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Leading a healthy life in the city of the future: a utopia?

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“Health - a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

‐ Preamble to the Constitution of the World Health Organization (WHO), New York, June 19-22, 1946

The announcement on 16 March 2020 of a long-term lockdown triggered a temporary urban exodus for 1.5 million French inhabitants, according to INSEE. The pandemic has had a massive impact on cities, changing their streets and the behaviours of residents: people wear masks and keep their distance. They are scattered and have access only to “essential goods”. The public health state of emergency was reinstated on 17 October 2020 and will run to 17 February 2021, rekindling the topic of leading a healthy life in the city.
“A first” in the annual index of public services published by Institut Paul Delouvrier in 2019: “the French rated public health as their number one priority, over employment, education and the environment.” Leading a healthy life in the city, according to the definition adopted by the WHO, which has been the authority since 1946, means living in “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
The health of the population depends on the interplay of countless biological, behavioural, socio-cultural and environmental factors called determinants of health. Most are specific to one’s location: air, water and soil quality; exposure to noise; possibilities to engage in regular physical and intellectual activity; and contact with other people and with nature, for example.
Thus, the local scale is best suited to act and respond to these needs, which prompted the WHO to launch a worldwide network of Healthy Cities in 1987. “Cities, viewed as living organisms, [commit to] act to improve their health and that of their residents by approaching the environment as a fundamental resource, to protect and to enrich through solidarity-oriented methods, in consideration of both local and international contexts.” “They give every individual the means to access culture and to achieve their creative potential.”
In the past, urban planning and architecture found solutions to transform these “living organisms” in response to epidemics. Present-day Paris was built in the 1870s, some 25 years after the cholera epidemic that claimed 18,000 victims in the capital over just six months, to feature more spacious avenues, dual aspect apartment buildings and bigger windows in line with a hygiene-oriented vision.
Today, the health crisis underlines the need for a more global approach to the link between the city and public health. The crisis has been a brutal reminder of health inequalities within the population, as it first took aim at the most disadvantaged, who are exposed to infection because of their working, living or nutrition conditions. Remember that there is a 13-year gap between the life expectancy of the richest 5% and the poorest 5% of men in France, according to INSEE. We are faced with the challenge of integrating health concerns in the urban dynamic, an effort which is currently insufficient. To do this, we must consider the determinants of health in designing our living environments; how, through our programming choices or building designs, can we maximise exposure to health protection factors and minimise risk factors? In 30 years, two-thirds of humans will be living in cities. There is an urgent need to meet that challenge.

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How do we build healthy living environments?

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The pandemic has made health one of the central issues tackled by urban planners and architects. “We must take a fresh look at our desires, our concepts, our methods, our practices, our ways of working together. In sum, we need to revisit our conception of urban space and what enables us to be together and build community. We must act quickly to create new kinds of know-how to accommodate new attitudes and make unexpected projects possible.” In its September issue, the periodical Nouvelles Urbanités signalled the end of business as usual.
The key, as underlined by the collective, is not just to build spaces that are more comfortable and more eco-friendly. Rather, the idea is to create a living environment that encourages residents to act in ways that promote their own health and that of the environment, without infantilizing them or infringing on their freedoms. But how? Can a neighbourhood change our behaviours or forge increasingly responsible citizens with more and more freedoms? How can the place where we live re-teach us how to function as a society, together, to face the shared threats of epidemics and global warming?
It will take all kinds of skill sets to answer that question.

