, it is a city that attracts many international visitors. I’m there for a meeting on my way to São Paulo, Brazil, where I have been invited to lecture to and advise public health, planning, and architecture professionals on improving health through the built environment.
I arrive in Rio with one of my team members in the middle of the afternoon. The next day, I’ll be meeting in the morning with a Columbia University colleague who has been stationed there at one of the university’s Global Center offices, now situated in several cities around the world. After checking in, and then hanging my meeting and presentation attire in the hotel room closet, hoping to get out as many wrinkles as possible from being folded in my suitcase for the nine-hour overnight flight from New York, I head down to the hotel lobby. The young woman at the front desk, who tells us that she hopes this job will help improve her English because she wants to pass the entrance exam to the university, recommends a few sights we can take in before dinner. She also instructs us to remove our earrings, to make sure we carry some cash to hand over in case we are robbed, and to stay on the beachfront drive and not wander into the back streets. With that, we enthusiastically, yet nervously, make our way outside to explore the area. We decide, however, to eat dinner at the hotel, since she’s also advised us to make our way back to the hotel before dark. “The beach is not safe at night,” she warned. Even with all the hotel rooms, like mine, facing the Copacabana beach, it’s not enough to keep it safe.
Rio de Janeiro would say it has invested a great deal of money in tourism. It has built a cable car that will take you up its renowned Sugar Loaf Mountain. It has built a train that will take you up to the huge statue, Christ the Redeemer, that perches on a mountain overlooking the city. My team member and I visit these sites, lamenting that we can not walk to them, meandering the city’s back streets, stopping at locally owned small businesses to eat and to shop. The tourist books, the hotel staff, the locals themselves all warn against such activity. So, instead, we take a Gray Line bus to visit these sites, and we eat lunch at the one restaurant that the tour buses all seem to use for tourists. For other meals, we eat at the restaurants in international hotel chains. I have to ask myself just how much, or rather how little, this form of tourism has benefited local businesses and shop owners. This is so different from New York’s Times Square, where all the pedestrians, many of them tourists, have propelled the district and its many stores into one of the top ten retail areas around the world.
Even in cities where incredible work is happening on such fronts as active transportation—cities like Bogotá, Colombia, with its weekly ciclovía and its TransMilenio Bus Rapid Transit system—the rapid pace of globalization creates challenges that it will take all our concerted efforts to address. In Bogotá, the introduction of global fast food giants is a recent phenomenon. My health department colleagues there have told me that many people in the city still cook and eat at home—and if they go out, they visit locally owned restaurants that serve traditional Colombian food. But they have observed many in the younger generation beginning to regularly visit the fast food venues.
Although the world does not yet have much experience with using zoning to control the proliferation of fast food and unhealthy food in our cities, towns, and suburbs, I believe we must proceed to do this. We have experience enough using zoning to help prevent our children from being exposed to alcohol retail outlets, for example. But a great deal of our focus in trying to control unhealthy food—both in our discourse and in our actions—has occurred on the national front, particularly with federal agricultural policies and subsidies. Although this is a necessary and essential component of the dialogue and work in policy-making, attempts at national change meet pushback from powerful food industry lobby groups, which means that change is slow at best and very much lacking or thwarted at worst. There is a great need, and opportunity, for cities, towns, and counties that really want to do something about the proliferation of unhealthy food in our neighborhoods—often the neighborhoods with the highest burdens of obesity and diabetes, with children trying their hand at making their own choices without the benefit of their parents’ better judgment—to act now to create a healthier balance of choices for their residents. Some cities have begun this work. In addition to Detroit’s ban on fast food restaurants in the immediate vicinity of schools, Los Angeles, for example, has put a recent moratorium on new fast food outlets in the areas of their city with the highest numbers of fast food restaurants. Such municipal initiatives, however, are still too few and far between. Even in Detroit, there is a need to expand the area of the fast food ban around schools beyond a mere five hundred feet.
