PHYSICAL WELLBEING

19. https://www. centreforlondon. org/publication/ health-and-wellbeing/

20. https://medium. com/slowdown-papers/6-a-language-incrisis-b88b39475fee

21. https://www. moh.gov.sg/docs/ librariesprovider5/2019-ncov/ situation-report---28apr-2020.pdf

22. https://www.ons. gov.uk/peoplepopulationandcommunity/ birthsdeathsandmarriages/deaths/ articles/coronavirusrelateddeathsbyethnicgroupenglandandwales/2march2020to10april2020

23. https://www. theguardian.com/ world/2020/apr/16/ inquiry-disproportionate-impact-coronavirus-bame

24. https://www. ethnicity-facts-figures.service.gov.uk/ housing/housing-conditions/overcrowded-households/latest#by-ethnicity

Even before coronavirus, there was growing recognition among governments of the need to invest in public health and, in particular, preventative healthcare. Coronavirus has brought a renewed awareness of our bodies. Early in the crisis, governments moved fast to prioritise health over commerce. As restrictions ease, change will be accompanied by a stronger awareness that citizens’ health and economic success are not in opposition, but intrinsic to one another.

We have long known that more affluent groups are healthier compared to poorer people in the same city. Recent research by Centre for London, supported by Therme Group, found that Londoners in the leafy suburbs in the city’s south west have some of the best health outcomes in Britain. Those in the poorer, grittier east had some of the worst.19 Access to greenery in cities often goes hand-in-hand with affluence; it is the poor who are most deprived of nature. Dan Hill argues in The Slowdown Papers that if the 1918 flu epidemic is anything to go by, air quality and social inequality will join speed and depth of response to coronavirus as significant determining factors in numbers of deaths.20

In many countries across the world, from Brazil to Qatar, from England to India, migrants and the native poor have been hardest hit by coronavirus. In Stockholm, the suburbs containing large immigrant populations have seen the most deaths. In New York City, black and Hispanic residents have been badly affected. In Singapore, migrant workers in dormitories accounted for 85% of cases at the end of April, despite being only 3% of the population.21

The Office for National Statistics in the UK estimated that people from BAME backgrounds were four times more likely to die from Covid-19.22 The causes are not fully understood, and the government has launched an inquiry,23 but it is already clear that people from BAME backgrounds were more likely to come into contact with more people who are infected; more likely to work in essential services; to live in densely populated areas; and to live in overcrowded housing. Less than 2% of white Britons live in housing where there are more residents than rooms, compared with 16% of those with black African background, 18% of those with Pakistani background, and 30% of those with Bangladeshi background.24 It should come as

25. Jacqui Stevenson and Mala Rao, Explaining levels of wellbeing in black and minority ethnic populations in England, University of East London (2014)

26. https://www. nytimes.com /2020/04/24/us/ politics/coronavirus-protests-madisonwisconsin.html

27. Maija Palmer, What your commute will look like in 2050, Financial Times, June 17, 2019\

28. GLA, Estimation of changes in air pollution in London during the Covid-19 outbreak, April 2020 https://www.london. gov.uk/sites/default/ files/london_response_to_aqeg_ call_for_evidence_ april_2020.pdf

29. https://www. theguardian.com/ environment/2020/ apr/11/positively-alpine-disbelief-air-pollution-falls-lockdown-coronavirus

30. https://cicero. oslo.no/en/posts/ single/the-flip-side-ofthe-new-coronavirusoutbreak-reduced-airpollution-mortalities

31. https://www. centreforcities.org/ publication/cities-outlook-2020/ no surprise that people from BAME backgrounds in the UK have always reported lower levels of subjective wellbeing than their white counterparts.25

Those countries that have been most successful in protecting the health of their citizens were able to emerge from lockdown sooner and are likely to be more economically resilient. Health and economic activity are not in opposition, despite sometimes having been presented as such (by the protestors at Madison, the Wisconsin State Capitol, on 24 April, for example26). They are inextricably linked, and the health and care of citizens is likely to be a central concern for governments for the foreseeable future.

Transport And Air Quality

Cities have developed over time partly in response to the influence of new transport technologies. They have also constrained the spread of those technologies. For example, the motor car has had a much bigger impact on urban form in the US than it has in Europe, where medieval city centres restricted road building. In America, cars enabled the growth of ‘dispersed’ cities with low-density housing and scattered jobs, like Phoenix, Salt Lake City and Dallas.