MOBILISING PROFESSIONALS IN URBAN PLANNING, HEALTHCARE AND THE ENVIRONMENT TO WORK TOGETHER

Co-defining a vision of what “healthy living environments” would look like along with experts from all disciplines (urban planners, architects, sociologists, local authorities, insurance groups, epidemiologists, psychologists, pharmacists, and experts or problem solvers in sport, food and medical services and facilities): that is the approach undertaken by Bouygues Construction in 2013 to share common goals in these subject areas. How can we imagine living environments that would help citizens adopt new, virtuous habits for their health which would have maximum impact on the risk factors associated with chronic diseases and help address some of the challenges facing the healthcare system? Those questions were explored during collaborative workshops which culminated in the publication Des territoires favorables au bien-être et à la santé (“Regions to promote health and wellness”). Project governance is one of the core principles identified to design neighbourhoods that promote good health. “Standing up a healthcare structure or a scientific committee as part of a construction or renovation project or involving scientists, healthcare and public health experts in a consultative process as early as possible enables the identification and prioritisation of the health challenges and concerns in the neighbourhood or region where the project is located, the definition of project-appropriate levers for action, and the measurement and tracking of the project’s impact on public health as part of an evaluation process,” explains Elsa Favreau, Forecasting Project Manager at Bouygues Construction. Thus, the aim is to work with that body to develop programming to positively influence or to mitigate the risk factors: promote a healthy, balanced diet, get bodies moving with active mobility and sport activities, encourage social interactions and a thriving community life, organise healthcare services and facilities so they are as close as possible to residents, facilitate the inclusion of people who are marginalised due to disease, disability or loss of independence and support their family and friends, and so on.
Once the vision has been defined, move on to projects. Around 20 healthcare experts (general practitioners, occupational physicians, pharmacists, neighbourhood nurses, etc.) associated with a property-development project: that is the innovative experiment being conducted by the urban planning firm Lyon Confluence, and Linkcity, the property development subsidiary of Bouygues Construction. They are jointly organising the healthcare services and facilities so they are as close as possible to the inhabitants of the Confluence neighbourhood in Lyon, on the southern end of the peninsula.
These pro-health urban planning approaches, which have been in development for many years under the aegis of the WHO Healthy Cities network and in academia, are increasingly translating into projects as the array of tools expands. One example is the 2020 publication of the Isadora guide (Isadora in French stands for “Integrating health in property development projects”) which counsels urban construction professionals in their operational undertakings.

Beyond these actions, our entire understanding of the urban space must be revisited, with an emphasis on the fundamentals: better account for the living world and ecosystems in the way we build and design the city for everyone, including the most vulnerable.

LISTEN TO NATURE

“[We must] open up construction more to the life sciences: ergonomics experts, ecologists, landscapers, naturalists, biologists, soil scientists, anthropologists, horticulturists, gardeners, allergists, ornithologists, entomologists, etc.,” tweeted Olivier Lemoine, ecological engineer and manager of the urban biodiversity division at Elan-France, in October. Ecologists such as Marc Barra and Philippe Clergeau regularly remind us of the humility required to restore balance to the ecosystem, of which we are but one component: it can only be beneficial to us. And the health of cities depends on it.
Now, “at universities and in architecture schools, nature is being integrated into training about the city,” observed a headline in Le Monde on 3 March 2020. Building vertically, removing asphalt to let water seep in, putting an end to digging and building parking silos, opting for bio-sourced materials over concrete, planting native species as much as possible in the ground, as well as trees, which also play the role of urban air conditioner thanks to evapotranspiration: these are all practices to fight global warming and epidemics. In light of global warming, greening cities has become a public health imperative. The heat wave in the summer of 2019 caused a 10% spike in deaths.

DESIGN FROM A CHILD’S POINT OF VIEW

“Making room for children in the city will improve the daily life of every adult, too,” Thierry Paquot asserted in Bastamag, on 4 May 2020. “It means slowing down, planting more trees, prioritising signed routes as if for a treasure hunt, tending to the façades of buildings at street level and turning school entrance areas into multi-coloured, joyful plazas free of cars. We must re-imagine the contours of the streetscape: a city for and by children is a city for everyone.” He also promotes this theory in Mesure et démesure des villes published by CNRS, 320 pages, 12 March 2020).
The approach has been advanced by the city of Basel, Switzerland, and the association Kinder Büro (“The children’s office”). The thrust is not just to incite planners to look at the city from a different angle, by seeing it through the eyes of someone who is just 4 feet tall, but to co-design a school, a street or a neighbourhood even with children so that these public spaces are inhabitable for even the most vulnerable. It is also a way to ground residents in their region and to motivate them to take care of it.

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What will cities and regions be like after COVID-19?

