The Five Stages

Stage 1.    🤷🏾 It’s not our job, our job is to build things people want, make a profit-bonus for our shareholders-owners-staff, meet government requirements, and contribute to country-regional-local economic growth.

Stage 2.  🙅 Health input will cost money, and stop us from building quicker, better, more affordably, delivering higher economic growth, and creating jobs.

Stage 3.    🤦🏻 That’s not us, we are the good proponents, we are socially responsible.

Stage 4.  🙋🏽 This is obvious! We already do it! No need for public health expert input and oversight.

Stage 5.   💁🏼 Okay, {grudgingly} I guess there's some value…at the design and recommendations stage…but hell no…to long term public health and wide stakeholder, community health monitoring. We have public relations, community liaison, and community development people for that.

What’s this about?

The above is a caricature, but I think it embodies a deep truth. Over the last 20 years of doing Health Impact Assessment, and Healthy Urban Design, there is still resistance to health being considered routinely. For many developer and proponent clients, it continues to be not at the heart of what they do or want to do.

Some sectors do have excellent internal and confidential health impact assessment frameworks and institutional guidance. Though, being nit-picky, they are not as open, and transparent, as they could be. They do and publish only what is legally required. With assessments being put in the public domain only for as long as they legally need to be. That is rarely the whole lifecycle of the development.

Every new generation of developers and proponents start at Stage 1. Over time, they move through the stages as they become educated in, or learn from experience, the value of thinking deeply about community health across all stages of a development. From, planning, design, implementation, operation, and where appropriate, decommissioning. That, community health when both not considered, or not considered well enough, can lead to serious negative health effects on communities that happen to live and work in their zone of influence. That zone is not just immediately around the development, but along transport corridors as people, goods, and services move to, and from, the development.

I’d like to say that developers and proponents face stock-price crashing reputational impacts, or even impacts on their bottom line, when they don’t consider community health and wellbeing. But from my experience, experience of other colleagues and friends, and news stories over the last 20 years, they don’t. They often get away with it and we, as citizens, communities, and professionals working in communities, aren’t able to hold them to account.

So, we will always need to make the case for health and highlight poorly designed developments and adverse health effects on communities.

Key Questions

Though, for me, the more important questions are:

How do we, win hearts and minds, make health in development the obvious and easy choice, this time, and every time? How can community health be as desirable to organisations, especially business, as the other products and services they procure. That it’s implicitly, and explicitly, part of their organisation, serving communities, doing business, and making money.

How come we still haven’t got detailed healthy impact and design manuals that detail how to design out and eliminate the adverse and unequal health and wellbeing impacts of energy, waste, mining, transport, housing, and other industrial projects. Why are these still ‘wicked’ and not tame problems; notwithstanding new technology and processes.

Why doesn’t every developer deliver on social infrastructure on time and to recommendations. Yes, of course, it’s not the developer’s role to deliver essential public services, for example, a healthcare service, but it is their responsibility to be socially responsible community, country, and global citizens. Taking the world as a whole, collectively, we don’t live apart and outside of the communities we develop, live and work in. Even companies are legal persons, ‘citizens’ of countries and the world.

Legislation, regulation, impact assessment, design principles, and guidance help. But they don’t seem to be winning hearts and minds. The culture of many private and public sector organisations is, I feel, still not genuinely and deeply orientated towards community health and wellbeing, at the district, regional, country, continental and global levels.  

In the field of HIA and healthy urban design, I think we’ve fallen into a trap, as more and more HIAs are done, and outline masterplan designs are health-proofed, the processes and assessments have become more transactional and technical.

The impacts, effects and designs are based on simplistic causal pathways and ‘theories’ of change. For example, availability of, and access to, moderate quality greenspace leads to an increase in the opportunity to do physical activity which leads to decrease or maintenance of current levels of obesity. Availability of, and access to a local community centre, leads to an increase in social interaction, which leads to an increase in social capital, cohesion, and neighbourliness. There is no deep public health-honed thinking of the complexity of the obesity and social capital causal pathways (logic diagram or ‘theories’ of change. Of what else is needed to make this a reality.

The over-focus on ‘hardware’ forgets the living ‘software’ that make for true healthy design and development. Infrastructure ‘hardware’ deposited in a space without understanding how that infrastructure interacts with existing and new settlements, and the people who live and work in them, does not create healthy spaces and places.

Developments fit into existing physical and social systems, and therefore needs developers and proponents who understand the ripple effects of how new, and modified, developments affect how people live, work, and connect with, and to, each other.

What can we do about this?

I think two key things are needed.