As cities grow, as new neighborhoods are being built and developed, as places like Bogotá globalize with the introduction of the international chains, it is imperative that zoning standards to set a healthier mix of food-related choices—ensuring the existence, or hopefully abundance, of venues offering healthy foods and beverages, and mandating a healthy ratio of healthy to unhealthy food venues and choices—be developed, implemented, and evaluated. We must not allow our new and existing neighborhoods to fall prey to a proliferation of unhealthy choices offered by international chains with deep, deep pockets for building and marketing. We must not accept the loss of local healthy food vendors, who have to struggle to compete. Local governments can begin to define the healthy choices—and the healthy minimum ratio of such choices to unhealthy ones—that must be present in all neighborhoods, so that their residents too can truly make meaningful choices for fitness, for losing or controlling their weight, and for their overall health.
Another key next step, globally, I believe, is training. Not just one-offs, but training that is repeated often enough for a sufficient number of people in the different disciplines needed to achieve environmental change to be trained. With support from the Kresge Foundation and the U.S. Centers for Disease Control and Prevention, such training was created and then offered repeatedly locally and across the U.S. by the New York City health department’s Built Environment and Active Design Program. Training can and should be implemented elsewhere for both practicing professionals and professionals in training across various disciplines—health, planning, architecture, housing, transportation. A replication of such successful trainings is needed in different cities to reach people around the world. And also needed are courses that can bring people from cities around the world together.
It is the first week of June 2015, and today is the first day of my Columbia University course Designing Healthy Cities to Reverse Obesity and Non-Communicable Disease Epidemics. After making my way to the course venue—a high-rise building at Columbia’s public health and medicine campus way uptown in Manhattan—on a dreary day of wind and rain, I load my overview presentation onto the classroom computer and then wait for my students to arrive. Those who have signed up for the course include university students, university professors, and practicing professionals in urban planning, public health, environmental sustainability, and even journalism. And my students will be local, from New York City, Long Island, and Connecticut, but also from Canada, Brazil, and Taiwan. The course is focused on teaching interested people from different disciplines to take available academic research and the evidence supporting it and apply it in the difficult real-world practice of improving our physical environments for health. It sounded to me like a fun challenge that could make a real difference in the field. Now, I’m working with universities elsewhere, including the University of Alberta in Canada, to create similar courses to reach those who may not be able to travel to New York. And we have been repeating that successful course at Columbia University annually.
There is also something to be said, though, for a course that aims to bring local professionals together to work toward solving their particular local problems. One of my recent trips abroad was to conduct multi-sector training for Macau, China. Macau is a special territory that, like Hong Kong, is exempt from the usual visitor visa requirements of mainland China. This comes as a relief, because several times I’ve had to spend hours waiting in line for the Chinese consulate, on the far west end of 42nd Street in New York City, to open its doors at 8:00 a.m. in order to get visas for consulting trips to Shanghai and Beijing. This time, all I had to do was email the organizers my training presentation and materials…and pack!
This training was a follow-up to a meeting a few years back in Shanghai at which I had been a special adviser to the World Health Organization (WHO) Western Pacific Region Office. The same WHO office was now organizing the training for Macau’s Health Bureau. Macau’s public health officials had been among the attendees at that Shanghai meeting, and had been intrigued by the presentations that had been given there by myself and by my colleague, Chew Ling, from the Singapore Health Promotion Board. They wanted to learn more about cross-sectoral approaches from me. And they wanted to learn more from the Singapore Health Promotion Board about their government-involved “healthy hawkers’ center” initiatives (see chapter 4). As well as local health professionals, the Macau meeting included a small array of other sectors, such as the police. The partnerships weren’t yet extensive, but it would be a start to their cross-sectoral work. Since it was a workshop, the participants would be broken up into cross-sectoral teams to brainstorm together and identify their local health priorities and potential locally based solutions.
