Healthy by design

Wellness-focused urban planning is crucial for China to increase life expectancy and reduce chronic diseases by 2030, experts say

A new report on designing healthy urban areas in China says cities "should integrate health into urban planning and design" as the first step toward integrating health into all policies.

The report, published in April by the leading medical journal The Lancet, says the key to building a healthy nation is creating safe, walkable cities where people can get exercise as part of their daily lives. This is especially important because the population is aging and cases of diabetes, high blood pressure and chronic heart disease have been rising.

A senior citizen operates a multifunctional chair designed for elderly people in a technology exhibition in Shanghai. Fang Zhe / Xinhua

This approach will be crucial for China to reach the goals of its Healthy China 2030 plan to increase life expectancy, reduce chronic diseases and provide universal healthcare by 2030, says the report by the Tsinghua-Lancet Commission on Healthy Cities in China, which was led by Tsinghua University in Beijing.

Toward this end, 38 cities in China have been chosen by the central government to serve as pilot cases for building healthy cities, the report says. In addition, the central government, working with the World Health Organization, plans to hold a healthy city conference of China's mayors in December in Chengdu, Sichuan province.

Gong Peng, professor of Earth system science at Tsinghua University and co-head of the Tsinghua-Lancet Commission, says all agencies of city governments need to cooperate to promote health.

"If I were to advise the mayor of a city, I would tell him to get the public involved. And break the walls between departments in the city.

"Everybody needs to join forces and share information. Give big data a big role in solving urban health problems. Emphasize the private sector, because they hire most of the people in the city."

For example, he says: "In Luzhou, Sichuan province, health and hygienic city development was traditionally administered by the health department. But Luzhou made it part of the urban construction commission, which has more money. Under the health department, it was marginalized. (And) in Chengdu, the health department is now invited to city planning meetings."

Gauden Galea, representative to China for the World Health Organization, says: "The aim to increase life expectancy across the whole of China to 79 years by 2030 means that there has to be over one week of life expectancy increase every month between now and then for 1.4 billion people, so we are not talking about a small endeavor. Certainly, it can't be done if the cities are not healthful.

"If we are going to achieve the goals of Healthy China 2030, we have to take health deep into all policymaking discussions."

The Shanghai Consensus on Healthy Cities, reached in 2016, was a big step toward integrating health in planning. A statement issued by more than 100 mayors from many countries who met in 2016 in Shanghai at a conference sponsored by the WHO and the Chinese government concluded: "(We are) united in the knowledge that health and sustainable urban development are inextricably linked and steadfastly committed to advancing both."

During the National Health Conference in August 2016, President Xi Jinping stressed that health is a prerequisite for people's all-around development and a precondition for economic and social development.

The State Council and the Communist Party of China Central Committee followed up with the Healthy China 2030 Planning Outline in October 2016, which concluded: "The first (core principle) is health priority. Based on conditions nationwide, healthcare should be prioritized and placed in a strategic position in the whole process of public policy implementation."

Since 1949, China has had great success fighting communicable diseases, improving hygienic conditions and improving care of mothers and newborns. Life expectancy has increased nationwide, from 41 years in 1950 to 65 by 1975 and to 77 today - only slightly below the level of the most advanced countries. A mid-May report from the World Health Organization said China has now surpassed the United States in terms of "expected healthy years" of life.

In addition, more than 95 percent of the population is covered by basic health insurance, according to Xinhua News Agency.

Gong, of Tsinghua University, notes that Premier Li Keqiang made the commitment that AIDS and tuberculosis, as well as any emerging infectious diseases, need to be treated for free. Though this goal has not yet been reached for all infectious diseases, much progress has been made. For example, everyone diagnosed as HIV-positive gets free treatment in China, Gong says.

However, at the same time that communicable diseases have been fought successfully, people have developed chronic diseases that are often caused by a sedentary lifestyle, unhealthy food choices, pollution or smoking.