The COVID-19 pandemic uncovered the downsides of city life: a lack of nature, space and privacy and, in some neighbourhoods, limited access to fresh foods, high population density and difficulty accessing healthcare. But the city also offers benefits: the willingness to act and the generosity of residents, as well as mayors with inspiring initiatives.
Cities as we know them today were themselves forged by struggles with epidemics and infectious diseases. The 1832 and 1849 cholera epidemics in France prompted a law in 1850 to clean up unsafe housing and led to the urban planning work overseen by Haussmann and Belgrand to refresh, ventilate and purify the city. That brought about city blocks with courtyards, dual aspect buildings, wider windows, new parks and green spaces and water and sewage systems.
Far from this hygiene-oriented vision, the health crisis is an opportunity to re-examine our urban models and to explore ways to improve them to design a city that takes better care of its inhabitants.

NOURISHING CITIES: TOWARD GREATER FOOD INDEPENDENCE

The crisis shined a light on access to food and food supply logistics. For most mayors, the locavore movement became a common-sense practice rather than a fashionable lifestyle choice. The future looks bright for community-supported agriculture, producer-owned shops, drive-up farm stands and open-air markets. There are drawbacks: ADEME reports that short circuits have a bigger carbon footprint than traditional supply chains, a problem yet to be resolved.
In the interest of greater food independence, cities like Paris and Bordeaux are adapting their urban planning documents to add more agricultural space.
“Many people have forgotten that Paris was an agricultural city for a long time, producing some of its own supply,” explains Audrey Pulvar, assistant to the mayor of Paris, in charge of sustainable food, agriculture and local supply chains. “It was not until after World War II that the farmyards and vegetable gardens of Paris ‒ those attractive, diverse spaces ‒ stopped supplying the city’s residents. Now, we are hardly at 10% of Paris’s current growing capacity; there are only 30 cultivated hectares divided into plots ranging from 450 to 600 m2 on average, scattered across the capital.” 
That is not a lot, given that “Paris in the time of Napoleon III [counted] 1,400 hectares farmed, 9,000 farmers, 1,700 draught horses and 2,300 cows, not including home gardens,” points out Jean Favier in Paris, Deux Mille Ans d’Histoire (1997). Today’s Paris only produces 800 tonnes of fruit and vegetables; yet “it takes 2.5 million tonnes to feed the capital. And we would need 150% of the surface area of Paris to produce that,” notes Audrey Pulvar. The idea is to experiment on all types of platforms (walls, roofs, etc.), with new forms of agriculture, such as soil-free farming (aeroponics, aquaponics) and to enable residents facing economic hardship to feed themselves as naturally as possible. Another pathway for these metropolitan areas is to cooperate with more rural regions in virtuous partnerships. The organisation of organic food chains in these regions could, for example, be secured by orders destined for the plates of Parisians.

BLENDING USES

What is the best way to occupy space inside homes and in public areas?
Mobility reduced to essential travel, recreation limited to 1 hour maximum within a 1-km radius of one’s home, teleworking for some of the population: being confined to a small living area, in conflict with our nature as bodies in motion, has compelled us to reflect on our homes and the arts of doing, to borrow a phrase from Michel de Certeau, as we practice them at home. Dissatisfaction stemming from accommodations that are tiny or ill-suited to working remotely was exacerbated, and compounded by limited access to the outdoors and nature.
“We can no longer consider flats without a balcony or terrace or some access to the outside, to nature,” affirms urban architect Anthony Béchu, along with many others. Furthermore, “We could have private space that are far more pleasant to inhabit by creating more passages between common areas and personal areas; an open door between the lounge and the bedroom is sufficient to escape, to walk a different pathway through the apartment. Thus, one can avoid walking through the corridor that usually accesses the bedrooms and bathroom. It has a psychological benefit.”
The lockdowns have seen significant changes in usage. There has been a boom in “remote everything” and amplified blending of uses in the home: telework, remote learning, telemedicine appointments, fitness and exercise, crafting, cooking, home improvement, etc. Good connectivity and the ability to adjust or rearrange the space for these different uses have played a critical role in how this period was experienced. From add-ons in the form of common space in the residence, which each occupant can use without owning to housing designed to accommodate telework (nooks, alcoves, etc.), the needs are growing.
The experience of widespread remote working (for professions suited to this type of work) will likely have a profound effect on future patterns of use of tertiary real estate. As a result, corporate offices would become “showcases” for the company’s values, uniting employees while affording them more flexibility in their work organisation and efficiency.
Public spaces are also being used in new ways, endowing them with greater flexibility. During the lockdown from March to May 2020, the streets of Paris, Berlin, New York and Bogotá were enhanced with new (temporary or permanent) bike lanes, in the place of car lanes, to reduce urban pollution and travel times and promote exercise. When the weather was fair, temporary terraces took over car parks and delivery zones. The agile modes of urban action (tactical town planning, chrono-urbanism) have proven their effectiveness in managing the crisis and returned temporal approaches in urban planning to the forefront. Regardless of the levers implemented (tactical, temporary, pop-up, reversible, transient, instant), the point is to observe uses to detect the potential for intensification, desaturation or adaptation and to organise such opportunities in respect of local balances.