Such trainings and courses are happening, too, in many North American cities. In Edmonton, Alberta, my old hometown (and now my new hometown, too!) I initiated a cross-sectoral course for the University of Alberta. The university had fairly recently created a School of Urban and Regional Planning, and its inaugural chair, Sandeep Agrawal, had seen my keynote presentation in Fredericton, New Brunswick at the 2014 annual national conference of the Canadian Institute of Planners. On one of the conference’s field tours—to see the new pedestrian bridge connecting city neighborhoods on opposite sides of the city’s river to the other—we got to talking. Sandeep had also joined an earlier field tour that day that brought him and several others to the site on bicycles. He was in his spandex bicycle shorts, helmet still on, when our discussion began. We talked about the course I had created for Columbia University, and another that I had designed for New York’s Pratt Institute. He recognized that he wanted to see just such a course offered through his new department.
And so, in February 2016, urban planning students were brought together with urban planners working in government, health ministry staff with local disease and risk factor data to share, recreation professionals, private sector developers, and even the mayor of the Edmonton suburb of St. Albert, Nolan Crause, and a former St. Albert city councilor, Len Bracko. (St. Albert was coincidentally where my parents first settled in the province, and where my brother and I started our schooling in Canada.) One developer, Greg Christenson of Christenson Developments, gave us a tour of one of his projects: a downtown development that had been designed to foster the revitalization of an area that was largely just abandoned railway lands, a nearly deserted area and desert-like, in need of city water and sanitation connections and other amenities. Greg led the tour and showed us bicycle and walking trails—both a transportation and a recreation amenity—that had been integrated among the development’s multiple condo and townhouse buildings, some geared toward seniors, others geared toward luxury downtown living. This had been a rails-to-trails project of sorts too, only starting with new, higher-density housing as the focus. We noted how the trails came to an abrupt end where the private development ended, only a few blocks away from Edmonton’s river valley network of parks and recreation trails. If only the different sectors, government and private, had found a way to co-create this initiative along with much-needed surrounding amenities, like bicycle lane connections onto the city’s streets. It is my hope that through the training course, the different disciplines and players being brought together will spark just such co-creation projects. And I am happy to report that now, three years later, the bicycle lanes have indeed been painted onto the connecting city streets, and these lanes in turn connect onto yet another off-road bicycle path leading to the miles of trails in the river valley.
Transforming Through Innovation and Technology
Innovations in technology. Innovations in recreation spaces. Innovations in the design of basic amenities. These too are opportunities that we will need to capitalize on, because thus far we have not done so sufficiently. There is a segment—or several segments—of our population that spends significant amounts of time watching sports. While favorite athletes and sports teams exert themselves, getting fitter, burning calories, these fans are sedentary, sprawled on their couches, eating potato chips or nachos. Or sprawled on paid-for seats in an auditorium or sports field, eating hot dogs and french fries. Even parents who have made it their mission to get their children active by signing them up for team sports find themselves sitting for hours on end as they wait for and watch their children practice or compete. Their usual alternatives are to sit on the benches or bleachers, or head to the café to have a hot dog, hamburger, chicken fingers, french fries, or pizza. As their children stay fit, the parents themselves gain weight. Time spent getting their children healthier takes a toll on their health.
Many people have said they have little or no time to exercise. But they would like to, they say. They continue to make their New Year’s resolutions. And they continue to fail.
In addition to transforming our neighborhood designs—transformations that will take time, particularly in existing suburban neighborhoods—perhaps we need to think about innovations in our recreation spaces. What if these parents, what if all sports spectators could find a more active way to pass the many hours they usually spend sitting? What if all the seats for watching Little League—or the major leagues—were not just seats? What if there were exercise bikes and elliptical machines that spectators could use at sports venues? What if parents had opportunities for healthy choices while ensuring that their children were active and healthy? What if children could see their parents modeling healthy and active behaviors in adulthood, while they play?
Taipei’s parks have done just that. Surrounding their playgrounds and children’s play equipment, instead of benches, they have outdoor elliptical machines, exercise bikes, and weight and stretching equipment for adults to use. Some parents and grandparents can be seen sitting on the exercise bikes, pedaling some, resting some. Others spend their whole time on the ellipticals, making good use of their children’s play time to get in their own physical activity.
