The model also indicates that, in order to ensure social cohesion and a civic community, the benefits of economic activity must be distributed in a way that is socially equitable: if it is not then, as Raymond Aron has remarked, "when inequality becomes too great, the idea of community becomes impossible". In addition to being socially equitable, economic activity must also be indefinitely ecologically sustainable; the community must not so deplete natural resources or so pollute the environment and otherwise impair ecosystem health as to irreparably harm future generations or distant populations. Finally, the community requires a livable built environment; this refers to the quality and nature of the built environment, including housing, roads and other transportation systems, other urban infrastructure and urban design and land use.

In the following sections, I will explore some of the implications of this model for policy, including monitoring and evaluation. However, for the moment, suffice it to say that a healthy community would be one that strove to be livable, sustainable, equitable, cohesive, have high environmental quality and be adequately prosperous - and would seek to balance these sometimes competing values. There is, however, one important caveat, somewhat implicit in the concept of sustainability but worth elaborating upon.

In our original background paper for the WHO Healthy Cities Project (Hancock and Duhl, 1986) we proposed a set of elements that would constitute a healthy city. One of those elements was a strong but non-exploitative community. This wording expressed our concern that strong communities, although often beneficial from the point of view of the individuals living within that community, can be quite harmful to those living outside the community. Thus we suggested that a healthy community, while being strong, would not exploit the weaker and more disadvantaged members within the community, would not exploit other communities to its advantage and their disadvantage, would not exploit the ecosystem beyond its capacity to absorb that exploitation without permanent harm and would not exploit future generations by destroying their options, as the WCED definition of sustainability suggests. Thus a healthy and sustainable community, while striving to meet the six qualities described in Fig. 1 and thus to maximize the human development of its members, will not do so through the undue exploitation of others. There is, in other words, a strong moral component to being a healthy and sustainable community.

Sustainable development, health and poverty in cities

The links between sustainable development, poverty and health are complex, but real. In this section, I will explore some of those links.

At the outset, it is important to recognize that those living in relative or absolute poverty will likely have less impact on the environment than those whose wealth allows them to consume the greater share of the earth's resources: rich countries are less ecologically sustainable, in these terms, than poor countries, while rich individuals are less ecologically sustainable than poor individuals. 2 Moreover, there is the very real danger that rich countries - and rich individuals - will 'buy' themselves out of trouble by importing resources needed for subsistence in the poorer countries and communities, while exporting pollution to them; indeed, there is already clear evidence that this is already happening.

At the same time, while consuming fewer of the earth's resources, those living in poverty are more likely to be receiving more than their fair share of environmental harm. Not only do they often live downhill, downwind, or downstream of pollution, or in situations that are fundamentally unsafe (i.e. in flood zones, on dangerous hillsides, on or near waste dumps etc.), they often work in the more dangerous occupations, where they are more likely to be exposed to toxic chemicals and other hazards and they often have to pay more than middle class families for worse quality and more highly processed food.

On the other hand, people living at the very margins of survival are often forced, through necessity, to destroy the environment upon which they depend - witness desertification in the Sahel or deforestation in Haiti. A similar situation exists among low income communities in cities in the industrialized world: people living in poverty often drive old and poorly maintained cars that consume a lot of gasoline and pollute the environment and they also may live in poorly built and poorly insulated housing which they may have little opportunity or incentive to improve, resulting in high heating bills and more pollution.

One vivid illustration of the health and social effects of environmentally unsustainable development can be seen in the health effects of global climate change, which were the topic of a WHO report in 1990. Changes in global climate patterns will have some direct effects due to higher temperatures, particularly in large cities in hot countries. But much more devastating will be the indirect effects such as the spread into more temperate regions of a wide range of insects that are vectors for a number of serious diseases; changes to food production capacity in many parts of the world and the flooding of low-lying areas such as Bangladesh, the Nile Delta, Florida and the Netherlands. Cities that are not directly affected by these changes will be impacted by the resultant mass migrations and the creation of large numbers of 'eco-refugees'. As always, it will be the poorest members of society who will suffer most.

