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October 2012 |
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John Ashton
www.drinkanddrugsnews.com
Soapbox
DDN’s monthly column
offering a platform for
a range of diverse views.
CITY
CHALLENGE
We must learn to balance
risk and freedom, says
John Ashton
MOST OF US ENJOY A LOVE-HATE RELATIONSHIP WITH OUR CITIES
.
We expect them to provide for a wide range of our needs and expectations, yet sometimes
they overwhelm us and we seek the open horizons of the fells or shoreline. We yearn to re-
establish a connection with nature and the seasons, which can seem elusive when surrounded
by bricks and mortar and a night sky devoid of stars because of light pollution. From biblical
times people have sought refuge in cities and escape from the narrow parochialism of the
village, where bigotry can rear its head and xenophobia is a close cousin of intolerance of
difference. Strength in numbers can be a big pull if your lifestyle falls outside accepted norms.
Yet the notion of city as nirvana has never gone unchallenged. The pull and push factors that
generate rapid urbanisation have always brought public health challenges in their train. We
know from public health academics such as the late Thomas McKeown of Birmingham that
disease occurs in populations when they migrate or their habitat and adapted way of living is
changed. Cholera flourished in the teeming slums of Victorian England and it took the
galvanised efforts of civic leaders (the church, the press, the business community and early
health professionals) acting through the Health of Towns Association to achieve sanitary
reform. That reform gave them the legislative and financial tools to tackle the urgent issues of
the day – safe water and sewerage, paved streets and refuse collection, housing standards, food
hygiene and a subsequent plethora of local authority provided public services.
The work of these early pioneers was driven by the so-called sanitary idea, much espoused
by president of the Board of Health, Edwin Chadwick. At its heart was the need to separate
human and animal waste from food and water. The responses were typically Victorian, rather
mechanistic but very determined. For Chadwick this took the form of the egg shaped, brick
lined sewer pipe – and his obsession with finding the right way of doing something and then
doing that everywhere. The town of Liverpool under its triumvirate of Duncan (medical officer),
Fresh (sanitary inspector) and Newlands (borough engineer) put in 20 miles of such sewers in
20 years and the country followed over the next couple of decades.
The impact of such measures was significant. As the nature of infectious disease came to
be better understood, and the Pasteurs revealed the germ theory of infection, prevention and
personal hygiene took their place alongside environmental action. Town planning joined the
party and model towns and cities began to separate out living areas from the industrial and
recreational. Salubrity was embraced as a core municipal function and local authorities began
developing a wide range of public services encompassing housing, parks and gardens,
swimming baths, social services, schools, abattoirs, tramways and gasworks and much beside.
Over 100 years later much has changed but urbanisation has gathered pace. A majority of the
world’s population now lives in large towns and cities, some of them huge. Many accommodate
vast slum areas where to the traditional problems of infectious diseases have been added the
modern scourges of non-infectious and degenerative disease associated with populations that have
begun to live for life spans undreamed of by our great great grandparents. Then there are the
lifestyle diseases associated with the existential dilemmas of a post religious age where each of us
must find our own path, negotiating the rules and ethics of a much more fluid social contract. This
contract is both more liberating and more daunting than when churchgoing was the norm,
everybody knew their place, and the state acted as enforcer of the status quo.
Cities of today are expected to meet even more of our personal ambitions. They must
simultaneously be places to grow people in, to offer them the optimal amount of test and
challenge, rites of passage, opportunities and support in sickness and in health. We have
begun to redefine how we understand them, as ecological habitats and as building blocks of
society. The challenges in developed countries are no longer the cholera and drains but issues
such as depression, drugs and alcohol and dementia. We are no longer subservient to handed-
down rules, but autonomous beings seeking to negotiate paths towards our dreams, and if the
questions of health and wellbeing are about anything, they are about co-production and co-
maintenance. The freedom to take and manage risk is a genie that is out of the bottle. The
search for a common game board for the modern city has barely begun.
So in taking stock in 2012, over 150 years after the first Public Health Act, there are many
questions to ask – ethical and political ones to do with power and control, governance and
autonomy, and freedoms of the individual and the collective. Such things come into
prominence when we focus on behavioural issues such as alcohol, drugs, violence and sexual
expression. One thing is certain: the city is here to stay and there is much to be said and done
if the dreams of liveable, aspirational and sustainable cities are to be available to all those who
seek their joys and frustrations.
Professor John Ashton CBE is regional director of public health for the North West. He will be
delivering the Alison Chesney & Eddie Killoran Memorial Lecture on 22 October in London. Visit
www.kachange.eu to reserve a place.