In Hong Kong, a dance club is using innovations in technology to green its space. Energy-capturing floors turn the stomping, jumping, moving feet of its customers into electricity. I have often asked myself: What if all our building hallways, the steps of our stairs, even our sidewalks used such energy-capturing technology? Sure, the technology might need improvement. Sure, it is expensive now. But adoption and use of the technology is precisely what is needed to bring down the cost and identify and fix the glitches. For ourselves and our children, there are now backpacks that can capture the energy of our movement, of our walking—energy enough to perhaps charge a cell phone. I have charged my own cell phone by plugging it into one of the outdoor exercise bikes on the streets of San Francisco. There are similar charger bikes at Charles de Gaulle Airport in Paris. What if our wish to make our environments greener could be made through our own bodies, through our innovative choices for health? What if more cities made the choice to use the technological innovations available now to motivate their residents and visitors to be healthier and greener all at once?
In Switzerland, there is a hotel whose back side you can ski down, creating an amenity usually associated with a trip to the national park. There is also, in Copenhagen, a residential building called the “8 House,” shaped like a figure eight seen from above. Here, front terraces connect to a long, low-grade, sloping ramp that makes its way up and down the figure eight; the ramp passes condo units as it makes its way up from the city’s street at the bottom to the top of the building, and then again from the top of the building past more condo units down to the bottom of the building and back to the streets. Residents use the long ramp to ride their bicycles from the street up to their condos at the end of their workday, and then down again to work the next morning. Denmark’s pavilion at the Shanghai World Expo also incorporated a ramp, this time one that coiled up a round building. These are just some of the innovations in design that we heard about from the architecture firm BIG—the Bjarke Ingels Group, named for its founder—at our Fit City 6 Conference. Bjarke Ingels, a youthful, energetic young architect, has built the reputation of his firm on innovative, playful, audacious designs. BIG is now constructing its unusually designed buildings all over the world, including projects in New York City. Bjarke has spoken of the new towers his group is building in Lower Manhattan, which twist upward and look as though they are stepped, evoking a sense of stepping up to heaven. Stairs, bicycle paths, ski hills, all on a building—we need more of this!
We need, too, more innovation in design for other basic amenities. It seems that wherever I go, I hear about the obstacles presented by the local weather. When I am in Canadian cities, or other cities and towns with snowy climates, I hear about the snow. “How can people walk and bicycle in the winter?” I am frequently asked. When I am working with clients in Miami, I hear the same concerns about weather, though the conditions are the very opposite. “How can people walk and bicycle in summer?” they ask me. “It’s too hot here for such activities.” And my response has two parts.
The first part of my answer is that when it comes to snow, operational decisions within cities and towns are critical. Cities and towns can, like Montreal, clear their car lanes, bicycle lanes, and sidewalks of snow with equal priority. If city or town officials are more courageous in their push for health and well-being, greening, and even retail and economic outcomes, they can clear the snow on bicycle lanes and sidewalks first. That’s what cities like Copenhagen do, allowing seniors and children as well as adults to use these routes for safe, easy travel throughout the year. Copenhagen is on track to reach its goal of at least 50 percent of its population traveling on city streets—and even suburban streets—on bicycles.