The relationship between poverty and health is not only a matter of ecological sustainability, it relates to the theme of social sustainability as well. While there is no evidence of a relationship at the national level between per capita GDP and life expectancy above five thousand dollars GDP per capita, there are two key pieces of evidence that relate health to equity. The first is that nations with greater degrees of equity have longer life expectancy and better health (Rogers, 1986; Cereseto and Waitzkin, 1986; Wilkinson, 1994). The second is that there is clear evidence within populations of a gradient of health status from poor to rich. Moreover, that gradient is not simply due to income and material wealth, since it applies at even the highest levels within a society, where material needs are more than adequately met. It seems that the gradient in health status within populations is more associated with issues of social status than income per se (Marmot, 1994).

It has already been suggested that "when inequality becomes too great, the idea of community becomes impossible". This seems to me to be precisely the situation in many American communities today; not only does the inequity within the United States reflect itself in lower overall population health status and life expectancy in comparison with most of the rest of the OECD nations, the inequity within cities in the United States has reached such a point that there is no sense of community. The horizontal linkages and the sense of social solidarity that make for Putnam's "civic community" no longer exist. The social web breaks down, social cohesion is lost and those who are socially excluded react with violence and despair. Here is a situation where economic activity is not only ecologically unsustainable, it is clearly socially unsustainable. The impacts on population health status and particularly the health status of the poorest, are only too obvious. Inner city ghettos in the United States have infant mortality rates worse than that of many third world countries and levels of violence that are beyond belief. Violence has become a major public health problem and a major cause of death, particularly among young black males.

While things have not yet reached that pitch in European and Canadian cities, the seeds of that potential are there too; we need to play close attention to the lessons to be learned from the American experience, one of which is that - as the famed American jurist Oliver Wendell Holmes put it over a hundred years ago - taxes are the price we pay for a civilized society.

Some implications of the model

An important aspect of the model that I have advanced here is that the various aspects that make up what I would describe as a healthy and sustainable community that promotes human development are sometimes in conflict with each other - although for the most part they are mutually reinforcing. Conflict is particularly likely around the aspects of economic adequacy, sustainability and equity. Much of that conflict arises at present because economic activity is too often seen as paramount, rather than merely a means to an end. Thus in the interests of economic growth, equity, sustainability, social cohesiveness, livability and environmental quality have too often been sacrificed. Perhaps the adoption of a model such as the one proposed here will enable us, in time, to see economic activity for what it is: merely one of a number of policy objectives and not necessarily the most important one.

However, many of the other policy criteria - for that is what they are 3 - are mutually supporting.

Greater equity contributes to community conviviality and social cohesiveness, while environmental quality and ecological sustainability are obviously closely related. Moreover, the quality and livability of the environment have important implications for the sense of social solidarity and the creation of a civic community. As our experience with slum clearance and the creation of highrise apartments (vertical slums) in many cities in Europe and North America has proven, bad urban design, poor environmental quality and a generally unlivable environment contribute to the breakdown of community. Conversely, we have also learned how to design and build communities that promote social networking and create a sense of community - even if we have too seldom applied that knowledge. (The "Community Architecture" movement in Britain is based on notions of community livability and social solidarity - Wates and Knevitt, 1987)

But perhaps the most fundamental implication of the model I propose is that we can no longer afford the luxury of planning in isolation. Environmental, social, economic, health and land use planning have to be integrated; we have to develop an holistic approach to planning "whole communities". Yet as Alexander, et al., have noted:

And they go on to suggest that the task of creating wholeness in a city can only be dealt with as a process and not by design alone. This of course has profound implications both for the training of planners and for the governance of cities. The issue with respect to the training of planners is quite straight forward: we need to train planners and others who can think and work across traditional disciplinary boundaries, specialists in holistic thinking and working. The implications for the government and governance of our cities will be described at the end of this paper.

While it would be premature to suggest that we have yet developed an holistic approach to planning, in the following section I will describe some of the emerging examples in the planning field in Canada that are taking us in the directions outlined above.

From concept to practice

The need to integrate the concepts of healthy and sustainable cities/communities has been apparent for some time. In this section, I will describe some examples of the ways in which Canadians have been moving from concept to practice. There are three main areas I will describe: linking directly the concepts of health and sustainability, involving the planning profession and changing planning practice.

a. Linking "healthy" and "sustainable"

A number of efforts are underway to link the concepts of healthy community and sustainable community in practical terms. One of these is the University of British Columbia Task Force on Healthy and Sustainable Communities (University of British Columbia Task Force, 1994). This task force, which brings together members of a number of different faculties and departments (Community and Regional Planning, Family Practice, Health Promotion, Health Care and Epidemiology, Nursing, Social Work) has been working to develop two tools for sustainability and to apply these tools in collaboration with the City of Richmond, "an island community of approximately 130 thousand people in the Fraser River Delta which is part of the conurbation around Vancouver, B.C.". (They are working with management and staff of the planning, health, engineering and community and government relations departments.)