CONNECTED CITIES

“With lockdowns and teleworking, demand for the internet is on the rise,” announced France Info on 19 March 2020. “To such an extant that platforms are starting to overheat. Is there a risk of service outages?” Despite a 70% increase in traffic, no major congestion has been seen in Europe, as reported by the Journal du Dimanche in May 2020.
Many large- and medium-sized cities resorted to digital solutions to support local business activity during lockdown.
“Digital resources were a way to communicate which businesses were open, to facilitate direct contact between producers and consumers and to smooth out home delivery of products from local merchants,” Caisse des Dépôts explained on its website in June 2020. “Other solutions could also be envisioned to maintain access to shops in city centres, such as tools to measure store traffic or to manage safe distances in queues.”
The telephone, which made its big comeback during lockdown, helped municipal authorities tend to the problems of their flock (excluding medical emergencies and contact tracking, which were handled by the national healthcare scheme and, to a lesser extent, by the StopCovid, then TousAntiCovid apps). Most set up toll-free hotlines, some of which were available 24/7. Dijon integrated the “OnDijon” system which manages the public space through a centralised oversight centre. “OnDijon enables us to be resilient during this crisis,” said Denis Hameau, the city councillor in charge of the project, on France 3 in April, 2020. “It provides us with an effective, innovative mechanism because we were able to take care of isolated individuals. In the digital divide and with people facing financial challenges, we can take care of things.”
No matter the role technology plays, the smart city will rely first and foremost on the mobilisation of its stakeholders and citizens to “stand up for their region” to resist the crisis.

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How to improve city life?

CROSS INTERVIEW

NICOLAS NOTIN, project manager for urban health and the Greater Paris Area at the Agence régionale de santé (regional health agency), in Île-de-France
ANTHONY BÉCHU, architect and director of the Béchu + Associés agency
MAXIME VALENTIN, head of sustainable development and innovation for the Lyon Confluence project

Nicolas Nicotin, setting aside the current pandemic, can we hope to live a long, healthy life in Paris?

N.N.: Within Paris city limits, overall, the health indicators are good. There are fewer chronic diseases and cardiovascular diseases than in most regions in France. However, there is great social and territorial disparity in health in the region, between the 8th arrondissement in Paris, and some northern municipalities: there is 7- or 8-year gap in the life expectancy among men! Setting aside the current pandemic, the major problem remains air pollution. Although the concentration of pollutants (nitrogen dioxide, fine particles and ozone) has stabilised, and even slightly decreased, it remains high near infrastructure such as national and departmental roads. It is a factor which causes or worsens respiratory diseases (asthma, bronchitis) and strokes. Noise pollution comes up nine times out of ten, among the issues raised by residents, but it is not currently being addressed using reinforced engineering methods.

On which urban problems has the pandemic shed light?