The second part of my answer is that, in order to address weather in the local context, we need innovations in design for the local context. Is there any reason why every bicycle lane must be nothing but a painted lane on the side of a street? Bicycle lanes can be moved from their usual position—precariously in between parked cars and moving vehicles—to a position between the sidewalk and the parked cars, with the parked cars acting as a protector. So, can’t bicycle lanes come with other amenities? Like roofs and awnings, perhaps? If bicycle lanes are more routinely located between city sidewalks and parked cars, then rainy cities can perhaps more easily find ways to shield both their pedestrians and their cyclists to keep them dry. Windy cities might consider more innovative landscaping and design to shield pedestrians and cyclists from the weather. Infrastructure materials matter too, and more can be and should be done to address them. Are there road surfaces that work better for the bicycle? Are there surfaces that work best for pedestrians of different ages and physical abilities and needs? There are now technologies to heat sidewalks so that they may never need to be shoveled…
And Also…The Social Determinants of Health
“We shouldn’t forget the social determinants of health, also,” I am telling Jenny Che, a reporter from The Huffington Post, who is interviewing me for an article about workplace health. As our interview ends, I emphasize again that organizations really need to support the health of the people who work for them by making healthy choices possible, in both the physical and the social environments that people find themselves in day after day.
Of course, I am thrilled that an increasing number of cities and countries around the world are finding help to improve their physical environments in order to address today’s epidemics of obesity and related chronic diseases, and at the same time to also improve their environmental and economic issues. But I also recognize that this isn’t enough.
I hope that another new movement may be afoot. A movement that will address persistent issues related to health, issues such as lack of access to good education, or even education at all, for children of families living in poverty; absolute and relative material deprivation arising from low wages and income inequality; and stressful working conditions. And these issues bring me full circle to my early days in medical school, when my interest in public health was piqued by this idea of health having a set of social determinants.
In 1999, I was in my third year of residency in Public Health and Preventive Medicine at the University of Toronto, and much of that year for me was taken up by my work at the Institute for Work and Health, a world-renowned institute for research into work factors and their impacts on health. I was summarizing the research that had been done on sources of work stress and cardiovascular disease. Each morning for nine months of that year I would find myself walking to the St. Clair West subway station from the walk-up apartment that I shared with roommates in one of the few apartment buildings that could be found just east of Spadina Avenue on Lonsdale Road in the Forest Hill area of Toronto. I would take the subway downtown to St. Patrick Station, then walk to a high-rise building at the northeast corner of Dundas Street and University Avenue. When I reached my floor, I would swipe my cardkey and enter the offices of the Institute.
During that time, I had recently completed the Master of Health Science program, and I had learned a great deal about the social determinants of health, including fascinating research evidence showing the impact of the sanitation movement and improvements to the physical environment on improving public health in the nineteenth and early twentieth centuries. I learned, too, the importance of social environments to public health; for example, the education of women is now well known in public health to be an important factor in improving key health indicators such as infant mortality, as well as child health outcomes later in life.
I also learned of the studies conducted by a British epidemiologist, Michael Marmot. Professor Marmot was the lead researcher in what came to be known as the Whitehall Studies. “Whitehall” referred to the offices of the British Civil Service, and the Whitehall Studies were a series of epidemiologic studies conducted on British civil servants, beginning in the early 1970s. Already by then it was well known that being poor was associated with having unfavorable health outcomes. Marmot, a young researcher, had decided to study British civil servants because he wanted to know whether poverty was associated with poor health outcomes due to absolute or relative deprivation. Marmot reasoned that since no one who worked for the British Civil Service would be in absolute poverty, by undertaking studies of employees within the Civil Service he would be able to begin to determine if relative differences in wealth and social status mattered. And indeed, he found, these relative differences did matter—they mattered a lot.
Marmot’s studies showed that, with respect to all health outcomes measured, there was consistently a stepwise gradient that could be found from the highest employment grades to the lowest. Those at the lowest employment levels showed the highest rates of deaths, regardless of the causes studied. Those at the next level up showed the next highest rates, and so on, until you reached the highest employment levels, which showed the lowest rates of deaths and disease. This actually seemed counterintuitive at the time. Since none of the subjects in the studies lived in poverty, it had been expected that perhaps those working at the highest employment levels would show higher rates of conditions like heart disease, caused by the mental stress associated with increased responsibility. But this assumption was proved wrong.
Marmot found that after he factored in all the physical and behavioral risk factors known for heart disease—high blood pressure, smoking, exercise, and so on—he was still unable to account for over 50 percent of the gradients that were seen between the employment levels. At least, not yet.