The two tools they have been developing are an index of 'ecological carrying capacity' and an index of 'social caring capacity'. The index of ecological carrying capacity measures the "appropriated carrying capacity" or "ecological footprint" of communities (or, for that matter, individuals). In simple terms, the ECC measures the surface area needed to meet needs such as housing, food, transportation, consumer goods and other resources and to dispose of wastes. (The average Canadian requires 4.8 hectares per capita simply in terms of energy, forest, agricultural land and built environment, to sustain them each year. As their report notes "this is far more than the per capita land available in the world if every human would consume at this rate - and wealthier families consume even more, see Footnote 2)

In addition to developing this tool, the task force has also been developing a tool called the social caring capacity, the purpose of which is to test the readiness and willingness of the community to address and deal with the problems revealed by the appropriated carrying capacity. While still at a preliminary stage, the criteria that appear to be important for assessing the social caring capacity include social equity, diversity, interconnection, safety, access to recreational and open space, minimization of household and familial stressors and inclusion in the decision-making process. The combination of appropriated carrying capacity and social caring capacity, it is believed, will allow the community to see both the collective impact of its actions and therefore the collective imperative to change and "to ensure that such developments are seen to be equitable and desirable".

What makes this of more than academic interest is that the City of Richmond is now attempting to take these concepts and apply them in the development of planning guidelines and in the process of decision-making on planning applications.

Another example of the way in which the concepts of healthy and sustainable communities are being linked was a conference organized in Ontario in the spring of 1994. The conference brought together several different "movements" operating at the community level - healthy communities, green communities, community economic development, social development and planning, local roundtables on environment and economy - to explore areas of common interest and concern and to identify potential areas of collaborative action. The conference, which was called "Building Healthy and Sustainable Communities Together", served to underline the common areas of interest and the shared sense of purpose among these different networks and to highlight both the importance and the potential of working together at the local level. The conference also identified some significant barriers to achieving that, including in particular the jurisdictional boundaries established by provincial and municipal governments and the difficulties raised at the community level when funding programs are so narrowly defined and communities have to go to multiple sources for what is in essence a common purpose.

One final example of the linking of the concepts that we are discussing is the work of the Healthy City Office in Toronto. Established in 1989, the Healthy City Office occupies an unique niche in the civic structure. Directed by a steering committee with representatives from a number of different departments as well as community members, the Office exists outside any of the existing departments; it reports as a corporate office to the committee of heads of City Departments. This gives it a city-wide mandate to pursue its three principal themes, namely equity, economy and environment. Thus it sees its task as one of working across City Departments and with the community to link these three themes in the quest for a healthier city.

One example of the way in which it does this is to present an annual series of awards (called "The Neighbourlies"), to community organizations that have shown leadership and initiative in the three areas that are the Office's mandate, namely environment, equity and economy. Thus the Office promotes both intersectoral action and action that integrates the themes which are central to our concern here today.

b. Involving the planning profession

From the outset, the Canadian Healthy Communities Project was founded on the assumption that the planning profession was a key player. Historically, there are close ties between the planning profession and public health; in fact in Canada the planning profession grew out of a concern for public health and conservation of the environment in the early part of the 20th century (Oberlander, 1985). Therefore, the Canadian Institute of Planners was approached and became not only one of three sponsoring organizations (the other two were the Federation of Canadian Municipalities and the Canadian Public Health Association), but became the base for the Canadian Healthy Communities Project; in addition, the steering committee was - and still is - chaired by the president or past president of the Institute. This resulted in the project being well known to planners and resulted in, at the very least, a lively debate in the planning literature (Plan Canada, 1989).

