Global, News, Newsletter

International health promotion leader Dr Trevor Hancock has helped put health on the agenda of thousands of cities and towns around the world.

Dr Hancock was a plenary speaker at the 23rd International Union for Health Promotion and Education (IUHPE) World Health Promotion Conference in Rotorua from April 7 – 11, 2019. Although recently retired from his position as a Professor and Senior Scholar at the School of Public Health and Social Policy at the University of Victoria he’s as busy as ever as he shares with us from his home in Canada about keeping the Healthy Cities Movement “moving”, plans for broadening, deepening and connecting the “Conversations for a One Planet Region” and about some spin-off projects in the works.

Hauora: Trevor you are one of the founders of the (now global) Healthy Cities and Communities movement? Can you please tell us what prompted you to launch this movement, what its aims are and what has been achieved so far?

TH: Well, I didn’t exactly launch the movement, but I did help pioneer it. I trained in medicine in the late 1960s/early 1970s in London and then spent four years in family practice in Canada. The last two years were in a community health centre in Toronto, where we served a somewhat under-privileged community. It was clear to me that many of the health problems my patients experienced were economic, social and environmental problems, not really medical problems, which cemented my interest in public health, so I did a Masters at the U of Toronto, graduating in 1980.

You can’t do public health without becoming keenly aware of the roots of modern-day public health in the struggle to address the terrible living and working conditions in the towns of the industrialising world in the 19^th century, and to the stories of John Snow, Edwin Chadwick and other leaders. One of those leaders I found particularly inspiring was Sir Benjamin Ward Richardson, a self-professed ‘disciple’ of Chadwick. In 1875 he gave an inspirational address to the Social Science Association on “Hygeia: A City of Health”, which is still well worth reading.

So when I started work as the Health Planner for the City of Toronto in the Department of Public Health’s new Health Advocacy Unit in 1980 , I had this work in mind. One of my tasks was to create a mission statement for the Department, and we adopted the following: Our mission is to help to make the City of Toronto the healthiest city in North America”. Note we said ‘help to’ – health is not created by a public health department any more than it is created by  the health care system; we recognised that many other City departments – and many other players outside City government – contibuted a great deal to the health of the city’s people, starting with clean water, sanitation, safe and healthy buildings and so on.

So we started to ask ourselves’what exactly is a healthy city, how would we get one, and how would we know we were one?’. As you can imagine, that led to a great deal of discussion and innovation. Luckily, as it happened – and never discount luck as a factor, but when you have it, exploit it! – 1984 was a banner year – the sesqui-centennial of the City, the centenary of the Board of Health, the 75^th anniversary of the Canadian Public Health Association and the tenth anniversary of the Lalonde Report. This made it possible for me  – working with a great conference committee – to put on ‘Beyond Health Care’, an international working conference on healthy public policy, a term, but not a concept, I had created in about 1980, inspired by the work of people like Nancy Milio and Peter Draper.

As part of the conference, we had a theme on healthy cities, but also – because it was after all a Toronto-based conference – we had a day we called ‘Healthy Toronto 2000’, looking at what it would take to make Toronto a healthy city by then. One of the keynote speakers was Len Duhl, a professor of public health and urban planning at Berkely, and one of the attendees was Ilona Kickbusch, then the Health Promotion Officer for WHO Europe and already working closely with Ron Draper at Health Canada -who had invited her – on what was to become two years later the Ottawa Charter for Health Promotion.

Ilona brilliantly saw in the idea of a healthy city a way to take the concepts of health promotion out into the city and make them real, and thus was born the WHO Europe Healthy Cities initiative, which had its first planning meeting in Copenhagen (WHO Europe’s HQ) in early 1986. Len Duhl and I were part of the planning committee, and together wrote the original background paper – and the rest is history!

As to the aims and achievements, they are quite simple: To put health on the agenda of city governments and governance processes, and to help cities plan with health in mind as a key objective. In that, I think we have been highly successful, the idea has been taken up – with varying degrees of success – in cities, towns and villages around the world – inevitably, with varying degrees of success.

But I think the key word here is ‘movement’. There is, inevitably, a wish to evaluate the work, but its rather like evaluating the women’s movement, the labour movement, the peace movement or the environment movement. They are always working, always pushing, and they have their succeses and failures, but they just keep going; that is what a healthy cities movement must do too.

Hauora: One of the challenges you point out for the 21^st century is that we’re going to have to look at dramatically different ways of organising our cities, our countries, our neighbourhoods, our own personal ways of life etc…What progress are we making on this and how big a role can health promoters play?