In 1997, Marmot finally solved some of this puzzle. Repeating his Whitehall Studies, this time he also measured another key factor that had been emerging in the research of the 1970s, ’80s, and ’90s as being an important one for heart disease: how much control one had over one’s job. The studies had been showing that job control appeared to be more consistently associated with the development of heart disease than job demands. The jobs most likely to be associated with the development heart disease were those that had high demands coupled with low job control. So, when Marmot included this factor in his subsequent Whitehall Studies, what did he find? The latest study showed that job control was about as important to the gradients in health as all of the other traditional risk factors combined, with the traditional risk factors combined accounting for about 45 percent of the gradient and job control another 45 percent. Marmot had now shown that he could explain about 90 percent of the employment gradients seen in health, gradients in health that had nothing to do with living in poverty. So, in addition to the absolute material deprivation that living in poverty poses, it would appear that elements in our social environments, such as hierarchy and a sense of control, are really important.
Since the early 1990s, another British researcher, Richard Wilkinson, has been publishing studies specifically focusing on income inequality and health. Unlike Marmot’s studies, which focused on government workers in Britain, Wilkinson’s studies looked across the world. He used known measures of income inequality and compared the health outcomes of more equal and less equal countries. He found he was able to draw a straight diagonal line across the plotted points on his graph comparing life expectancy to income inequality. As income inequality rose across countries, life expectancy dropped, and all sorts of health and social outcomes—ranging from child health outcomes to crime and mental illness to obesity—also got worse.
Wilkinson and his colleagues have conducted further studies, including those looking at how income inequality can affect people in poor neighborhoods and in wealthy neighborhoods. His studies found that greater income equality benefited the health of people in both wealthy and poor areas. In other words, income inequality is not an issue that only the poor should be concerned about, at least not if we care about improving our health.
Bill de Blasio won the November 2013 mayoral election in New York City by running a campaign based on addressing what he called “a tale of two cities.” One, a city of the wealthy and prosperous; the other, a city of the poor.
One of my previous projects as a consultant was with New York City’s Regional Plan Association, helping them to integrate health considerations in the development of a Fourth Regional Plan for the New York Metropolitan Region, a region consisting of the many cities, towns, and suburbs surrounding New York City in the three states of New York, New Jersey, and Connecticut. In this work, with funding supports from the Robert Wood Johnson Foundation, we considered the health priorities in the region, and we recognized that if we were going to do something about improving these health outcomes, the physical and social environmental determinants had to be addressed. Income inequality, for example. The New York Metropolitan Region is marked by growing inequality. And it is not only the poor who are getting poorer. The middle class is getting poorer, too. In the New York Metropolitan Region, studies have shown that only the top income quintile enjoyed an increase in median income between 1990 and 2013. The second-highest quintile showed stagnant incomes, while the other three quintiles showed a decrease in their incomes. In other words, the trickle-down theory so popular with some did not work, at least not in the context of the New York Metropolitan Region’s economic growth. Instead, we saw a trickle-up of wealth, and a growing gap in the incomes of the rich compared to everybody else, something being seen increasingly elsewhere too.
In the New York Metropolitan Region, we also found disparities in educational access. Forty-two percent of Blacks and 40 percent of Hispanics were living in high-poverty neighborhoods, and their children were disproportionately attending schools in poorly performing school districts. With education such an important determinant of health, it is no wonder that the health of these demographic groups is disproportionately poor. The assault of unequally unhealthy physical and social environments on these poor children is leaving its mark permanently on their health.
When Dr. Mary Bassett was appointed Health Commissioner by Mayor de Blasio, I immediately sent her an email asking for a meeting. I wanted to discuss what we could possibly do with the new mayor within the context of the social determinants of health. She accepted, and I prepared for our meeting by undertaking a literature search and drafting a document listing ideas for discussion, a document I would leave behind for her after our meeting.