At the same time, the Canadian Institute of Planners and the Canadian planning profession became involved in the concept of sustainable development and sustainable planning. Not surprisingly, the two concepts were brought together. A 1990 report, "Reflections on Sustainable Planning", (CIP, 1990) concluded that "the concept of sustainability is essential to our survival and should be viewed as the intent and central operating principle of planning." The report also noted that "implementation should demonstrate full regard for issues of social equity" and that:

The CIP report recognized that sustainable development has social and cultural dimensions, has implications that go well beyond local impact, that we have to learn to live better together and that the Healthy Community Project had already generated important lessons for sustainable planning, including the importance of local support, action and ownership, the key role played by municipal government and municipal planners and the potential for planners to play a proactive role. The relationship between healthy communities and sustainable development was summed up in the accompanying figure (Fig. 2).

This recognition of the complementarity between healthy communities and sustainable development on the part of the planning profession in Canada is important not only because it legitimates the link between the two concepts but because it sees this as of fundamental importance to planners and legitimates their role in addressing these issues in their communities. As one planner put it recently, the healthy community approach provides four important functions for a planner: it provides a sense of purpose that puts the person back into the picture, an intellectual tool and a package in which to fit diverse elements, an organizational tool that can structure teams of planners and the centrality of grass roots participation, which enlivens the planning process (Bain, 1994).

A more recent evolution of the link between healthy and sustainable communities can be found in a report reviewing alternative planning approaches in Canada (Hygeia Consulting Services and REIC Ltd, 1994). The report, which was commissioned by the Canada Mortgage and Housing Corporation (a Federal government agency concerned with housing and urban development) reviewed four recent alternative planning approaches - pedestrian pockets, neotraditional design, eco-villages and co-housing. In examining the alternative approaches and in evaluating a set of eight case studies, the report's authors used a framework based on the healthy and sustainable community model outlined earlier (fig. 1). The report develops and proposes an evaluative framework for judging urban plans that includes resource conservation, environmental impact, economic viability, social equity, livability, community and health and safety. Thus the groundwork has been laid for planners to apply a much more comprehensive planning framework in the years to come. Indeed, as described in the next section, this is already beginning to happen.

c. Changing planning practice

Slowly but surely, planning practice in Canada is shifting to reflect this new awareness. I will briefly describe here several examples of ways in which planning practice is changing, beginning with plans for several new towns, 4 and moving on to discuss ways in which a number of different communities have incorporated these ideas in their official plans.

New towns

THE BAMBERTON CODE

Bamberton represents:

Bamberton is a proposed new community of roughly 12 thousand people north of the city of Victoria on Vancouver Island in British Columbia. The community's design is based on ecologically sustainable development but includes an important emphasis on a sense of community, face to face interaction and services within walking distance. Guiding the development is a set of principles, the "Bamberton Code" (see box) which establishes the values that underlie the whole project. Based on this code and an extensive community consultation, the developers have created over three hundred design principles which are organized into ninety issues in eleven categories. The categories include community planning, character and culture, social planning, the economy, the environment, transportation and travel, town site, housing, utilities and amenities, visual impact and leisure and tourism. Taken together, these values and principles provide a detailed blueprint covering everything from governance to pest control. Some of the characteristics of the proposed development include:

All these factors will result in a great deal of public participation in the design and ongoing management of the community.

However, despite all these positives, public opposition and a cumbersome and politically charged development approval process have been serious challenges to the project. Opposition is grounded in a wide-spread fear that Bamberton will be a continuation of the kind of development which has been prevalent in southern Vancouver Island. Complicating the issue is the fact that Bamberton is being developed by four union pension funds; British Columbia's social democratic government does not wish to be seen to be favouring a unionbacked project and thus the special consideration which might be due to Bamberton because of its innovative approaches may be interpreted as mere political favouritism. As a result, the project is being required to go through a full environmental impact assessment which might well delay or indeed prevent the project from taking place.

Another example of an innovative development that was in fact killed by rigid development and investment guidelines was the "Heart of Spingdale". The intention was to develop a "healthy village"/neo-traditional design pilot project, with mixed use (including home occupations and work shops, a range of prices and affordability and reduced auto dependence) in the midst of a large traditional suburban sprawl development north-west of Toronto. The "Heart of Springdale" would have had a population of approximately five thousand people and would have been "an urban village" based on the model of older, downtown sections of Ontario towns. The strengths of the plan were its concern for conservation and its compact form, designed to provide both economical land use and a congenial, urban built environment with a mixture of uses and a diversity of housing. The plan integrated the "New Urbanism" style 5 with the principles of conservation and environmental protection, raising densities to a level at which the additional cost of this New Urban infrastructure was overcome, yet the product remained highly marketable.

