In The Beginning . . .
An interview with Ilona Kickbush

by Joe Flower


This article appeared in The Healthcare Forum Journal, vol. 37, no. 3, May/June 1994.
International Copyright 1994 Joe Flower All Rights Reserved
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  1. Origins
  2. Launch in Europe
  3. Global growth
  4. Healthy Cities and politics
  5. Healthy Cities and public health
  6. Healthy Cities and hospitals
  7. Measuring the health of cities
  8. Opposition and resistance
  9. Where is health created?



Ilona Kickbush, Ph.D., has had as much experience as anyone in the world at actually trying to build healthier communities. She was the director of lifestyles and health for the European Regional Office of the World Health Organization, and in the summer of 1994 moved to Geneva to become WHO's director of Health Promotion on a global scale. She is one of a handful of people who have turned the idea of "Healthy Cities" from a concept into a reality. Through Kickbush's initiative, WHO Europe made "Healthy Cities" a major regional project, and began giving the yearly symposia that helped turn it into a worldwide movement.

I got the chance for a good long talk with her at the December 1993 "International Healthy Cities and Healthy Communities Conference" in San Francisco. I wanted her to tell me what she could about what works: what gets people excited, what are the practical politics, what are the obstacles and where does the opposition come from?

To that end, I had her lead me step by step from the origins of the project within WHO, through its launch in Europe and its subsequent global growth, to the links between healthy cities and politics, public health, and hospitals -- and, along the way, her own growth from a rebellious outsider to an effective insider. She discussed the differences between building healthy cities in the United States and Europe - as well as how European hospitals have benefited from the American experience. She was very clear that "creating health" is not something you can do for people, not something you can do in a boardroom or in a laboratory - they need your catalysis, but they have to provide the energy, they have to be in on the process, they have to own the result.




I started as an academic political scientist, looking at new ways to organize health systems, at all sorts of social movements for health, such as the woman's movement and the self-help movement. Towards the end of the 70's, I came in contact with the World Health Organization (WHO). They asked me to work for them as a consultant, and then to join them at the regional office in Copenhagen to develop a new program of health promotion.

When they asked me to come work with WHO permanently, I didn't quite believe them. I had come for just 3 months to work on programs dealing with women and health . after a few weeks they asked me to work on wider ideas on prevention and health . They were in the process of a reform symbolized by the concept of primary health care. Their policy, Health World 2000, stressed the social factors that contribute to health.

But I didn't necessarily trust large institutions. there was an open positoin but I didn't apply for it. I thought I wouldn't get it, and I was not sure I wanted it. But on the last day of the process, they sat me down and asked me to write an application. In the end, the committee gave two recommendations. It said, "If you want the usual, take Mr. A. But if you want innnovaton, take Kickbusch."

And they did. The senior officer said, "You've been selected. The organization has decided to take the risk with you." I said, "You're not asking me whether I am willing to take the risk with the organization."

I was an absolute freak in terms of that organization: I was female, I was not a medical person, I was in my early 30s. I was the kind of person who would go to work in purple coveralls. People were taking bets on how long I would last. But that was over a dozen years ago. I have found a style to live with the organization and yet remain my own person, and remain an innovator

We began inter-regional work in close collaboration with Halfdan Mahler, who was then the director general. We developed a global holistic concept for health promotion, which became the Ottawa Charter when it was adopted at a large conference in Ottawa.

A range of people said, "You can never implement this kind of thinking. It is too complex, too integrative." We felt challenged, and we started to think about how one could do that.

sometimes you just have these flashes. We were working on the "Health For All" strategy, helping governments in Europe set national targets for health. But I had always been a bit uneasy focusing on national governments only, while we had all this rhetoric about community involvement. We realized that, Historically, most public health innovation had actually come at the local level. Yet in recent years health policy had not involved local authorities. We also noticed Canadian initiatives, such as an enterprise called Healthy Toronto 2000, that the Public Health Department of Toronto had begun.

Besides that, there was a range of theoretical writing on urban health. And there was our own Health World policy, which focused on the national level. I felt very strongly that we should move into the local arena.

