Health might initially be regarded as a bit of a misnomer in that people associate health with doctors and medicine, but health is actually dependent upon everything in the living environment. In fact, medical care accounts for only 10% of health in people and communities. The factors directly and indirectly influencing health are numerous: social, economic, environmental and personal (both physically and mentally). The approach of Healthy Cities aims to bring all these interests together in one coordinated approach so that citizens and representatives from all sectors of society can shape the quality of the entire community.

The World Health Organization (WHO) signed onto the concept early. From the first office in Europe the program has quickly expanded beyond WHO to more than 7000 projects all over the globe. In some places the Healthy Cities idea has been embraced and branched out to Healthy Islands, Healthy Villages and even Healthy Schools. Sustainable communities, safe communities, livable communities and others are using the same idea.

At first, with the assistance of WHO, local governments and community associations formed coalitions to improve community health and solve environmental problems. Now communities help communities, and work in informal networks of people, helping each other. The obvious challenge from explosive worldwide growth and the negative effects on health issues such as housing, employment and safe environment loom as a threat to human development and shows that the need for healthy cities is urgent.

Eyemine spoke with the man behind this new movement and new way of thinking, Dr. Leonard Duhl, at UC Berkeley. He is the force behind the International Healthy Cities Foundation and the accompanying website, http://www.healthycities.org/

___________________________________________________
Eyemine: Can you tell us a little about your background?

Leonard Duhl: I was raised in Manhattan and trained as a physician in Albany, New York. My father was a dentist, and was part of the planning commission in New York City. I was exposed to all aspects of the city, with my father showing me many different facets of city life in New York. This early exposure led to my preoccupation with prevention, social systems and active participation in community events. I originally wanted to be a pediatrician, stemming from my desire to get to people early and prevent unhealthy behaviors. I later decided to focus on psychiatry, looking more specifically at behavior.

In 1950, when the military draft called, I joined the US Public Health Service. They sent me to Contra Costa County in Northern California where I read small 70mm tuberculosis x-rays. Ninety percent of those x-rayed were people in the more well-to-do communities. This lead to my involvement in the community--looking at a bottom-up approach instead of programs that see public health as a police function.

Eyemine: What does Healthy Cities do?

Leonard Duhl: Healthy Cities is a process of working toward more competent and healthier communities by bringing together a large group of concerned people, which include residents and representatives from the private, business, public, and nonprofit sectors. Up to relatively recently the preoccupation with health is primarily with medical care. In the last ten years or so we've come to the point where we are in healthy cities, where we realize that only 10% of all health deals with medical care. The rest deals with genetics, standards of living, jobs, education, housing, and communities. We're beginning to see that medical care won't work without dealing with its context and with the other issues mentioned.

You can't deal with health without a multidisciplinary approach. The Healthy Cities process gets everybody around the same table for a change. This is not done in government, health systems, or universities. Our purpose is to find broadly agreed upon dimensions--or vision--that will describe a healthy city and suggest processes that will enhance a city's health, and the health of its people. Eyemine: What is the Healthy Cities concept?

Leonard Duhl: Healthy Cities is not an organization. It is a network of people and groups, interacting together. Each runs its own individual programs tailored to the specific needs of the community it is serving. The concept is using a collaborative problem-solving process that allows a broad spectrum of community stakeholders to create a vision of well-being and implement a plan to turn its vision into reality. Built into the Healthy Cities concept is getting everybody around the table, including the community residents. The minute you do that, you're involved in community-building. You then need the skills to build community. This is what some call social capital.

What are the skills you need to build community? Well, you can do as many architects and city planners do: lay out the city to look like a grid, a circle, or even a tree. Or, you can talk about what I call the social architecture, and understand how people relate to each other.

Let me digress a moment, and talk about building economic capital. Trevor Hancock, who is a founder of Healthy Cities, reminds us that capitalism that focuses just on economic capital, and forgets social and personal capital, is not true capitalism. I see our business, yours and mine, as extending our capital to this broader scale.

Years ago I was involved with designing the new town of Columbia, MD. The question there was, who's going to live there? How are they going to relate to each other? Are they interested in issues like safety? Do you want neighborhoods? Do you want diversity of the population? We found we had to concretely plan to get the population to diverge. Well to get it diverse, you had to bring businesses in. You had to bring in those businesses that would attract minorities. You had to bring in computer businesses. The city of 70,000 is now mixed.

What is social architecture? It's what we call both the government and the informal culture. Our focus is how we relate to each other, how we talk to each other. Can we solve problems? How do we solve problems that come up, what I call social competence? That's what I meant when I talked about the medical system. I have a lot of social competence in a lot of systems, so when my wife is sick I can deal with all those. Not perfectly, because the system is extremely complex and chaotic. My problem with community building is how I can get the average person to have that ability or have someone who can help them work through the system.

The second point is to organize. In the old days I used to organize by the telephone and by travel. Part of it is getting older, and I don't like to travel as much as I used to. What happens now is, once I know these people I can use the Internet.