First, we need to teach developers and proponents how to take a step back, pause and see the big picture. I feel all of us involved in HIA and healthy design need to be more aware when we’re becoming too technical and transactional. When we forget the relational and transformational. This means pushing back on developers, proponents, and clients’ desire to get the health stuff done, whether public or private sectors. It’s easy to say but it’s not an easy thing to do. I still find it very hard to do, which is why I’ve written this think piece, I want to hold myself to this standard too!

The rewards though are worth it. My most relational, and hopefully transformational, work, in HIA and healthy design, has come when clients have been genuinely committed to, and been seen to be committed to, community health and wellbeing. They have taken a step back, paused, and taken the time to deeply listen to, and take account of, all the other stakeholders’ perspectives. They might have just been a one or three committed operational people, or senior people in the middle or the top of an organisation, or even their main planning consultant. By genuinely taking account of the values, priorities, and perspectives of, affected stakeholders, and weaving them into the fabric of the development, they made communities feel this is ‘our’ development, and not ‘their development’. I feel lucky to have been involved in a few, but I shouldn’t feel lucky, 20 years on from when I did my first HIA, it should be the norm.

This may sound, and be, utopian but if we are to further enhance what has already been achieved with HIA and healthy urban design, we need to pivot. We must recognise that while a transactional and technical orientation, to incorporating health into development, is more straightforward, easier, quicker, and creates some quick short-term wins, we may be losing out long term.

Health in development needs to facilitate and nurture socially connected. and cohesive. communities, whether they are new communities or existing ones. This has to be part of the objectives of any development, regardless, of the type. This requires a relational and transformational type of health in development. It will, let’s face it, obviously be more expensive, more complex, harder, and slower to do well. These are all upfront costs, rather than costs spread out across a decade of bad planning, design, construction, and operation. Hence, it’ll be more difficult to sell to politicians, senior management, and shareholders. Yes, there’ll be NIMBYism and short-term interests – social, economic, political – but that’s part of the job as health and environmental practitioners, advisors, and consultants. Navigating and understanding these perspectives and seeing how they can be blended into developments, fighting misinformation and myths, and being advocates where that is needed.

Second, developers and proponents must stop thinking that health in development finishes when the health impacts are assessed and the development’s design health-proofed. They need to recognise that it must continue with developer-paid long-term monitoring and oversight until, at least, the whole development is built and has been operating for a year or two. For industrial, energy and waste projects this will continue through to decommissioning. The costs have to be factored into the financial viability assessment. Just like social infrastructure and amenities it is the cost of development, the cost of doing business, the cost of making money, no ifs, no buts. This monitoring will only be intensive at key transition points as the development moves from one stage to another. Outside of these transition points, it will be light-touch. This monitoring has to be done by individuals and teams that are independent of developers. Those doing the monitoring must include someone with deep public health knowledge to identify potential negative health impacts early. Have the skills to develop a multi-way dialogue between developers, proponents, communities, and planning authorities. Lastly, they need the authority to bring stakeholders together to build a partnership of equals to co-manage developments whether they are houses, roads, energy schemes, transport infrastructure, or industrial facilities. Public relations, community liaison, and community development professionals, no disrespect intended, are not enough.

This will also fill a key gap in health in development by generating long term ongoing evidence on what the real positive and negative project impacts and health and wellbeing effects are. And the best long-term ways of reducing negative effects on communities. Not retrospective research but real-time research and data collection. Data that if anonymised and publicly shared can go a long way to understanding and tackling the question I posed earlier about why we don’t have detailed healthy impact and design manuals for each sector. We don’t know, and can’t act on, what we don’t measure. This monitoring and action will help to develop a set of systematic ways of countering all the main types of negative project impacts and health and wellbeing effects of development. And, if the monitoring is responsive, it will be, and become, the single most important practical demonstration of a developer’s deep commitment to community health and wellbeing. So, we never have bad developments just a range of good to outstanding ones.

A New Sixth Stage

By doing these two things we can add a new sixth stage:

Stage 6: 😎 Community health is in our organisation’s DNA, from our vision, and objectives, to our organisational culture, operational systems, and everyday practices. Community health and wellbeing, and working with, and being a part of communities, alongside our other key objectives, including meeting political objectives and making a profit, is the ‘rainbow’ thread that runs through everything we do.

So, let’s do more of the relational and transformational health in development, alongside the technical and transactional, because that’s what all of us, developers, proponents, practitioners, advisers, consultants, planning authorities and communities want when we step back and look at developments outside of our own narrow personal, professional, and organisational interests.