The Challenges of Being Open

Density, Health and Well-being

Singapore is an interesting case of a city that is at a stage of planned population increase, driven by immigration rather than by Singaporeans (whose birth rate has been steadily declining). Thus the rising population and higher density is accompanied by increased social diversity: over the past 30 years, Singapore’s foreign born population has increased from five per cent in 1980 to about 22.8 per cent in 2010. Coupled with an increased mobility, shaped by the new economy of services, tourism and travel and the growing foreign born population, today Singapore faces the challenge of managing the health risks associated with high-density living, increased mobility, a more sedentary lifestyle, and the stresses associated with urban living.

Although modern Singapore has worked to manage most of the negative impacts of high-density living, such as widening inequalities, environmental degradation and social disruption, the impact on health has not been easily mitigated. The degree of interaction increases in highly dense communities, assisting in the rate of spread of infectious diseases. The 2009 H1N1 influenza virus is a case in point. In the three months following its identification in Mexico in late April 2009, it became a global pandemic affecting practically every country in the world. In Singapore, researchers tracked the transmission of the virus by looking for antibodies, a type of immune response to infection. They found a rate of infection in the general population of 13 per cent, and identified the use of public transport as a risk factor for infection. Amongst military conscripts, the infection rate was double that of the general population. Both findings suggest that higher degrees of social contact and interation were important in facilitating the spread of the H1N1 virus.

Singapore’s ‘openness’ can have its drawbacks in relation to infectious disease. The two major epidemics of recent years in Singapore – Severe Acute Respiratory Syndrome (SARS) and H1N1 – were both imported. Singapore’s relative openness to travel and the movement of people also means that even ‘traditional’ infectious diseases, such as tuberculosis, can be a risk. Despite control efforts, the rate of tuberculosis continues to be relatively high in Singapore, due in part to the high-population density in the city and its openness to the global movement of people.

While it is easy to appreciate the impact of urbanisation and high-density living on highly contagious infectious diseases, the impact on chronic disease is not as obvious and more likely to be missed. Nevertheless, urban environments can play significant roles in chronic disease development. Overweight and obesity are ‘conditions of modernity’ that are strongly linked to the development of medical diseases such as diabetes mellitus, hypertension and some types of cancer. Since the late 1980s, many Western countries have reported a growing epidemic of obesity in their countries. Studies in India and China and other developing countries around the world have also illustrated how obesity, diabetes and hypertension seem to increase in tandem with rapid urbanisation and modernisation. Recent research has suggested the concept of ‘obesogenic environments’ as a risk factor for this ‘modern plague’. This approach recognises the importance of environmental factors in the causation of obesity and its related medical problems, and specifically identifies some urban factors as risks. Some of these factors are related to high-density living, including the modern built environment, with its focus on convenience and minimising physical activity (for example, in the use of lifts and escalators), the urban transport network, which aims to deliver convenient and efficient mechanised transport to the masses, and the absence, in some dense cities, of parks and sports or other recreational facilities that can promote physical activity. The health impacts of high density living need to be taken into account by urban planners and incorporated into their designs so that adverse effects can be mitigated or ameliorated.   

Singapore’s health management issues today, which stem from affluence, increased mobility and diverse points of contact, are in dramatic contrast to its past, where the problems were created by poverty, congestion and poor hygiene conditions. Developed in 1819 as a port city under the British, the openness of Singapore created challenges and conflicts for urban planning and management. The dynamic flow of goods and commodities in and out of the city was paralleled with the flow of migrants in search of a better life. The development of the port occurred closely alongside the growing congestion of the city, as infrastructure struggled to keep pace and a confined territory restricted the availability of land for expansion.

Two fairly detailed surveys by the Department of Social Welfare in 1947 and 1954 provided an idea of the extent of congestion in Singapore’s central areas. This extract gives a sense of the cramped sleeping arrangements: ‘bunks in passage ways, … tiered bed‑lofts  …people sleeping under or over staircases … in five‑foot [passage]ways, kitchens and backyards, and other places used for sleeping without enclosures or partitions’. In 1947, the percentage of households using such spaces was 21 per cent in ward one (the harbour area stretching to west Chinatown), 16 per cent in ward two (the rest of Chinatown, including the business district, extending east to Middle Road) and 26 per cent in ward three (comprising areas east of Middle Road, bounded by Serangoon Road and the Kallang River). By 1954, when the second survey was done, the figures had increased to 38 per cent in wards one and two, and had dropped slightly to 25 per cent in ward three. These conditions are described in more detail in Barrington Kaye’s Upper Nanking Street, arguably the first urban sociology study attempted in Singapore. Upper Nanking Street was one of the most congested neighbourhoods in  Singapore in the 1950s, in the heart of Chinatown. Kaye’s case interviews in particular provide an enduring account of the hardships faced as residents coped with cramped, spartan and often insanitary living conditions, unemployment and ill-health.

The 1960s and 70s were a time of social and physical transformation in Singapore. The city-state had gained its independence, and had a government which was elected and therefore more responsive to the population. The new government put in place a more effective set of infrastructures, in order to secure the political legitimacy to govern. This period saw, amongst a number of major national projects, the development of a comprehensive public housing system and plans to decentralise the population, in response to Singapore’s increasingly congested and unsanitary conditions.. At the time, the central area described by Barrington Kaye (1,700 acres of land around the Singapore River) housed a population density of about 247,000 persons per square kilometre (640,000 persons per square mile), making it one of the world’s most congested slums.

Starting with the 1958 Master Plan, efforts were made to decentralise the population. This trend continued with subsequent plans, such as the 1971 Ring Concept Plan, based on a ring of development around the water catchment area and linear development along the southern coast. This plan was formulated to provide for a future population of four million (a projection which has been revised continually upwards). High-density residential developments follow the water catchment area and the southern coast and are served by an island-wide system of expressways and a mass rapid transit system.

The public housing development programme took the form of new town development, based on high-rise public housing with supporting amenities such as schools, markets, polyclinics, and recreational and sports facilities. Community centres located in housing estates enhanced the integration of residents from different ethnic groups. The policy of encouraging married children to stay close to their parents was also significant. Thus the integrated development of the new towns both met the daily needs of households and facilitated community life.

The early new towns, such as Toa Payoh and Queenstown, adopted a plot ratio of about 2.8 (i.e. the floor area of the building allowed was 2.8 times the area of land). As the population increased further, taller apartment blocks of up to 30 storeys were built and building densities began to creep upwards, reaching a plot ration of 3.5. More recently, it is not uncommon to have plot ratios above four, while at Duxton, public housing has been built to 50 storeys and a plot ratio of nine.

High residential and buildings densities are needed to accommodate Singapore’s growing population and its expanding economy, ensuring hygienic conditions and decent living spaces for its residents, as well as social and recreational facilities. Such densities, combined with the increased mobility and openness that is typical of today’s global cities, present new challenges to health and well-being in Singapore. As in the 1960s, when Singapore’s new government initiated a major infrastructural development project in response to poor health and living conditions in its central areas, once again there is a need to integrate the approach to urban planning and management with today’s health challenges: emerging and re-emerging infectious disease and chronic disease.




Kee Seng Chia is Professor and Dean of the Saw Swee Hock School of Public Health at the National University of Singapore. He is also Adjunct Professor of Epidemiology at the Karolinska Institutet, Sweden.

Chye Kiang Heng is Professor for Architecture and Urban Design in the Department of Architecture and Dean of the School of Design and Environment at the National University of Singapore.

Kong Chong Ho is Associate Professor of Sociology and Vice Dean (Research) at the Faculty of Arts and Social Sciences, the National University of Singapore.