N.N.: One subject that came back to the forefront with Covid-19 is the inequality between health sectors in different departments, which stems from socioeconomic inequalities. The crisis affected the most disadvantaged populations, those most exposed due to their work and housing conditions. The vulnerability of Seine-Saint-Denis in the face of the virus comes from factors such as overcrowded housing (up to five hundred people live in a shelter designed to house two hundred), education and work that cannot be performed remotely. Moreover, the municipalities hardest hit by Covid-19 struggle to access quality fresh products. Young people affected by excess mortality generally suffered from comorbidities such as diabetes or obesity. But if you compare Neuilly-sur-Seine and Garges-lès-Gonesse, you’ll notice that the ratio of these diseases is 1 to 6. Finally, vulnerable areas are the ones suffering the most from environmental nuisances (pollution and noise) and have more difficulties accessing health care.

Could these problems be resolved by urbanism?

N.N.: There is an urban divide between Paris, which is encircled by the ring-road, and the suburbs, which causes a segregation. Currently, in Île-de-France, about thirty municipalities have started working on the matter of urbanism that would foster health, with a systemic long-term vision on housing, urban development and transport. They came to us to discuss general health matters – how to reduce environmental nuisances, live a healthy lifestyle, have access to health as well as medical and social services. This forces us to work together and face our respective responsibilities.

Anthony Béchu, how can we repair this divide between Paris and the suburb?

A.B.: The capital walled itself in without reaching out to the villages and small towns in the surrounding area. We now need to reconnect them and turn the ring-road into a real urban boulevard. We need to put some green space back in between these satellite towns and the big city, give them back their function as food providers, and recreate kitchen gardens in the middle of Paris. Local farmers must be included in city life. It’s only logical, when we know that 80% of food worldwide is consumed in urban areas. Everyone agrees to reintegrate nature into the city and restore the ecosystems. But this will not happen smoothly. The issue of shopping centres, for example, is an urgent one to resolve. What will we do with these buildings in the shape of shoe boxes? One of our teams is working on the matter.

Your daughter, Clémence Béchu, calls you a “space doctor”. What does that mean?

A.B.: My job is to optimise people’s lives in the spaces where they spend the majority of their time: we spend nearly 80% of our time inside buildings! The streets, plazas or courts where homes and offices are located, the way in which we will include vegetation and let in the light, the materials used, air filtration, ceiling heights to control the heat, colours, etc., all of these things have an impact on well-being.
We could create much more pleasant private spaces by creating more passages between common areas and personal areas: an open door between the lounge and the bedroom is sufficient to escape, to walk a different pathway through the apartment; it saves you from having to go through the hallway which generally leads to the bedrooms and bathroom. It has a psychological benefit. An additional room should be added, either a space to welcome guests or to telework, using subventions or tax exemptions.
Finally, we can no longer think about apartments without balconies or terraces, without access to the exterior and nature. Even next to the ring-road or a highway. In fact, at the Spallis site, to the south of Saint-Denis, north of the Pleyel intersection, we created a noise barrier on the ring-road side, and courtyards on the city side, with balconies and other openings looking out onto them.

How can we combine respect for biodiversity and new housing?

A.B.: Brownfield lands and abandoned buildings still remain to be reinvented. The polluted lands adjacent to the city need housing in synergy with nature, with vegetation climbing up the walls and roofs. There is also a lot of work to be done to remove some of the asphalt, and to regenerate the soil and make it permeable once more. Soil pollution must be cleaned up so that farmers come back to the city and children can see the blue sky again. That is the work we initiated in 2015 in the ecocity of Shenyang. It was so polluted by mercury that we could have taken our temperature just by putting a fish under our arm!
Nature is an engineer that we need only imitate to reduce our environmental footprint to a minimum. That is the principle of biomimicry. We raised the D2 tower at La Défense, on a very small piece of land surrounded with buildings, by drawing inspiration from trees and funnel basket fish traps, which enabled us to save 30% of material: the tower rests on a concrete central pillar, like a trunk, from which stem branches, or in other words, the different floors. The outside structure – the tree’s leaves, where magpies have made their nests, rise up to shape the archways under which grows a garden in the clouds. The vegetation settled there, and mushrooms and slugs made a home at a height of 171 metres. From the 6th floor up, there is no more pollution in the soil of the balconies and terraces.
Now, we also have to think about buildings’ flexibility. We created a workshop just for that. How can we design a building that could turn into something else? We need to give back permanence to that which becomes obsolete with time. Any thought process will need to include this flexibility.