Our meeting was on a very cold day in early 2014, and I made my way to her midtown Manhattan office, in the high-rise building that housed the Doris Duke Charitable Foundation, where she had until recently been program director for their African Health Initiative. I was shown to her office and found Mary frantically sending emails, clearing her desk, and preparing for a trip to Zimbabwe, after which she would take up her new position at the Department of Health and Mental Hygiene. Mary had previously been a deputy commissioner at the health department when I first started, and I remembered her as someone who cared deeply about social justice. Tall and slim, Mary had a head of dark, curly hair that was just starting to be peppered with gray.
Mary asked about my ideas, and I was only too happy to share them, having waited for years—a decade and a half, in fact, since my residency project on work stress and heart disease—to delve once again into the social determinants of health.
According to the World Health Organization, health has three major determinants:
the social and economic environment,
the physical environment, and
the person’s individual characteristics and behaviors.
The above three categories can be broken down further into:
Income and social status—higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
Education—low levels of education are linked with poor health, more stress, and lower self-confidence.
Physical environment—safe water and clean air, healthy workplaces, safe houses, communities, and roads all contribute to good health.
Employment and working conditions—people in employment are healthier, particularly those who have more control over their working conditions.
Social support networks—greater support from families, friends, and communities is linked to better health.
Culture—customs and traditions, and the beliefs of the family and community all affect health.
Genetics—inheritance plays a part in determining lifespan, healthiness, and the likelihood of developing certain illnesses.
Personal behavior and coping skills—balanced eating, keeping active, not smoking, not drinking inappropriately, and how we deal with life’s stresses and challenges all affect health.
Health services—access to and use of services that prevent and treat disease influence health.
Gender—men and women suffer from different types of diseases at different ages.
The World Health Organization defines the “social determinants of health” as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”
Other organizations have also attempted to quantify the impacts of the different determinants. In the United States, the Robert Wood Johnson Foundation has worked with the University of Wisconsin to quantify the different factors contributing to health. While clinical care contributes about 20 percent, physical environmental factors and health opportunities together contribute about 40 percent, and social and economic factors—like education, employment, income, family and social support, and community safety—are thought to contribute the final 40 percent.
In my work with the Regional Plan Association, we created an adaptation of this model of the determinants of health for urban planning. In this adaptation, we showed that the physical environment can shape not only water and air quality, but the opportunities for health-related behaviors, behaviors like tobacco use, diet and exercise, and alcohol and drug use. We started to show also how the physical environment can additionally shape the social and economic environment. Housing policies are particularly important.
In 2014, I wrote a paper for the World Health Organization entitled “Working Across Sectors for Health Equity” for their special report Cities for Health. In this paper, I discussed the possibility of improving the physical environment and standards for the physical environment across all neighborhoods, including and especially impoverished neighborhoods, as one critical way to address the health disparities so often seen in our cities. But in my recent work with the New York City Metropolitan Area’s Fourth Regional Plan, I have also been advocating for increased consideration and action on the interplay of our physical and social environmental factors. We can shape even educational access with the choices that we make concerning housing. Yes, really. If we have only large, expensive, single-family homes in good school districts, then only wealthy children will have access to those schools. If we have only poorly designed low-cost apartment rentals in poor school districts, then the local tax base formula used in the United States to fund schools means that those school districts will never be able to improve. So, our housing mix policies—our built environment policies—and whether they integrate a range of incomes in all our communities are also drivers of the social environments of different neighborhoods and consequently affect health outcomes.
But the social and economic environments that are not shaped by the physical environment also need to be addressed.