Our strategy was a bit like the "Healthy People 2000" agenda that you were developing in the states, so I was constantly reading this "Healthy People 2000" stuff, at the very moment in 1984 when I was attending the "Beyond Healthcare" conference that Trevor Hancock had organized in Toronto. [A number of people gave papers there, including Trevor, John McKnight, and Len Duhl.] At that conference I saw a pamphlet for Trevor's "Healthy Toronto 2000" conference, about making Toronto a healthy city. It was on the following day, and my plane was leaving that morning, so I couldn't go, but I looked at that pamphlet and thought, "Why can't we do this in cities all over Europe?" I thought it was a very good idea. I was really proud of myself

Back in Copenhagen, I presented the idea to the decision-makers. I suggested that we embark on a project called "Healthy Cities." The World Health Organization has traditionally dealt with national and international policy, so this was a shift intheir thinking. There had always been community-based health projects. But WHO had not worked systematically with local authorities, with the political level of city governments. But that was our intention with the project, to get a political commitment to health from city governments. The regional director said, "Do it, but don't fail."

In 1983 Trevor Hancock organized a conference in Toronto called "Beyond Healthcare." So when I got permission to launch this project within the European region of WHO, we decided to involve some of these people in the project planning group.

We did a feasibility study, and we were lucky that somebody drew our attention to the fact that Len was traveling through Europe. He came and helped with the feasibility study.

First I did a feasibility study, and then we put together a planning group that included Len and Trevor. I had heard that Len was coming to Europe, and I contacted him to come and help out. He was known as an innovator, as someone who dealt both with public health and urban planning, without staying in the usual boxes.

Launch in Europe

We launched it officially in 1985 with a planning group, which started by outlining the concept in greater detail. Len Duhl and Trevor Hancock wrote the basic booklet on that. We then developed a five-year work plan for the project. We developed entry criteria for the cities. We started to work on indicators for the cities. We met with representatives from about twenty-four European cities to discuss the project. We asked them, "Do you really want this kind of project?" And they did.

We went through a period of designating cities, and started with eleven in 1986. There were several rounds of designation. By the end of the five years we had thirty-five project cities in Europe.

We developed a system of business meetings of the cities, at which the representatives from the project cities would come together twice a year to decide on the direction the project should be going. It became a very democratic forum. After the first few years we disbanded the planning group and the cities began to manage the project themselves.

At the end of the five years, when there was a discussion as to whether the project should continue, the cities actually tightened up the criteria for membership. They themselves wanted a project that was tougher on them.

Global growth

The idea caught on in two ways. For one thing, because our planning group had members from other parts of the world, such as Len from the United States and Trevor from Canada, the idea was also brought to these countries.

Beyond that, we organized "Healthy Cities" symposia every year. As the word got around, people would come from Australia, from New Zealand, from Japan. The idea seemed to catch on.

In those first years, from '86 to '89, we saw the "Healthy Cities" idea spreading in developed countries. Then we started getting interest from developing countries. We passed those inquiries along to our colleagues at WHO headquarters, where the Environmental Health Division has been very active in promoting the concept and working with cities in the developing world. Now there are "Healthy Cities" initiatives on practically every continent and in a large majority of countries.

Never in our wildest dreams did we think it would become the global movement it has become. We never thought it would become more of a movement than a profesional technical program. We began to realize that at our annual symposia in 1987 and 1988. The minute we saw that, we started to organize it more like a movement

There was, in fact, a great debate arose as to whether it is a project or a movement. People wrote long articles and gave papers. This was one expression of a great conflict about the question of ownership: does WHO own this idea? Can anyone just go off and do it?

As I saw it, my job was to help it spread as widely as possible, and yet make sure that people adhered to the standards and direction set by WHO. In the end, it was a creative push that actually contributed to the success of the idea. national networks and cities were competing with each other, wanting to get the WHO stamp of approval, or saying that they didn't need it, and coming up with their own program.

It became a very democratic project, in which the project cities actually became the planning group, with WHO acting as a secretariat.

All this was very new for WHO. It was their first network project, their first truly participatory project, the first with regular business meetings, the first that involved a real evaluation process.

The European region is the only one that organizes the project in this very structured way - we designate project cities that we work with in depth, plus a range of other cities, associated with the idea through national networks, who just choose to implement the "Healthy Cities" principles.

WHO is not playing this role of selecting and designating cities in other countries. They have found their own mechanisms for organizing themselves, and for deciding who can join up. In some cases they have set tough criteria. In others cases, there is nothing more that a network of people wanting to implement the "Healthy Cities" idea. It comes in all shapes and sizes.

People also adapt it to their political cultures. In Canada, they didn't call the project "Healthy Cities," they called it "Healthy Communities," because of their different political structure at the urban level. That's been a debate here in the States as well -- some groups have different ideas about what for them constitutes a "tribal grouping." It is an integrative concept, which other types of communities besides cities might find useful.