TH: There are many parts to this question – or questions. For me, the central question for cities – and for governments at all levels –  is ‘what business are we in?’. If you ask that of national governments the answer you get – if not in their words, at least in their deeds – is ‘grow the economy/the GDP’. (New Zealand has recently proved itself the exception, with a budget focused on wellbeing.)But this focus on economic growth and the GDP has been a tragic mistake, especially for high-income countries. First, that growth has resulted in the massive and rapid extraction and depletion of the Earth’s natural resources, in particular forests, fisheries, wildlife, freshwater, topsoils, minerals and fossil fuels. That extraction has been accompanied by massive and rapid pollution of the air, water, soils and food chains, with perhaps the most worrying – at least right now – being CO₂ pollution from fossil fuel combustion, leading to the global climate emergency.

“… this focus on economic growth and the GDP has been a tragic mistake, especially for high-income countries.”

Also, some, perhaps much of that growth is what Herman Daly, a leading ecological economist, has called ‘Uneconomic growth’; economic activity that harms people, communities or the planet – or all three. Yet all this uneconomic growth is included in the GDP, which does not distingish between good and bad economic activity. In the health field, the most obvious example is tobacco production and use (although we could also include production of unhealthy food, alcohol, etc.) which kills millions and maims millions more. Even worse, all the money spent on health care for people with tobacco-caused or diet-caused disease also adds to GDP; how stupid is that?

What’s more, this economic growth does not improve our lives, even if it gets us more ‘stuff’. We know that above about $20,000 GDP per capita, further increases in GDP do not correlate well, if at all, with life expectancy and other health and social outcomes. In The Spirit Level, Kate Pickett and Richard Wilkinson show that in high-income countries, it is the degree of equity, not the level of wealth, that correlates with these outcomes, while the World Happiness Report and other studies show that GDP is not well correlated with happiness.

As a result, further aggregate growth is impossible, we already exceed the Earth’s biocapacity and need to reduce our use of these ecosystem goods and services – quite drastically in the high-income countries, whose ecological footprints are well above our fair share, in the range of 3 to 5 planet’s’ worth of biocapacity. Meanwhile, low income countries have the opposite problem; they do not have the wealth it takes to achieve high levels of human and social development.

We need to take less so that others in need can have more, which means a redistribtion of power, wealth and resources both between and within countries and communities, as called for by the WHO Commission on the Social Determinants of Health. 

All of this leads to the conclusion of Kate Raworth in her book Doughnut Economics: we need an economy that is ecologically restorative and socially just, that is focused on meeting the social needs of everyone while living within planetary limits. And that means a very different set of values to live by, very different communities and societies to those we have today. I have an abiding faith that this can only happen from the local level up, it will not come down from the top, where elites have too much money and power at stake. Progress on this is slow, but it is happening, as I will discuss shortly.

But what can health promoters do?

• First, learn about the global challenges of the Anthropocene – the new age of humanity as a dominant global force that I discuss below – and what new approaches and solutions we need. Recognise that this calls for an eco-social approach in all our work and all our communities.
• Second, discuss it with your colleagues, your families and friends, your clients and communities.
• Third, work to create it, identifying allies and partners who are working to create this new world – especially young people (think of the climate strikers), environmentalists and the new social/green entrepreneurs who are working to create the new economy we need.
• Fourth, apply the two fundamental principles of public health that I identified 40 years ago: Ecological sanity and social justice (today we would say sustainability and equity), ideas that directly relate to Kate Raworth’s call for an economy thast is both restorative and distributive.
• Finally, never lose sight of Margaret Mead’s wise words: “Never believe a small group of people cannot change the world; indeed it is the only thing that ever has changed the world”. 

One final point: We are not simply health promoters, more importantly we are citizens. So if we can make it part of the work we do, that is definitely a bonus. But if not, we did not surrender our citizenship when we took on our professional roles. So take it on as a family, a citizen activist, a school parent, a club member or a faith community member or whatever other social role makes sense. Find your allies and work with them. Or simply change the way you live, in big or small ways. It all matters, it all makes a difference.

Hauora: You have said one thing that is important to understand about the Anthropocene is that it’s just not about climate change and we need to look at the bigger picture? Can you please elaborate on this?

TH: The Anthropocene is a new geologic epoch, identified in geological terms as a layer of new materials (e.g. glass, plastic, concrete, radioactive elements and their decay products, elevated CO2 levels) and a change in future fossil deposits (e.g. wild animals now make up only 4% of the mass of land vertebrates, with humans (anthropos in Ancient Greek) and their domesticated species making up the rest) that will be clearly seen as anthropogenic – caused by humans – by future geologists.