The best example of planning on the Internet of recent events was what happened in Seattle. They organized that whole resistance to the World Trade Organization on the Internet. Nobody physically met to plan. They were interconnected. They arrived there from all over, arranging it through this kind of communication. This tells me that the Internet stuff is pretty powerful for organization. But what held all of them together? The only thing that held them together was their common values - or, coalitions of some shared values. Though some were mostly interested in the workers maintaining their jobs, and others interested in the environment, we can say, We're not in the same business, but there's enough overlay that we'll work together. So those values hold you together.

Community is really something held together by values. Nowadays, I believe a community is a basic set of values that hold our "family" together, where each of them is completely independent and can do anything they want, if it fits into the common value system. It is a "we" mentality. You couldn't run the Internet unless people accept some basic concepts of the transmission of data. If you won't play by the rules, you can't play on the Internet. Though some people screw it up beautifully.

Linux is very interesting because they use a technique which I've learned: give it away free and then you can challenge Gates and Microsoft. A lot of the interesting stuff on the Internet is giving it away--you want my protocol, you can have it; you need my programming tools, you can have them. If you just come out with a good product, it doesn't matter; what only matters is if you get all the conditions for success around it.

I'm interested in how you help communities increase their competence. It's a way of thinking. We redefine health as social competence and quality of life. That's the first goal I have, because I get into some countries in Latin America and they say, health is in going to see the doctor. I don't want to just see the doctors! I want to see the mayor; I want to see community groups. That's my first goal. My second goal is I want to give them a set of general principles about how to work. Every project is different. However, I can use an idea in Bolivia or an idea in Ohio that can be used someplace else. What I want to do is mix and match properly. When we got this thing going, we decided to spin off the United States. That's what we call Healthy Communities (http://www.healthycommunities.org/).

We have organized state organizations: we now have 38 states; we have communities and a community toolbox. We could translate that toolbox for the international set. It would be great. People in communities are really interested in doing that with the toolbox. You want to put it in Japanese? Go put it in Japanese. We're not holding on to anything. We've decided to give it away.

Eyemine: How is Healthy Cities structured?

Leonard Duhl: It is structured in three phases. The first phase is to invite key interested participants from diverse and varied backgrounds to be a part of a planning group. The committee will set an agenda and do a needs assessment of the community, (especially it's assets), obtain information about local health indicators and research other communities to get a broad range of ideas. (I call this casing the joint.) Then, we hold meetings to present the information, discuss the concept and brainstorm for possible ways to create a healthier community, establish objectives and begin short-term projects. We also get the media involved in the project launch and open up future meetings to anyone interested. The second phase is the formulation of an action plan. Conduct a community assessment and develop primary objectives that are measurable and consistent with your vision. Establish a baseline and review the results of the community assessment. Develop an action plan and project proposal for community approval. The third phase is sustaining your healthy city's project. This is done by staging media events to celebrate project achievements as goals are accomplished. Convene a task force to monitor progress, ensure project accountability and make adjustments as necessary.

Eyemine: How did you come to this idea?

Leonard Duhl: I finished my training in psychiatry and took a position at the National Institute of Mental Health (NIMH). At NIMH, I looked at its mission: the care, treatment and rehabilitation of the mental ill, and the mental health of population of the US. Through this work I discovered the city impacts of mental health and how poverty is related to mental retardation. This lead to my recognition of two things: (1)The need for active community participation and (2) The need to bring organizations together at the national, state, and local levels. Essentially, the need for an integrated approach concerned with equity. In 1968, after the death of Martin Luther King Jr., I left government and accepted an offer in city planning in Berkeley, California. I taught city planning and public health, preoccupied with personal and social change, and how communities can respond in a more equitable manner. In 1984, I did a speech at a conference called Beyond Health Care. Through this, the World Health Organization picked up on the Healthy Cities concept and began implementation of the Healthy Cities program. There are currently over 7000 Healthy Cities programs worldwide.

Eyemine: Why did you see a need for this?

Leonard Duhl: I responded to the fact that people have no way of communicating. It goes deeper than just the media, the US government needs to support public health initiatives and bring some coherence to policy.

Eyemine: What are the languages right now that are represented on www.healthycities.org?

Leonard Duhl: Obviously the major language is English. Everybody reads English. Everybody in this business is writing English. Together with money, they have become the lingua franca of the world. That's why I'm trying to have more languages on healthycities.org, because I'm not interested in the top-level people reading this, who all read English. I'm interested in the level middle, some of whom don't. One thing I discovered with Brazil, everyone talks Portuguese and nobody talks English, so we had to move into the Portuguese area if we wanted to go to Brazil. Brazil is impossible in English. We have sites in Japanese, French, Portuguese, and Spanish. Some papers we are getting in Chinese and Russian. Hopefully we can add Arabic.

My problem is, how do you get the idea from the bottom up, and what do you do on the top that will facilitate the bottom? Now I've used the Net mainly because I feel that for me maybe it is the best tool nowadays to do this.

Eyemine: Where do you toggle the balance between your right to access and learn as much as you can from your readership, versus the readers' right to privacy and knowing you're not setting up a lot of cookies?