Cars are increasingly seen as a barrier to the creation of liveable cities and neighbourhoods. More and more, they don’t work even for drivers, let alone for pedestrians. In central London, Transport for London reports, the average car speed is 7.4 mph. In Bogota, drivers spend an average 272 hours a year sitting in cars.27

Cities with denser concentrations of jobs and better designed public transport systems have much lower energy-use than cities in which jobs are scattered and cars are required. They are also healthier. People sit less, traffic fumes are reduced and calmer streets offer more opportunities for social interactions which - as we shall see - have a marked impact on wellbeing.

Air quality correlates to the number of cars on the road: more congested roads have more toxic air. In London, levels of nitrogen dioxide (NO2) almost halved in the month following the introduction of coronavirus lockdown measures, according to a report published for the Mayor of London.28 When Delhi’s 11 million registered cars were taken off the road, the city saw the clearest and bluest skies for years. Normally toxic megacities such as Bangkok, Beijing, São Paulo and Bogota reported unprecedented declines in pollution.29 Researchers at CICERO, Norway’s climate research institute, estimated that 50,000 to 100,000 premature deaths may be avoided in China by reduced levels of air pollution during the crisis.30

Excluding the impact of the COVID-19 pandemic, more than one in 19 deaths in Britain’s largest towns and cities is linked to air pollution, the Centre for Cities reports.31 While research from King’s College London found that when air pollution was in the top half of the UK national average there were an extra 124 heart attacks a day, on average. This is on top of the 500,000 deaths a year in Europe which are

32 already attributed to air pollution, which is also linked to strokes, asthma, especially in children, and a range of other illnesses.32

Centre for London research, supported by Therme Group, found that 2 million people in London live with illegal levels of air pollution. This is not an intractable problem: the introduction of the Ultra Low Emission Zone (ULEZ) has already made a significant difference to air quality, improving roadside air pollution by 44%. As with health more generally, however, low income and ethnic minority groups, who are more likely to live in polluted areas and on busy roads, are disproportionately affected by poor air quality. Women, too, who still do the bulk of unpaid labour - shopping and childcare - tend to make more journeys on foot. In Vienna, surveys have shown that roughly two thirds of car journeys are made by men, while two-thirds of journeys on foot are made by women. ‘If you want to do something for women,’ says Eva Kail of the city’s planning unit, ‘do something for pedestrians.’33

Taking Action

Walton, Personalising the Health Impacts of Air Pollution, King’s College London, November 2019, http:// www.erg.kcl.ac.uk/ Research/home/ projects/personalised-health-impacts. html

33. https://www. washingtonpost.com/ politics/2020/04/25/ wisconsin-protestors-attack-stay-at-home-orders-unnecessary-or-government-cabal/

34. https://www. iea.org/reports/global-ev-outlook-2019

35. https://www. telegraph.co.uk/ news/2019/09/09/ electric-scooterswould-beat-cars-70per-cent-city-centrejourneys/

Increasingly, European cities are trying to rid city centres of cars altogether, to encourage more walking, cycling and use of public transport. Paris has eliminated cars from the lower quays of the Seine. In Ghent, 35 hectares of the centre are almost car free (taxis and permit holders may enter, but must not exceed 20mph). The city of Pontevedra in Spain has eliminated cars from its centre, resulting in no road deaths since 2009 compared with 33 fatal traffic accidents between 1996 and 2009. Carbon dioxide emissions are also down by 70% and Pontevedra has gained 12,000 residents at a time when other cities in the region are shrinking.

Masdar City in Abu Dhabi is a government-backed eco-city, designed to be car free in a region where cars have long been seen as essential to the smooth running of modern life. China has launched a number of similar initiatives, including the Great City on the outskirts of Chengdu.

Many cities have introduced car free days or times, or pedestrianised quarters in city centres. In Paris, Mayor Anne Hidalgo has brought in car free days in the centre one Sunday a month, and has developed a 15 minute city strategy. The strategy ensures all basic everyday needs (for education, culture, healthcare and commerce) are no more than a 15 minute walk or cycle ride from everyone’s front door.