For example, a study by the China Center for Disease Control and Prevention and Peking University found that, in 2013, 10.9 percent of Chinese had diabetes - up from about 3 percent in 1990. However, only about one-third of the diabetics were aware of their condition. Another 35.7 percent of the population were prediabetic, meaning that, without treatment and lifestyle changes, they are likely to get full-blown diabetes in the next five to 10 years.

In addition, the Tsinghua-Lancet Commission report concluded that mental disorders and depression in cities are a growing problem.

Vanessa Candeias, head of the global health and healthcare system initiative at the World Economic Forum, says that WEF-Harvard School of Public Health research calculates that the economic costs in China of noncommunicable diseases and mental illness will amount to $23 trillion between 2012 and 2030 - more than $1 trillion per year.

Meanwhile, experts say that making a city walkable is an essential component of a healthy urban area, since walking is considered key to a healthy lifestyle.

A 2014 study published in the journal Preventive Medicine said people were significantly more obese in Chinese urban neighborhoods that were rated less walkable.

"We need a walkable city that is accessible as a whole, where our reliance on cars is reduced, thereby promoting active lifestyles," says Chinmoy Sarkar, assistant professor of urban health and environment at Hong Kong University.

"Proper land use allocation that optimizes the city's density and mix of uses can enhance access to services and recreational blue-green spaces," Sarkar adds. "We need to design spaces so they are actually used by the resident populations, including older people. Design that explicitly aims to promote health will make cities more accessible, promote active living, encourage social interactions and reduce dangers."

Many Chinese cities are making progress in improving walkability. Beijing, Shanghai, Chengdu and others are in the process of building hundreds of kilometers of greenways. Guangzhou, the capital of Guangdong province, has achieved one of the highest levels of walkability in the world, after redeveloping the banks of the Pearl River to create 60 miles (96.6 kilometers) of greenways linking 7 million people.

A study released in December by the Natural Resources Defense Council rated 95 percent of Chinese cities to be "somewhat walkable" or "very walkable".

However, the dangers posed by cars and other vehicles create problems in walking around China's cities.

Besides pollution - calculations by Beijing's Environmental Protection Bureau concluded that vehicles are now the predominant source of air pollution in the city - vehicles create other risks. According to the WHO, 260,000 people die in China each year as a result of road incidents - and 60 percent of those are vulnerable pedestrians, cyclists and people on motorcycles.

Pedestrians in Chinese cities are often startled by couriers on nearly silent electric scooters speeding down the sidewalks. And walkers have a hard time crossing the wide roads in China's cities, especially with aggressive drivers making left-and right-hand turns and motorcycles and electric scooters coming from all directions.

A report issued in May by the Traffic Management Bureau of the Ministry of Public Security said that almost 4,000 pedestrians were killed in accidents at road intersections in the past three years. Ninety percent of those deaths were caused by vehicles that did not adhere to traffic rules, it said, adding that the bureau plans to improve traffic surveillance, expose those who break the law and set up more footbridges.

Beijing has announced that it plans to encourage 75 percent of residents to commute by public transportation, bicycle or walking.

But John Zacharias, chair professor at Peking University's College of Architecture and Landscape Architecture, says there will be conflicts with motorists.

"I would say that (Beijing's goal) is absolutely achievable, but it is going to be extremely painful because, the thing they don't want to do yet is restrict the supply of road. Cities are super-reluctant to reconfigure the roads - to reallocate the road for other uses. I don't see how else it is achievable. The car ownership rate in Beijing is high. Why would people give up their cars unless there are serious costs to driving a car?"

Zacharias' research has found that increasing the perceived safety of the environment by reducing crossing distances at major intersections, providing shade on streets and other such measures can have huge effects on the willingness of people to walk in their daily lives.

"What I can see is that you can increase walking distance for sure at least 30 percent, and possibly as much as 50 percent, by changing the walking environment," he says.