However, while similar to a traditional, much older urban form that might have fitted well into the downtown of existing cities, the "Heart of Springdale" was something of an anomaly, sitting as it would have been in the midst of low rise suburban sprawl. The plan was called into question by the local municipality with respect to issues such as the proposed higher densities, narrower road widths and grid-like road configuration. A more automobile-oriented street system without laneways or on-street parking was requested by the city, while substantial concessions were made on many other neo-traditional design parameters to accommodate conventional suburban standards. After two years of developing and modifying plans and dozens of meetings with municipal officials, rate payers groups and the public and growing signs that the investors were getting cold feet about the innovativeness of the project and the resultant delays and uncertainties, the developer withdrew the application.

A more successful effort to introduce neo-traditional concerns can be seen in Cornell, a community of approximately 27000 residents currently being developed to the north-east of Toronto. The objective is to create a model community based on the principles of New Urbanism including diversity of land uses, a well defined public realm, integration of new development with existing adjacent development, preservation and enhancement of the natural environment and built heritage, transit supportive and pedestrian oriented, a full range of commercial, cultural and community facilities and a range of housing types. As with Bamberton and the "Heart of Springdale", the obstacles faced by Cornell have included the challenging of standard development guidelines and practices in areas affecting issues such as rights-of-way and road allowances, as well as the tendency of reviewing agencies to seek improvements in their own particular area of concern without considering the implication for other areas which affect the overall quality and performance of the project. Nonetheless, in this case, the combination of the management team's good planning practice in maintaining the overall vision for the community and encouraging other players and stake holders to look at the urban fabric as a whole, combined with the support of the local municipality and - perhaps most importantly - the fact that 80% of the lands are owned by the Province of Ontario, which is the principal developer, has meant that Cornell is proceeding.

The Province of Ontario is also the key player - in fact, the only player - in the final example of planned new communities. Seaton is a 7000 acre site northeast of Toronto acquired by the Province in the early 1970s as the site for a new town to support a planned new federal airport. The new airport was never built and the town was never developed. Now the Province is contemplating the development of a community of up to 90 000 people on the site and has recently held an international design competition. The competition called for the design of a model community which would demonstrate a real alternative to conventional suburban planning and development, providing an attractive urban environment in which car dependence would be reduced, respect would be shown for natural features and systems and for heritage, the community would be socially healthy and diverse and economically healthy and the plan would be practical and economically viable. One of the three finalists was a consortium of which I was a member.

Our plan (CEED, 1994) was based on the water carrying capacity of the land, envisaging no connection to the main trunk water and sanitary sewer systems of the region; instead, the community would use only the water and snow that fell on the land, treating and reusing some of that water using innovative ecological treatment processes. (In our opinion, the water-carrying capacity of the land was for 45-55000 people, not the 90000 suggested by the government.) Among the other innovative features of our design was the intent to design the community from the household level up. Thus we began to ask what were the environmental, social and economic needs of the individual household, then the block, then the neighbourhood, then the "village", then the town as a whole; we then began to explore how those needs could be met in that same sequence from household to town.

For example, we asked how such basic needs as food and safety could be met and services such as education and healthcare could be provided at the household or block level in the 21st century. Food needs might be met partially through individual or community gardens and food buying clubs, community kitchens or communal dining spaces as in co-housing; safety might include hard-wiring alarms to a central alarm system for smoke, fire, burglary or for summoning assistance, while urban design to promote "eyes on the street", the development of neighbourhood watch programmes and so on will improve safety. Education will be enhanced by the rapidly growing "information highway", with access to educational TV and information sources via the home TV screen, while at the block level there might be recreational rooms for crafts and hobbies and access to information and library services on-line. Increasingly, healthcare can be provided in the home and again the information highway will permit access to "guided self-care" computer programs and on-line and voice - and even video - connections to local health services for advice and consultation, while at the block level one or more supportive care units and "service rooms" might be available to enable people to stay in their local community and receive services from visiting staff.

All of these developments pose challenges to our conventional planning systems and regulations: the creation of healthy and sustainable communities will require significant changes to our planning processes and a significant integration of environmental, social, health and economic planning in the 21st century.