The global stock of electric cars is growing (by 63% to 5 million in the year to 2018)34 - which offers the hope of reducing pollution. The growth of micromobility start-ups, such as Bird, Lime, Voi and Bolt, offers the possibility of getting more people out of cars onto electric bikes and scooters. Electric micro-mobility is often faster in cities than travel by car. One study showed that e-scooters could reduce journey times in UK cities by 70%.35 There have, however, been concerns about safety so, if micro-mobility is to be a ongoing solution, there is a need for better infrastructure.

In 2017, the Chinese city of Xiamen opened a 7.6km elevated cycleway linking all the city’s major business districts, five residential areas, and 11 bus stops. The cycleway can take 2,000 bicycles an hour. Xiamen, which had already banned motorcycles and mopeds, has much cleaner air than most Chinese cities.

Barcelona

Until recently, air pollution in Barcelona caused 3,500 premature deaths a year in the metropolitan area (population 3.2 million). Barcelona and its surrounding areas consistently failed to meet EU air quality targets. Traffic was the chief cause of noise pollution, with 61% of residents living with noise levels higher than those deemed acceptable by legislation. The city also had a high level of road accidents (9,095 in 2015) and a growing obesity problem.

An ambitious new plan currently being implemented aims to create 503 ‘superblocks’ across the city turned over to ‘citizen spaces’. Traffic is routed around them. The superblocks are complemented by 300km of new cycling lanes and a plan for no one to be more than 300m from a bus stop.

The first superblock to be implemented in Poblenou in the north of the city in 2017 met resistance from car owners and local businesses, but much of the hostility has dissipated. There are 30% more businesses in the district than there were. Many more people make journeys on foot or by bike. It is estimated that if the superblocks plan were implemented in its entirety, the life expectancy of the average resident in the city could increase by almost 200 days and would save the city €1.7bn a year.

36. https:// www.nytimes. com/2020/04/16/ health/coronavirus-obesity-higher-risk.html

37. https://www.nhs. uk/news/heart-andlungs/having-deskjob-doubles-risk-ofheart-attack/

38. Alpa Patel et al, Leisure Time Spent Sitting In Relation to Total Mortality in a Prospective Cohort of US Adults, American Journal of Epidemiology, vol 172, Issue 4, August 15, 2010

Copenhagen is the cycling capital of the world, with 41% of trips to work, school and college made by bike. Citizens cycle a total of 1.4km on an average weekday. Residents own five times more bicycles than cars and, as more people have taken up regular cycling, individual safety has improved. Cyclists’ feelings of safety have risen by 43% since 2006.

The city has more than 40km of cycling track. Over 40 years, parking spaces have been progressively cut by 3% per annum, enough to make a difference over time without triggering opposition. This has allowed for extensive cycle lanes and wider pavements on main streets, as well as shared surfaces on smaller streets.

A ‘green wave’ coordinated traffic light system minimises cycle congestion at peak times, keeping cycle traffic flowing. Cycle storage on suburban trains and changing facilities in offices help to ensure that a third of all trips are by bicycle, a third by public transport, and only a third by car.

Obesity

In the rich countries of the OECD, obesity currently affects 19.5% of people. In the US, the figure is 35%. Obesity has doubled in US children since 1988 and quadrupled in adolescents.

Centre for London research, supported by Therme Group, found that 38% of London’s 10- and 11-year-olds were obese. As with health outcomes generally, the situation was worse in the poorer outer London boroughs in the east and better in the more affluent south west.

Poorer places tend to be saturated with cheap, unhealthy fast food. ‘Where you grow up strongly influences your chances of being overweight and obese’, notes Kieron Boyle, Chief Executive of Guy’s and St Thomas Charity, ‘and for families on the lowest incomes, this correlation has only got stronger over time’. People with obesity frequently have other medical problems, such as diabetes and high blood pressure. Early research suggested that obesity and diabetes were factors in hospital admissions for younger people (under 55) with coronavirus.36

Without wishing to romanticise manual work, it’s clear that many inhabitants of cities don’t get enough exercise. People with sedentary occupations - a high proportion of those who live in cities - can easily sit for up to 15 hours a day. And people who sit a lot are twice as likely to have a heart attack, and two-and-a-half times as likely to suffer cardiovascular disease.37 Men who sit for six hours a day or more increase their mortality risk by 20%. For women, it’s almost double that.38

Cities weren’t always sedentary places. Up until around 1850, in most cities - even big ones - everyone travelled on foot. Charles Dickens regularly records walking from one side of London to the other and back in a day. Cities don’t have to be sedentary places now: urban walking is one of the great joys of city life. For many commuters using public transport it’s also a necessary part of everyday travel. But some cities are much better set up for walking than others - and the difference is their relationship to cars. It is much safer, healthier and more pleasant to walk in streets that have less traffic and fumes.