In May 2019 the Anthropocene Working Group of the International Commission on Stratigraphy voted strongly to recommend it be recognised, with a start date in the mid-20^th century. This corresponds to what has been called ‘The Great Acceleration’;  a sharp acceleration, especially since 1950, in changes in a wide variety of natural systems (e.g. climate, nitrogen and phosphorus flows, species extinctions etc. ), in turn driven by a similar sharp increase in socio-economic forces (e.g. population – especially urban population, global GDP, fertiliser-use, fish catch etc.).

So the Anthropocene needs to be understood not only as a geological phenomenon, but one that reflects and indeed records global ecological changes that in turn are driven by economic and social development. 

In the 2015 report I led for the Canadian Public Health Association on the ecological determinants of health, we made two key points:

• First, the world’s natural systems are our life support systems, the most fundamental determinants of our health; we do not last long without air, water or food. Nor can societies exist without the materials and fuels we take from nature, the recycling of nutrients and wastes is the protection from UV radiation that all come from nature. Moreover, for the past 11,000 years we have benefited from a generally benign, warm and stable climate during which agriculture and cities – what we think of as civilisation – have developed.
• Second, all of these ecosystem goods and services are being massively and rapidly disrupted, and all at the same time. It is not just climate change, but ocean acidification, pollution and ecotoxicity, resource depletion and the start of a sixth Great Extinction. Moreover, they often interact and reinforce each other, usually in negative ways.

Faced with these widespread, rapid and massive changes, we need widespread, rapid and massive responses; again, my belief is that these are much more likely to come up from the bottom than down from the top. Tobacco control is but one of many examples where it has been persistent grassroots activism and local leadership that has ultimately led to signifant national and international change; the same can be said of gay marriage.

But I am also very conscious of the fact that when it comes to creating social and cultural transformation and large value shifts, this is not done simply by applying science, evidence and logic. We need to reach people emotionally and spiritually as human beings, what I call ‘heart, gut and spirit stuff’, and for that we need to work with faith communities, the arts community and other ‘unusual suspects’.

Hauora: In Victoria British Colombia where you live you started what is called “Conversations for a one planet region”. What is the aim of this initiative and how many countries has it spread to? Can you give us some tips on how to get it started in NZ?

TH: The Conversations came out of an initiative I started at the University of Victoria (UVic) before I retired. UVic in the Anthropocene is an attempt to bring together faculty and students from all disciplines across the university to address the challenge of the Anthropocene. In my opinion, this is the greatest threat facing us in the 21^st century, but it also contains many opportunities. So how will universities respond (so far, no better than governments or other instituons, which is to say hardly at all!)

We realised early on that we needed to do work with the community, in this region of 350,00 people and 13 local municipalities, to explore what should be the response to the Anthropocene at the local level. We suggested the concept of a One Planet Region as a way to address this locally (an idea we later learned had been pioneered by Bioregional in the UK, a group we now work with). We defined a One Planet Region as one that achieves social and ecological sustainability, with a high quality of life and a long life in good health for all its citizens, while reducing its ecological footprint to be equivalent to one planet’s worth of biocapacity.

We started the Conversations in early 2017 because we were concerned that people were not even talking about this issue; climate change, yes, but not the entire complex of global ecological changes that constitute the Anthropocene, and not about how we need to respond locally. So our mission is to establish and maintain community-wide conversations on One Planet living and a One Planet Region. We adopted as our slogan “Learn – Discuss – Imagine – Design – Create”, because if we are not learning about the situation we face and discussing it, we can’t begin to fully imagine both the future we face and the alternative future we want.  And if we can’t imagine it, we can’t design and create it.  

We meet monthly in the Community Room at the Central Branch of the Public Library. Our meetings are free and open to anyone, and we have no budget; use only local volunteer speakers – since we know we have the knowledge and expertise here to address these issues successfully. We cover a wide range of issues, from energy and food to housing and transportation, economics, the role of the arts and of faith communities – and much else.

But while we have been doing this for three years, have a group of 30 – 70 people each month, get good discussions and have a good reputation and some influence and local political impact, we recognise that this is of limited utility. Our participants are generally the ‘usual suspects’ – older, whiter, wealthier, better educated, and living near the downtown. An important and potentially influential group, to be sure, often with good connections to important people and groups, but far from enough.