New official plans

Not only are communities and developers beginning to create plans for developments that are more environmentally and socially sustainable and healthy, but a number of communities are beginning to incorporate these concepts in their official (land use) plans. For example, the city of Parksville on British Columbia's Vancouver Island is a rapidly growing community of 10000 people. In the face of this rapid growth, the residents of Parksville and the City Council, under the banner of Healthy Communities, developed a multi-stakeholder process to define a set of community values and write a new official community plan based on those values. Input was received from more than 1000 people who completed surveys, registered for workshops, visited the Community Visions Office and participated in focus groups. The statement of community values that guides the new official plan emphasizes environmental integrity, maintenance of a small town atmosphere, economic vitality, social equity and a range of human services and amenities accessible to all, transportation emphasizing economically viable and safe alternatives to travel by car and a continuation of the public input process. These values have been integrated into a decision-making check list which is applied to new development in the community (see appendix 1).

But it has not stopped there. The Healthy Community process has now been used to undertake the development of an overall strategic plan for the city. This resulted in the creation of a "Healthy Community Advisory Commission" and a new organizational design for city government with an Advisory Planning Commission and a Parks and Recreation Advisory Commission linking with the Healthy Community Advisory Commission to focus on the relationship between Commission decisions and the city's strategic goals. Five committees or task groups have been formed that involve over 100 volunteers working in areas such as cycling, economic development, environment, housing and mobility and accessibility for people with disabilities. As a recent report on the project notes:

After three years, the city has "a set of community values ... which has formed the basis for a new community plan and which has broadened the framework for decision making at the municipal level ... a set of innovative municipal policies introducing specific guidelines for inclusion of affordable housing and environmental monitoring, transportation alternatives and a mixture of residential housing operations ... a mechanism for resolving differences of opinion ... (and) a committed partnership between city and residents along with the political will and regulations to support maintenance of the commitment over the long term" (Healthy Communities Parksville, 1993; 1994)

Similar efforts are underway in other communities in Canada. For example, the Regional Municipality of Halton to the west of Toronto, is one of the fastest growing areas in Canada with a population of 320 000 people. In revising its official plan in the early 1990s, the Regional Planning Department based it on two principles: land stewardship, which proposed that ownership and use of land should take into consideration long-term effects. The second principle is that of "healthy communities" which is interpreted as looking at all measures of quality of life. This has led to the development of integrated land use and social planning policies intended to address a set of human and social development goals. The following areas were targeted:

Similarly, York Region, another large suburban region north of Toronto, has recently incorporated healthy communities in its official plan.

Thus it can be seen that there is a growing commitment to the integration of healthy and sustainable community concepts in planning practice in Canada. The implication of this for the sort of communities we design and build are profound. If we are successful, we will have a significant impact on the environmental, social and economic health of our communities and the environmental and social sustainability of those communities for future generations.

But as the example of Parksville illustrates, changing our planning practice will have significant implications for the structures and functioning of our government and for the broader issues of governance of our cities. These aspects are addressed in the next and concluding section of this paper.

Implications for government and governance

The implications for government and governance are more profound. 6 We need a shift in our values as a society such that economic growth and development is no longer the overriding social and political objective, but merely one objective that has to be balanced with other objectives such as sustainability, equity, livability, social cohesion and environmental quality. And we need processes and structures that will enable us to do this.

We need ways to bring together all the competing sectors of a community to develop a shared vision and a shared understanding of what we need to achieve - this is what is meant by governance. (Of course, without social cohesion and a civic community, this important first step cannot be achieved.) We will need to create new government structures that will provide the forum for such an holistic approach and the mechanism for accountability. We need policy tools that enable us to evaluate policies in terms of their impacts on human development and the elements that comprise a healthy and sustainable community that supports human development (i.e. social solidarity, community livability, environmental quality, ecological sustainability, economic adequacy and social equity). And we will need to develop indicators that will enable us to measure our progress in these terms.

The Healthy Cities approach has a number of implications for the structure and functioning of local government. In this section, I will briefly discuss the following aspects: 7

The purpose of government

It is necessary at this point in our history, faced as we are with major challenges to the ecological and social sustainability of our way of life, to raise explicitly the question 'what is the central purpose of government and governance?'