Because of the very different types of cities and communities that there are around the world, "Healthy Cities" as a term has become an umbrella concept. For instance, the commitment of city government, a notion that we made central to our own work in Europe, would be less central in other cities. Where the cities are very large you would look for a commitment of a kind of substructure within the city -- rather than, say, the mayor and government of Mexico City, which would be much too far away from the problems on the ground.

In a number of cases the national government sponsors the idea. Canada and Australia, particularly, started out with government funding for national networks, and involved public health associations and other partners. It has been interesting and positive that, particularly in North America, organizations of cities, like the Civic League here, and the Urban Institute in Canada, were linked to the idea from the start -- networks that were not within health-oriented bodies, but within bodies dedicated to bringing cities together. In Europe we have not been so successful at bringing organizations of cities totally behind the "Healthy Cities" concept.

We have been doing vision workshops all around the world. We bring people together and say, "How would you define a healthy city?" Once you pose that question, then they see the city in a broad integrative way. Suppose, on the other hand, that you ask, "What do you think contributes to your health?" Then people will jump to the medical system rather quickly.

Healthy Cities and politics

Just yesterday, here at the International Healthy Cities and Communities Conference, former Surgeon General C. Everett Koop said that we need to find something glamorous to make prevention and health promotion attractive. We have found that, for politicians, this notion of initiating healthy cities within their spheres of influence have actually given them a fair bit of glamour and have led to very successful enterprises -- as well as quite reasonable funding at the city level.

Wouldn't it be wonderful if we found a way to really improve people's lives that would get the politicians reelected? This has happened with the "Healthy Cities" project. In cities that have joined the "Healthy Cities" project, we have seen health counselors run in local elections with a health agenda, saying, "I am the person who brought `Healthy Cities' to this community." That, in turn, has influenced their opponents to try to attempt a game of one-upmanship, saying, "We will implement this project even better, and we will work even more on health." We know of a number of cases where the people concerned have gained very high visibility through the project, or have been reelected because of it.

The "Healthy Cities" concept has spread beyond even what WHO is doing. Neither I nor my colleagues in headquarters could tell you accurately how many cities or communities are using this concept. It has spread like wild fire. We can only count those who have been in contact with us, or that show up in lists of national network members. Several thousand cities and communities around the world, at the minimum, are using this in one way or another, being active, organizing themselves, and networking amongst themselves.

The movement illustrates an ever-changing balance between "bottom-up" solutions and "top-down." To some extent it depends on your perspective. WHO is used to working with national governments. If you work with cities, they are "bottom-up" in comparison. Within a city, on the other hand, you get the conflict between the city government and the community groups. In pushing city governments to put health visibly on their agenda, we hope to legitimize some of the bottom-up initiatives from the community. Hopefully they will have more influence with the kind of agendas that they have been pushing.

It should become a win-win situation, both for those who have the political responsibility to make their cities healthier places, and for the many community groups that are interested in their immediate living environment.

Healthy Cities and public health

There are other subtleties to involving public health authorities and people who run healthcare organizations. In a number of cities the public health department has become quite a staid, dinosaur-like institution. They aren't always happy when the city politicians come along and say, "We would like to embark on a project with WHO called `Healthy Cities.'" In a number of cases we have noticed something interesting: we ask cities that want to working with us to establish an office for the project. If that project office is linked too closely to a public health department that is very traditional, the project won't develop as well. It will develop better if the project office is situated in a way that it can work with many different sectors -- or placed directly with the mayor's office or with the health counsellor's office.

In some cases, in some countries, public health has become a very staid, very medicalized, very neglected enterprise. Public health is seen as the poor sister of medicine, a place where they take care of the sanitation and hygiene things over there. It is often seen as a control institution -- it has an authoritarian ring to it, as a kind of "health police" that checks us for communicable and sexually transmitted diseases.

The "Healthy Cities" project should help change city policy on health, but it should also help rejuvenate public health departments, and lead to a new public health. In some cases we have seen a significant change in how public health departments work and for what they consider themselves responsible. In many cities, where the health department of cities was called the "Hospital Department," we have seen them rename themselves the "Health Department," and begin really shifing their agenda toward prevention and health promotion.

In Europe, most public health people are doctors. So the tradition of the master of public health (MPH), which in the US can be a very respected professional degree, is only just beginning to show up in Europe.

In order to pull in healthcare groups, we have created other projects which interact with the "Healthy Cities" projects. For instance, in one of our project cities, given the way that the health system is organized, the city has the responsibility for all the hospitals. They needed a new approach to hospital policy. So we created an initiative called the "Health Promoting Hospital." We developed a pilot project with them around the concept, and that project has now become a network of its own.

