Building Healthy Cities

The Experience and Challenges Faced by China

Cities are crucial for China’s economic development. Further urbanisation is one of the key elements of post-central planning reform and is seen as the solution to rural poverty. However, as people concentrate in cities, they face various health challenges. These concern not only the provision of good health care services but also the prevention of disease, improving the quality of living environments and maintaining a healthy lifestyle.

Due to its long history of public health campaigns, there is a strong belief in China in the positive impact of city hygiene on public health. Public health campaigns (PHCs) originated in the 1950s during the Korean War as a means to fight the threat of chemical and biological warfare, and were later institutionalised as a civilian affair and continued regularly until 1966, playing an important role in disease control and health education. They were suspended during the Cultural Revolution, but resumed in 1978 before being transformed into award schemes that encouraged cities to reach certain public hygiene standards in 1989, under the so-called Hygienic City Campaign (HCC).

Cities wishing to become a National Hygienic City have to go through a series of campaigns in order to climb up the ladder, step-by-step. The campaigns focus on health education, city appearance, environmental sanitation, public hygiene, the cleanliness of drinking water, food hygiene and infectious disease control, among others. Taken together, there are more than 60 indicators to measure and hundreds of targets to meet. Although central government sets the indicators and targets, local governments do not have to follow a prescribed campaign model. Some cities in the less developed western provinces face less pressure from industrialisation and migration and end up spending more on upgrading public toilets, setting up modern sewers and improving the provision of drinking water, than on improving air quality. Cities have to go through several stages from the local level to the top to become a national level winner, as do districts and rural townships participating in the ‘hygienic district/township’ campaigns.

The key motivation for participating is that officials in winning cities have a good chance of being promoted. Outstanding individual performers may be honoured and even rewarded financially. Participating cities also receive special grants from higher government authorities. It is, therefore, not difficult for organisers to attract willing participants. By the end of 2009, 118 National Hygienic Cities, 28 National Hygienic Urban Neighbourhoods and 377 National Hygienic Counties and Towns had been awarded.

The HCC helps to transform a city in many ways. It motivates a greater investment in basic services and public infrastructure than local governments would otherwise be likely to make and increases public awareness of hygiene issues. In order to win, city authorities need to choreograph wide-ranging support from lower level officials, public and private enterprises and the general public. As a result, a large part of the campaign is about educating the public and getting them involved. If run well, a campaign’s knock-on effect can be engendering the public to demand better services from the local government in the future. The competitive nature of the campaigns helps to keep local officials accountable and dramatically increases their responsiveness while the campaign is in progress.

Sustaining the benefits can, however, be a major challenge and the structure of the competition helps in this regard. First, it takes many years to become a national level winner: it took Guanghzou 18 years to finally be awarded the title, Xining ten years, Nanjing 14 years and Yichang 12 years. Second, some of the indicators in the competition concern institutional or governmental changes that are hard to reverse. Third, the National Committee checks a sample of the past winners every three years and cities failing to meet the standards are given a warning or stripped of their title. Finally, new competitions have also been set up, such as the Civilised City Campaign, providing new city-wide challenges to winners of the hygienic city competitions.

In spite of these benefits, and the mechanisms put in place to sustain efforts, the HCC is controversial. A single-minded focus on winning awards can disrupt regular services and have negative impacts upon local businesses. In some cities, such as Kunming and Guangzhou, for example, government officials were required to commit to deliver certain results. Failing to deliver meant they would lose their jobs. This method enhanced the responsiveness of officials but it also meant that they became ruthless in the face of obstacles. In Kunming, for example, officials demanded that all small businesses remove anti-theft protection to make the markets look nicer but no compensating efforts were made to improve safety. The ensuing tension between the public and policy-enforcers culminated in a riot in 2009. In a bid to reduce litter and waste accumulating in public spaces, businesses in Xining and Lanzhou were required to decrease opening hours to align with the guidelines set by policy-enforcers.

In addition to receiving grants from higher government authorities, cities also try to raise funds from district governments. Sometimes, businesses, public sector organisations and individuals have been coerced to contribute, through direct financial contribution as well as through providing materials and committing their own time. In order to increase accessibility to public toilets and drinking water, for example, state enterprises in Xining were required to open their facilities to the public and school terms were cut short in order to secure student volunteers for the effort.