Galea, the WHO representative, says neighborhoods should feature mixed use and include what he calls "self-contained villages".

"The opportunity should be taken to develop communities. You see massive residential communities - in order to get to anything you have a long journey to make - especially if you are disabled or elderly. So a well-functioning community within the city would have a number of functions - a shop, a place of education and other services," he says.

According to Gong, of Tsinghua, "If a city has safer roads, people will walk more. Right now, the government is promoting exercise facilities within a 15-minute walk of all citizens. But it needs to be easy to move around - you need clean air and unobstructed sidewalks. It must be safe to go from one side of the street to the other.... We need to better allocate the space."

Convenient neighborhood medical care provided at a sustainable cost is also seen as a crucial aspect of healthy cities. Among measures that cities are pursuing are family doctor systems, tobacco control and big data technology.

"The government is very determined through health sector reform to promote primary healthcare, to address two challenges - access and equity - and the overall efficiency of the health system," says Qiao Jianrong, coordinator of the health systems and health security team at the WHO in Beijing.

In the Chinese health system, people are flooding into top-level rather than primary care hospitals, Qiao says. "The cost is increasing rapidly, which the country cannot afford going forward. The government has very clear plans to promote family doctors through healthcare reform. There are all kinds of pilots of a tiered healthcare system across the country, to try to steer people to use family doctors."

She adds that "Xiamen is a city that is leading the way in its family doctor system. The city is doing very, very impressive work in terms of community health centers that can provide services for elderly, for children, and for chronic care, and can refer patients to second-and third-tier hospitals."

Galea, of the WHO, also notes that millions of people in China suffer from high blood pressure.

"I can't imagine a healthy city that allows smoking in public places or that doesn't identify the people with high blood pressure and treat them," he says. "There is a huge gain in terms of years of life from just those two simple measures."

The Tsinghua-Lancet Commission report also points out that more than 50 percent of men in China smoke, and that reducing that number is crucial for the nation's health.

The report also credits Beijing for implementing and enforcing a strict ban on smoking in public places or workplaces. Shanghai and Shenzhen have since implemented policies similar to Beijing's, and Xi'an and Hangzhou are considering such laws.

Galea cites the success of a national tobacco control law in Russia that includes smoke-free public places. "They implemented a national law in June 2014. The level of freedom from smoke has been transformed. And there has been an almost 20 percent reduction in total smoking due to this one law."

Gong says Chinese cities have also begun the process of integrating data technology into city planning.

"Yichang city in Hubei province now makes all the information within the city available throughout the government. They have built a system very effectively collecting public safety, transportation, medical data. They break the silos.

"Originally, each department monitored its own data. This belongs to public safety, this belongs to transportation and so forth. Now, the smart city development commission is in charge of all the monitors. This is a good example of how smart cities can benefit health."

Candeias, of the World Economic Forum, says: "Given the cost of the problem and how complex it is, the solutions need to be multi-sectoral and multi-stakeholder."

To achieve this, she adds, "there are several ways that technology can help. For example, to support the individual, there are gadgets that can gamify treatment compliance or specific apps that help people achieve healthier behaviors. Informatics infrastructure can make the healthcare delivery system more efficient.

"When it comes to the city environment, sensors can monitor air pollution and other determinants of health. Technology can support the actual urban planners so that they can make the city a healthier place to live and one in which being healthy is the easiest option for the individual."

Galea says that there is a lot of excitement about changes in healthcare now in China. The WHO representative says the commitment to universal care and quality is very high. Also, tied to the Belt and Road Initiative, China is reaching out to world cooperation on health. And healthcare offers many opportunities for businesses - in drug development and artificial intelligence applications for healthcare, and for new innovations.

"China is spearheading the 'health in all policies' approach at the city level," Galea says. "It is a very substantial movement that is ready to take off."

davidblair@chinadaily.com.cn

(China Daily European Weekly 06/08/2018 page1)