The Physical Effects Of Stress

We deal with stress more comprehensively in the next section but for now it is worth saying that stress leads to direct physical effects, releasing cortisol into the blood and bringing a heightened risk of heart disease. Types of work with no ‘skill discretion’ or ‘decision authority’ have repeatedly been found to have this sort of direct physical consequence.

In cities, where increasing numbers of people work in the gig economy, stress may be exacerbated by long hours and a feeling of living precariously on the margins, leading to a host of other physical problems.

Ageing

Before the coronavirus pandemic, the proportion of the world’s population over 60 was expected to rise from 12% in 2015 to 22% in 2050.39 Covid-19 has affected the elderly more than any other group: in late April 2020 the WHO reported that up to half of those in Europe who had died of coronavirus were in care homes. But the underlying trend remains: older people are the fastest-growing cohort of the population.

Recent months have shown how inextricably linked the lives of older people are with those of everyone else. Fear for personal safety - particularly acute for the old - has had an impact on the personal behaviour of everyone and, profoundly, on the economy. The coronavirus crisis has also exposed failings in care of the old: care workers in most developed countries have typically been characterised as low skilled and poorly paid.

Post coronavirus, public health infrastructure will have to respond better to the needs of older people. Cities are set to age faster than rural populations but they are rarely designed with much attention to the needs of their older citizens. As the WHO notes, beyond biological changes, ageing is also associated with other life transitions such as retirement or the death of a partner. ‘It is important,’ they conclude, ‘not just to consider the approaches that ameliorate the losses associated with older age, but also those that may reinforce recovery, adaptation, and psychosocial growth.’40

Coronavirus and the fear of future contagions may leave a lasting mark. How, in such circumstances, are older people to escape the stereotypes of passivity and vulnerability that are, in themselves, detrimental to resilience?

In future, there will be a need to rethink the urban form and infrastructure so that cities are liveable over the life course, with affordable and flexible housing. Easy access to services will become more important, as will flexible jobs and opportunities for lifelong learning.

A better designed urban realm could help mitigate social isolation and offer opportunities for preventative healthcare, including more opportunities for contact between people in the community and more opportunities to exercise and be in touch with nature. A renewed concern with public health, plus the tendency of older voters to be politically engaged, is likely to make provision for people as they age a more significant priority. Ensuring citizens can stay healthy will become increasingly important in reducing long-term healthcare costs. This could and should improve the wellbeing of people of all ages.

Philadelphia

In collaboration with the AARP (formerly the American Association of Retired Persons), the city of Philadelphia evaluated the safety of its pavements and intersections with the aim of making it easier for older people to walk around the city. An Executive Order for Complete Streets was enacted to ensure pedestrian and cyclist safety was prioritised. While this brings benefits to everyone, the initiative was prompted by a desire to make it easier for older people to access public services.

The Built Environment

Cities, then, pose many hazards to physical health, and any proposal to improve wellbeing should take into account the myriad physical interactions that take place in cities every day, and the impact of the built environment on human health.

The possibility of a reduction in traffic offers the hope that cities could become much greener; that spaces currently given over to parking, for example, could become growing spaces, ‘parklets’ or filled with trees. With our increasing awareness of living in the Anthropocene era - a period of geological time in which human actions are the dominant influence - tree planting has become less about civic improvement and beautification, and more about the ecosystem, helping to improve air quality and slow the build of atmospheric carbon dioxide. Cities would be very different if streets were redesigned with wellbeing as their purpose, rather than the efficient movement of traffic.

Faced with ageing populations and growing strains on health budgets, cities will increasingly have to focus on preventative healthcare, on helping people to interact with nature and with each other. If this is done properly, it will change the urban fabric so that more attention can be paid to exercise, healthy food, and experiences that refresh and renew people, offering a sense of wonder and meaning that helps reduce stress with all its debilitating physical consequences.