So we have plans for broadening, deepening and connecting the Conversation. We want to expand the Conversation to engage a much wider range of participants, both geographically and demographically; deepen the Conversation by creating safe spaces where people can explore the mental, social and spiritual dimensions of the change we seek; and connect the Conversation to others doing similar work across the region. To that end, we have recently incorporated as a non-profit society so we can pursue funding, because while having no budegt is in many ways commendable, it is also limiting. Some of the new activities we want to pursue are:

1. Video, webcast and livestream the current Conversations programme, enabling people in other sites in the Greater Victoria Region to join in from where they live.
2. Establish a Kitchen Table Conversations programme to facilitate and support families, neighbors, workmates and others to have smaller, more personal Conversations.
3. Undertake One Planet Neighborhood Co-design Charettes that bring community members and design professionals together to imagine and design such a place.
4. Establish People for a One Planet Region, a group of citizens in every municipality who are able to speak at Council meetings to support the One Planet approach and to oppose proposals that take us in the wrong direction.
5. [Perhaps] create One Planet Region Awards to recognise people, organisations, businesses and governments that are working  to create a One Planet region.

We also have several spin-off projects that we are pursuing, in collaboration with others:

• We are working with the Community Social Planning Council to look at the social justice and employment implications of a One Planet Region.
• We are starting a discussion about an initiative around art, nature and place as a way of engaging people through the arts in considering the global ecological challenges, and possible actions.
• An ecological economics group is forming, linked to the Green New Deal, looking at what an ecological economy would look like locally.
• We are planning sessions based on Joanna Macy’s “The work that re-connects”, to help people come to terms with the climate anxiety and eco-grief they may be experiencing.

I hope this has given you some ideas, but remember, it takes very little to make things happen. You don’t need a budget, an organisation or staff, just some willing and like-minded people, a bit of energy and good will. Remember Margaret Mead’s wise words and just do it!

Hauora: You were in NZ for the 23^rd IUHPE World Health Promotion Conference, co-hosted by HPF in Rotorua last April? What were some of the highlights of the conference for you?

TH: The first highlight was the fact that the greetings from the Maori Elders were all in Maori! Oh sorry, you don’t understand Maori? Too bad, this is Aotearoa and here we speak Maori – it was assertive and yet was done in a respectful way. I loved the self-confidence of that, and indeed the strong participation of Maori people throughout was an inspiration.

Second, of course, the fact that ecological change and the need for an ecological awaresss was finally getting the attention it deserves in health promotion.

Third, shmoozing! Not only do I love seeing my friends from all over the world (and yes, I am aware of the irony, if not ineed the incompatability, of the carbon footprint involved), but those personal contacts facilitate the sharing of ideas, work and commitments for years to come. There is a lot you can do apart, via Skype and webinars and teleconferences, but there is an energy that comes from being together in the same place, sharing food and drink and relaxation, that boosts your energy and enthusiasm when you return home.

Fourth, of course, New Zealand itself, a beautiful country I have now visited twice, with friendly and welcoming people, certain challenges notwithstanding. Certainly the New Zealand government is proving inspirational, both in its response to the Christchurch mosque shootings and in its commitment to a wellbeing budget.

Hauora: You retired in July 2018 from your position as a Professor and Senior Scholar at the School of Public Health and Social Policy at the University of Victoria. What have you been doing since then and what are your plans for the future?

Well, I only retired from a job, not from life or work – or dancing for that matter! I have been busy organising the Conversations – as noted above, writing, speaking at all levels from global events such as IUHPE to local community groups about these ideas and generally being an activist. I am very excited by the growing activism of young people and looking for ways I can help and support them – without taking over or getting in the way!

In particular, I hope to write several books for the general public about the work of public health. I have been writing a weekly column on population and public health issues for five years (see https://trevorhancock.org/) and I have come to recognise that we do a lousy job of communicating what we do, and the importance of our work – and then we wonder why nobody knows about us or loves us or funds us! So, I have committed to do no more writing for academic or professional journls or books, other than the commitments I already have.

And of course I am dancing. I have been a Morris dancer for 40 years – traditional English folk dance, think non-violent rugby involving dancing, singing and drinking! It brings me great pleasure, even joy, and is an antidote to the serious nature of so much of my life – although that too is fun, it has to be if you are to keep doing it.

I dance twice a week, walk our dog in the woods, parks and coastlands every day with Franny, my wife and companion for almost 50 years (her retirement project is a Masters in Medieval Studies, we are well matched) and generally stay active. In one of the two Morris sides I dance with I am, at 71, the second youngest dancer; our oldest dancer is almost 95, and comes to practice every week and then to the pub. I intend to be Fred when I grow up!

© Trevor Hancock, 2019