How do you foster the life of a neighbourhood?

A.B.: We give roots back to places and people who have lost them. If you take people somewhere without providing strong identity roots, they become adrift.
We need to create places where people feel at home; people need to find their own culture again inside their own neighbourhood and be connected to the history of the place at the same time. This is fundamental. Thus, one of the major problems Africa will face in the future will come from the migration towards the cities, which expanded according to the American models. The villages, tribes and associated social and societal organisation model where these future residents come from are actually calling for a different kind of urbanism: it is imperative, if farmers are going to have a place in cities and if cities are going to feed us. The reference point for cities is the culture of the people living there. In India, Louis Kahn used bricks and local materials, and when the residents arrived, they thought to themselves, “This is mine; I am home.”
Next, a certain social diversity must be ensured to enhance vitality. A neighbourhood must be a town within a city. Along these lines, in collaboration with Alain-Charles Perrot, we designed the “International gastronomy and wine city of Dijon” on the site of the old Hôtel-Dieu: an inhabited park, a 3.5-hectare eco-neighbourhood which includes a hotel school, cultural areas, a living gastronomy museum, seminar rooms, various types of housing units, senior housing and coliving spaces, as well as public areas such as markets.
An urban development and architecture project is like a menu to be enjoyed. Everything there to be seen, heard and felt has to create a harmony which makes us feel good.

So you are contributing to the creation of the “city of proximities” advocated by Anne Hidalgo?

A.B.: As architects and urban planners, we’ve always worked on creating the city of proximities! I was born to a father and grandfather who always thought about the use and function of things more than their shape, and about what a building was going to leave behind it. To build a neighbourhood in the same way we build a building, we work with the urban space and with the residents of that space in mind. In our offices, we put ourselves in the shoes of others through roleplaying games, in the humblest possible way, to zero in on the needs we would have. We also talk with the mayor, the municipalities and the residents. Without these discussions, our work would lose some of its meaning, as discussions also enrich our designs.

Maxime Valentin, how have you, little by little, put health at the heart of the Lyon Confluence project, a project to renovate a central neighbourhood?

M. V.: The issue of health was brought up indirectly as SPL Lyon Confluence initiated the Lyon Confluence project twenty years ago. It is a 150-hectare neighbourhood at the south point of the Presqu’Île, at the heart of Lyon, where the Saône and the Rhône rivers meet. As developers, we started thinking about the well-being we wanted to ensure for the residents, starting with air quality.
We worked in-depth to restore the green and blue urban frameworks and make the neighbourhood greener by planting vegetation in open ground around most of the buildings. Very few underground spaces were built. We only created one car park underground, which is shared, to free up the courts, make them green and reduce heat islands; in Summer, the temperature there is cooler than that on concrete streets by 2 to 3 degrees Celsius. The buildings with openings on different sides are naturally ventilated.

Which health services have you put in place to guarantee this quality of life?

M.V.: Five years ago, in response to DIVD (Démonstrateurs industriels de la ville durable, or sustainable city industrial demonstrator), a call for projects launched by the government, we created Eureka, a consortium designed to develop ideas on health and well-being, among other subjects. When we created this, we realized that we were not working with the health sector. The professionals we sought out, namely the AST (action – health – work), general practitioners, pharmacists, and neighbourhood nurses, were very favourable to the creation of a project; we just needed to define it. There were already health facilities nearby. However, through our exchanges, we realized that the matter of prevention was neither addressed nor structured.
A 1,000 m2 building created by Linkcity was going to host the project. One of the floors is dedicated to prevention. The top floors are reserved for general practitioners and nurses. A team of three operators, called Alliance Santé, was brought together specifically for the project: Office Santé (a health centre operator), radiologists (which were lacking in this arrondissement), and the AST – occupational health.
This synergy between general practitioners, occupational health and radiology gives depth to our response on the matter of quality of life by ensuring both health care and prevention services in the neighbourhood. Occupational health services refer patients to the doctors on the top floors of the healthcare facility, or make the appointments with them directly, and these doctors refer patients to radiology services when they need preventative screening tests (for breast cancer, for example). We save time and trips. And we save a lot of energy.

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