In addressing this topic, I want to refer back to the CPHA definition of sustainable development and suggest that the central purpose of governance - and of governments - is, or should be, enhancing the human development of the population. While this may be implicit in the structures of governments, with their functions relating to health, education, social welfare, environmental protection and so on, it is rarely explicit and it certainly does not appear to be at the heart of business. In fact, too often it seems that the central purpose of government is very much aligned with that of business, i.e. economic development. But as I argued earlier, economic activity must be understood as a means, not as the end. If the means - economic activity as it is currently practiced - threatens the end - human development - then we must change the means, not the end.

The approach to government

Health does not result mainly from the actions of the healthcare sector but from the combination of the actions of society as a whole. Therefore it should be abundantly clear that if we are going to create healthy cities by working intersectorally to develop healthy public policies, we have to develop an holistic approach to government and governance. We can no longer afford the "luxury" - actually the stupidity - of dealing with issues as if they were discrete and independent, unconnected to each other. An holistic approach begins with the recognition that everything is connected to everything else. We cannot sit contentedly in our disciplinary and departmental silos any longer, because individual sectors can no longer respond to and meet peoples' needs. Instead we have to begin to work intersectorally and collaboratively to achieve our common purpose.

For example, we know now that safety in the community is no longer simply the responsibility of the police - indeed, it never was. Rather, safety depends among other things on how our children are educated, what values they learn at home, in school, in church or through the media, how social and economic needs are met, the way our streets and buildings are designed (whether there are what Jane Jacobs calls 'eyes on the street', for example), how we light our parks and streets, how well neighbours know each other and look out for each other and, of course, how well our police and justice systems work. So creating a safe community is everyone's business.

But if we are to take this notion of wholeness seriously, we have a problem: not only are our governments not structured for an holistic approach - an issue I will come to shortly - but we lack the concept of wholeness and we lack people skilled in taking an holistic approach (see earlier discussion). If we are going to take an holistic approach to governance, we will need new skills (and perhaps new holistic disciplines), new processes, new styles and new structures.

The level at which government occurs

Several years ago at a WHO workshop on the future of health in Europe, the Swedish political scientist Jan Eric Gibland argued that the nation state is being pulled apart by two opposing forces. The first of those forces is "supranationalism"; as a result of GATT, the European Union, the North American Free Trade Agreement and similar multinational agreements (and, one might add, the emergence of the powerful multinational corporations), decision-making is increasingly being drawn up to the supranational level. At the same time and perhaps in reaction to that, we are seeing the growth of what he termed "parochialism" or localism, in which people want to establish their local identity and exert more local control. In part this is to be seen in the growth of regionalism and nationalism (most horribly, of course, in the former Yugoslavia, but also in northern Italy - the Lombard League - Scotland and in Canada - Quebec, to name but a few).

But localism is also to be seen in the re-emergence of the concept of the city-state. Jane Jacobs, for example, has pointed out that it is cities that create wealth, not nations and as a consequence has suggested that local currencies might well re-emerge (Jacobs, 1984). And of course, the Healthy Cities movement can be seen as another testament to the need that people feel to exert more local control, in this case over what makes their city or community healthy. This is entirely consistent with the concept of health promotion which is, after all, about people increasing control over their health.

The same forces that are pulling apart the nation state may be being replicated at the city level. First, if we take the notion of ecological sustainability seriously, we cannot consider simply the city but the bioregion of which it is a part. For example, a recent Royal Commission on the Future of the Toronto Waterfront (1992) took the position that it is not possible to consider the waterfront in isolation, but in the context of the entire bioregion, defined as the watershed of the rivers that drain into Lake Ontario along the entire length of the waterfront. Another example: Adelaide in South Australia has a watershed management plan that covers the entire coastal plain in which the city sits. And of course the work of the University of British Columbia Task Force on Healthy and Sustainable Communities on the concept of the "ecological footprint" of cities is also in essence a bioregional concept. So the city is being pulled in the direction of decision-making at the bioregional level.