As a secondary source of revenue increase, some local governments focused on urban regeneration to improve the city’s appearance. Xining and Kunming wanted to attract more tourists and cities in the Jiangsu province wanted to attract more investment. These efforts create situations where cities might plant grass to quickly increase their green areas, without thinking about the impact on increased water consumption.

Above all, the top-down approach of the HCC tends to invite cheating. Some local governments resort to fraudulent measures in order to make a good impression on inspectors. During their inspection period the city of Jiaozuo in Henan Province temporarily turned many unhygienic restaurants into bookshops or tourist agencies in order to avoid inspection. In another example, some small restaurants in Xining did not open their toilets to customers so that they would remain spotlessly clean, while others stopped offering tissues to customers in order to prevent littering.

Given the drawbacks of the HCC, should it be stopped altogether? There are several reasons why a hygiene campaign of some sort should continue to exist. First, the HCC does lead to increased public awareness, which may make the possibility of the public demanding a better environment and improved hygiene in the future more likely. During campaigns, people use Internet forums to expose the fraudulent practices of the local governments, as well as to show their appreciation of improved cleanliness and new facilities. They were also more outspoken and dissatisfied when standards dropped again after the campaigns. Second, concerns about sustainability may be of second order in comparison to taking action in the first place. Indicators and management style can then be improved in order to avoid creating perverse incentives. However, whether people can rely on government officials to make such improvements themselves is questionable.

It is, however, important to point out that cleanliness is only relevant to some of the health problems faced by China’s urban residents. In 2009, a health survey was carried out in 589 cities with nearly one million interviewees. The average age of people suffering from high blood pressure, high cholesterol and high blood sugar was found to have dropped from over 50 to just 30 to 40 years. Such results are not just a problem of unaffordable health care, but also reflect dramatic changes in lifestyle. Unhealthy eating habits, long and stressful work, irregular sleeping patterns, over-indulgence in Internet surfing and frequent business banquets, are all possible contributors to urban health problems. The survey shows that the richer a city becomes, the poorer the health profile of the population gets, with Beijing, Shanghai, Guangzhou and Shenzhen faring worse than less prosperous cities.

Influenced by the World Health Organization’s (WHO) ideas about healthy cities, some second-tier Chinese cities, such as Suzhou and Hangzhou, have made an early start in exploring a broader conception of healthy and liveable cities. In 2007, the Ministry of Health set up a task-force dedicated to promoting a healthy lifestyle throughout China and a number of cities and urban districts were selected as pilots for ‘Healthy City’ schemes.

As the country becomes increasingly urbanised, health challenges increase. Rapid growth of urban population and unaffordable housing, in particular in megacities, generates poor and overcrowded housing conditions in suburban slums and urban villages. These neighbourhoods do not always receive equal basic services and suffer from poor infrastructure. According to the WHO, the proportion of China’s urban population using shared sanitation has grown from 25 to 30 per cent between 1990 and 2008, while the proportion defecating in the open has risen from 3 to 6 per cent. Such residents are more likely to be affected by infectious diseases, posing major threats to cities.

Changes in lifestyle and environment mean that a broader range of health issues, formerly considered private, are entering the public domain. People are more aware of the problems associated with these issues and are demanding improved services. For example, the need to deal with stress, depression and other mental health problems, especially suicides resulting from poor working conditions and long working hours, has received more attention. Public media has also brought several issues into the spotlight, including infectious disease outbreaks, notably SARS, and various food security cases. Changes in public perception put greater pressure on policy-makers to respond, demanding more profound changes in the planning and governance of cities.

These public aspects have much do to with how urban environments are designed and constructed, how urban businesses are operated and how urban people lead their life. In spite of China’s dedicated hygiene campaigns, according to the WHO it has the world’s highest rate of chronic obstructive pulmonary disease due to the country’s serious environmental pollution. Urban public health campaigns therefore must be about much more than making the city look more attractive. Rather, there needs to be greater determination and concerted effort to tackle the major sources of environmental problems.

Bingqin Li is a Lecturer in Social Policy and a Research Associate at the Centre for Analysis of Social Exclusion (CASE) at the London School of Economics and Political Science.