Leonard Duhl: It's a very serious problem. If I had to opt for something, I'd opt for total privacy. However, I have no problem with aggregating data; aggregating personal material bothers me quite a bit. Though I am interested in it, I don't think it's anybody's business. But, when they start aggregating data to say this is what's happening in universities, these are the trends, I don't mind that. I don't want their names, I just want to know if we're reaching government people or we're reaching business people or we're reaching someone else. That's it.

I hate the registration stuff, because I'd rather do without ever having my data available for commerce. I'm a privacy buff, but now there's the other side. There's no such thing as privacy in the world, because, anyone can find out anything about anybody. It's very hard to hide now. You may have to change your DNA, you may have to change your fingerprints, and you may have to change your name. My social security number is no longer private. Everybody uses it.

Eyemine: What do you feel is your responsibility to the reader as they come in to visit your site? A privacy statement, is that adequate?

LD: No, I don't like privacy statements. I would just say to them, the only information about you we're interested in is what kind of general area of work and where we can be help to you. I'm also interested in where you work. I'm not interested in the name. This is because in my business I'm looking for a pattern shift. This is a very important phrase in our business: pattern shift.

Let me tell you the story of when I was in China. My students started to giggle one day--it was my birthday coming up and they wanted to have a birthday party. Then something strange happened, because students who normally come to me about things suddenly started to shut up a little bit. We had a party, I went home, and the phone starts ringing. I pick up, and they say, Hi! I just wanted to talk to you. That's not the way people normally call me up. So I sit there and I say, if people are calling me like this, and things are really uncomfortable, then my wife is planning a surprise party.

And surely the surprise party came, but it wasn't a surprise. Why? Because I found a shift in their behavior, their telephone behavior. My wife looked perfectly normal, no one revealed any secrets, but their behavior pattern shifted, and I knew something was up. All long-range planning relies on patterns. It doesn't rely on the straight development of a particular pathway, because I can say, this pathway will go like this, this, and this.

Eyemine: In Eyemine we all have different backgrounds and we've all done different things, as you have. Your involvement with urban planning, your medical background, and now as an instructor and researcher--it's all about data collection. Some of it is social and qualitative and cultural, and sometimes you need to activate it physically. But, this doesn't mean the user interface has to be intimidating, it can be very intuitive.

Leonard Duhl: Yeah, it is intuitive. An old friend of mine used to say about students is if they have made lateral shifts in their lives, their odds of contributing are much better than those who followed a bureaucratic path. I have one student, who started as an architect, became an environmentalist, got a public health degree, went to medical school, and went into psychiatry. He was making lateral shifts always. And all the good students I know have made these shifts. He did the reverse of what I did. The dull ones have said, "Well, I start here, I go to the next step, and the next step."

You have got to watch the parameter of people's interest. So if I ask, How do you deal with the mental health of the population of the United States? I say you can't do it by psychiatrists or therapists. Well, who's involved? Well you begin to see teachers…and suddenly I found myself in the city. I said, "Okay, I'm interested in the city." So I got involved in planning Columbia, MD, and ultimately I got a job in urban development. Then I made another lateral shift into something else. I got into politics and I worked with Bob Kennedy and I realized that it was political action, small p politics that make change more than the big P Politics. How do you start small "p" politics? I have a trick I use very frequently when I want to start a program. I report to my boss that I started this program and it's amazingly successful, but it hasn't started yet. They get the message that it's successful, pretty soon it becomes successful because you've set the groundwork for it. So I always tell people it's better than it is. By saying it, it becomes a self-fulfilling prophecy, and self-fulfilling prophecies are very important for change.

I'll give you another story. If you tell a student that they're going to be a superstar, they tend to turn out to be a superstar, even if they're not now. I was involved in figuring out how to get kids to take part in the White House Conference on Youth. I was told to go collect youth group leaders from organizations like the Boys and Girl Scouts. I said, no, no, no. What I'm going to do is get a list of every high school student in the state and send him or her a letter saying You've been chosen as an outstanding representative of young people. Would you come to a meeting in this region? We sent the letter to every tenth kid; I didn't send it to all of them. Then they came to a regional meeting. Of those that came, we talked about the issues, and again randomly sent a letter to every tenth kid who showed up.

Finally a hundred kids arrived in the state capitol. Within one year not only were they leaders; they had taken over every resource organization in the state. And not only that, they became Congressmen, leaders of business, politicians, etc. Now when you can really do that, it's a self-fulfilling prophecy. There is tremendous power in good public development. When you can really convince people that they're the best, they become the best. And you have got to tell your staff, you have got to make sure that they know they're the best there is. You have to support them and mentor them. There's nothing like going over to someone and saying, You're great.

Leonard Duhl, MD of International Healthy Cities Foundation is a physician, with a background in Urban Planning and is currently a Professor and researcher at UC Berkeley in the School of Public Health. He is responsible for setting up www.healthycities.org, and can be contacted at hcities@uclink4.berkeley.edu