Second, at the same time - and as is the case for the nation state - the city is being pulled apart by decentralist forces. For example, a number of European cities that are part of the WHO Europe Healthy Cities project are in the process of decentralizing their governments. This is not necessarily in response to the Healthy Cities approach, but it is certainly consistent with that approach and it reflects the need that people feel at the neighbourhood and community level to have more influence over the decisions that affect their health, wellbeing and quality of life. And it reflects the reality that it is no longer possible to govern large cities from the centre. So the level at which city government occurs is moving both upwards to the bioregional level and downwards to the neighbourhood level in response, at least in part, to the concepts associated with healthy and sustainable cities.

The style of government

A section of the mid-term report on the WHO Europe Healthy Cities Project (Tsouros, 1990), discussed the need to move from the old management style to a new management style more consistent with the approach of health promotion. It is a style that emphasizes 'power with' rather than 'power over', negotiation rather than directives, process rather than structure, collegiality rather than hierarchy, collaboration rather than competition, an holistic rather than a sectoral approach, 'both/and' rather than 'either/or' and 'win-win' rather than 'win-lose' strategies.

This new style is emerging in many organizations and is not so much a product of the Healthy Cities approach as consistent with the approach; without such a change in style, it will be very difficult to attain the objectives of the Healthy Cities approach in any city or community.

The structure of government

On the principle that form follows function, changes in the process of government such as those described here will require changes in the structures of both government and governance. (For a fuller discussion of possible changes in the structure of government, see Hancock, 1994b.)

The problem is that we have got a system of government that is essentially based in the 19th century, both literally and metaphorically. The origins of departments of public health, of public works, of parks, of planning and other municipal departments are found in the 19th century. They are organized on the 19th century models of disciplinarity, of separate sectors. The problem is that most if not all of the issues we face in the 21st century cut clear across these 19th century structures (Fig. 3). So we have a set of 21st century issues that do not fit in to our 19th Century structures. Since the current structure is no longer capable of responding adequately to the challenges we will face in the 21st century, we will have to create new structures.

One example is the growing interest in "roundtables" as a means of addressing the problems we face. In Canada, for example, there are national and provincial Roundtables on Environment and Economy that were set up in the late 1980s in response to the visit to Canada in 1986 of the Brundtland Commission. The Roundtables bring together business, government and environmentalists to address the issue of sustainability. There are also growing numbers of local Roundtables in a number of municipalities. More recently, the City of Sudbury, a city of 70 000 people in northeastern Ontario, has established the first Roundtable on Health, Economy and Environment, which brings together local government, local business (it is housed at the Chamber of Commerce), local unions, community groups, the University, environmentalists, the health care sector and others, to address the task of improving Sudbury's health, environment and economy. The 'Commissions' established in Parksville, British Columbia and described earlier are another example of the emergence of new structures in response to the changing needs of cities.

The democratic process of governance

Winston Churchill said that democracy is the worst form of government - except for all the others! But that is not to say that democracy can't be improved upon; indeed it should be improved upon.

One of the important things to understand about Healthy Cities - rooted as it is in the concept of health promotion and thus of enabling people to increase control over the events and conditions that affect their health - is that it is fundamentally about democracy in the city. As Draper and Harrison (1990) noted with respect to one of the key strategies of health promotion and the Healthy Cities approach, "healthy public policy is impossible without healthy democracy", a view that is consistent with the WHO understanding of healthy public policy as requiring accountability (WHO, 1988). Thus it is perhaps not surprising that a week-long WHO training session on healthy cities held in Horsens, Denmark in October 1993 for cities from eastern and central Europe was supported by the Danish Democracy Fund; presumably the Fund recognized that learning how to create a healthy city is about learning how to develop and use democracy.

Some of the dimensions of democracy that are important in the creation of healthy and sustainable communities include:

For as the Executive Director of the (Canadian) National Roundtable on Environment and Economy noted in an editorial recently:

He concluded by saying :

So in conclusion, when we begin to talk about what is a healthy and sustainable city, we come inescapably to question our systems of governance and our structures of government and to begin to talk about how we can have a more truly democratic way of creating healthy and sustainable cities and communities. That is the challenge we face as we try to promote health and preserve the environment, as we seek to ensure just and sustainable human development in the cities, towns and villages of the 21st century.

But ultimately, what this all comes down to is social and political will. Do we have the social and political will to reorder the priorities of our societies and communities, to shift our values, to aspire to higher objectives than economic growth and consumer happiness? If we do not, then I fear we are doomed. But if we do, I believe we can indeed create healthy and sustainable communities that maximize human development.

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