Mary Bassett has implemented some of the ideas we discussed together—for example, creating a new office within the New York City Department of Health and Mental Hygiene with a focus on health equity—but there is a great deal more to do. I have suggested that the city, under its current administration, could become an example of what is possible in terms of making interventions to positively affect the critical social environmental determinants, just as we showed what was possible in making changes to physical environmental determinants under Mayor Bloomberg. Why not use City of New York government projects and workplaces to show what can be done? With Mayor de Blasio having emphasized income inequality—the “tale of two cities”—as his main campaign platform, I suggested that the City set an explicit maximum income gap, even if not initially for the unionized employees, then for its non-union employees. We can do this in Canada also, for example, starting with the income policies found in public health and health care organizations and the government sector. I suspect that in the public sector it would in fact be very feasible to set a relatively narrow income gap, since the existing differential between top and bottom pay scales is unlikely to be of the width seen in the private sector. In the U.S. private sector, there is, on average, an over-300-fold difference, which can stretch to an over-1,000-fold difference, between CEO and worker salaries. I am still waiting to see this happen in the public sector in New York, and I find myself asking: If not under the administration that won an election based on its commitment to ending income inequality, then when?
For those who believe that there should be no limits on income when it recognizes talent and results? A fixed income gap is not a fixed maximum income. Rather, it’s a policy that would allow everyone in a company to feel motivated toward growth, because company outcomes that bring the CEO and top executives bonuses and higher salaries would mean bonuses and higher salaries for everyone else in the company, too. I believe in our unlimited potential—and I believe in fairness, and in being equally motivating to all of a company’s employees.
There is much talk of minimum wages these days, but much less talk about what can be done to address income inequality. However, in the United States, as in Canada, after years of stagnant minimum wages, there is now a reconsideration of these wages that can leave even full-time workers and their families in poverty. Even in 1997, when I was studying for my master’s degree at the University of Toronto, minimum wage had fallen so far behind the initial 1970s levels that a person earning a minimum hourly wage would have to work over seventy hours a week to reach the poverty threshold set by Statistics Canada. Fortunately, there are initiatives now that are raising, or planning to raise, Canadian and American minimum wages. But these discussions must ensure that indexing for inflation is built in, so that any new progress made isn’t soon lost again to inflation.
As I sit with the reporter from The Huffington Post, I find I must also share with her some additional ideas that I have for these social determinants of health. I tell her I think responsible companies, and even government employers, can start to set standards for a maximum income gap. We could opt for a maximum six- or ten- or even twenty-fold difference in the ratio of top to bottom salaries and a maximum ratio too for top to average salaries in our organizations. It is not unheard of. Though the situation may be changing more recently, Japan has had gaps in the range of a six-fold difference between CEO and worker salaries. Japan, I tell her, has today’s longest life expectancy and lowest per-capita health care spending.
I tell her about job control. “Employers don’t have to wait for their employees to take a stress management course, courses that many employees don’t take up even when offered, probably because they have to rush home to their kids after work,” I tell her. There are things employers can start to do now. They can directly structure their workplace social environments to give their employees more control over their jobs, wherever and whenever that is appropriate. So, while someone sitting at the front desk might not be able to work from 9:00 a.m. to 5:00 p.m., if a business is open from 8:00 a.m. to 4:00 p.m., perhaps the person sitting in the back office can if that is the needed flexibility that makes the difference between more work-life balance rather than less. If there are multiple front desk staff, perhaps there is some way to stagger their schedules according to their needs rather than using a system that sets those schedules arbitrarily. There are many other strategies. Some cities in Europe have restructured bus routes and schedules with the help of their drivers to more realistically achieve the scheduled stops, to increase a sense of control for the drivers, and to drive down their high rates of heart disease.
And again, fundamentally, I find myself talking about the creation of more choices. In the social sphere, as it is in the physical environment, helping people to be healthy, to be more fit, is fundamentally about what our governments and our organizations can do to give people more choices. Choices shape our health—whether we are choosing how best to structure our seven- or eight-hour work day so it balances our family’s needs, or choosing what we buy because we have a non-poverty-level wage, or choosing to work harder or less hard because company outcomes ultimately shape our incomes as well as our CEO’s, or choosing to eat healthy food or drink water because it is available to be chosen, or choosing to walk or bike to work.
When we can make these choices ourselves, we are taking control of our health. And a key role of fit cities is to facilitate such choices, to make them choices that are truly possible for people.