Now we are interlinking the various networks we have created, such as the "Healthy Cities" project, which deals with local authorities and community groups; the "Health Promoting Hospital" project, which deals with the organizers of healthcare, and the "Health Promoting Schools" project, which works with the educational sector. We try to interlock these networks for a real interdisciplinary approach.

Healthy Cities and hospitals

Medicine, of course, is organized totally differently in Germany than it is, say, in Sweden, or in the UK with its National Health Service. So the way medicine is involved in building healthy cities also differs significantly, according to how the health system is structured, and what responsibility really lies with the local authority.

In working with European hospitals, we have found that some of them can make great use of the experiences of people in the U.S. who have tried to make the hospital a new kind of place. I'm thinking, for instance, of Tom Chapman when he was at Greater Southeast in Washington, D.C. We have been very impressed with that. We have used these American experiences as examples that we have given to the Europeans, saying, "This is how a hospital must change its functions."

The particular kinds of things that Greater Southeast has to do are specifically American, given the structure of your cities. But that experience gives the Europeans the idea of how many institutions, whether hospitals, or schools, or some other institution, which were created for one function only, are becoming multi-functional institutions. That's where we are trying to help these institutions get, through mechanisms of organizational development and democratic decision making.

Measuring the health of cities

We summarize our experiences in Europe and experiences that we have gathered from around the world. We have developed 20 steps toward building a healthy city. And we have worked hard on a group of Healthy Cities Indicators, which bring together social, health and environmental measures in one instrument.

For the second round of our project we have reached the agreement with all cities that in order to enter the project they have to first report where they stand on all these indicators. One of the most interesting things was that a number of the cities, found that they couldn't answer the questions because they hadn't gathered these kind of indicators at the local level. Some cities can't tell you anything about the local smoking rate, for instance. Or how many of the teachers in this city smoke?

Once we can find out that, say, 60 percent of their teachers smoke, then we can discuss with the city a target they might set, say, to reduce that by 20 percent in the next three years. That's why we put such attention on these indicators. It forces the cities to check on their information systems, to create new ones where necessary, and then to set themselves goals and targets in relation to the information that they gather.

They set their own goals. We do have European goals, set in the Health World policy that I mentioned. We have 38 targets for the European region, and there are a number of numeric targets, much like the Healthy People targets in the U.S., in which your Health and Human Services Department has set national targets to reduce cancer by this much and cardiovascular disease by this much by this date.

In some cases, cities use our targets as a yardstick. For instance, one of our targets would be to reduce alcohol consumption by 25 percent by the year 2000. But in order to turn that into a city target you have to know what your baseline is and what amount of change is realistic and achievable. But we do believe in the "bottom up" way of looking at things, and each place is different. The goals of a particular place might be very different from the major health problem in that place.

Some of our cities have done fascinating things, such as using community groups to do analyses of both the health understanding and the health needs of each of the neighborhoods in the city. The city of Copenhagen has done this, and then taken those results back to the populations of those neighborhoods to discuss it with them. Based on those discussions, Copenhagen has developed a whole new city health policy, focused on setting up mechanisms to improve social support networks. It has moved away from the classic notions of dealing directly with unhealthy behaviors such as smoking, drinking, and unhealthy diet. The city has defined it as a major part of the health problem that people feel lonely, neglected and useless. Now the whole city's health policy is written towards those social goals, rather than toward specific medical goals.

In some cases the project has become too medicalized. When this happens, its overall scope and chance for changing the everyday quality of people's lives has not been so great.

Of course, once again there are differences that arise from the way the healthcare system is organized. For instance, in a number of cities in America, a "Healthy Cities" program might set a goal of raising the vaccination rate. But most European cities would have a nearly 100 percent vaccination rate, because of the way we organize these things. That is standard. So people would be less troubled by getting their basic health requirements met.

There is little doubt that the baseline public health and health security policies we have in Europe changes the kinds of issues that cities would be working on. People are insured. People have access to the health system. We don't have to deal with some of those basics.

Homelessness is a growing concern. It is definitely on the increase in major European cities. The French and the Germans have a tremendous problem. Poverty and homelessness are issues which we took up at our first business meeting of the second round, and they are issues that we want to look at more closely. Still, we don't have nearly the homeless problem you do - it is growing but it is not as extreme as it is in some cities in the States.

Opposition and resistance

We get resistance to these ideas and processes from people who want rapid outcomes and rapid results who insist that you do something today and the result has to be available tomorrow. If you are trying to involve other people in more parts of decision making, if you take the trouble to involve the community, "Healthy Cities" is a rather slow and difficult process. In some cities, there has not been much willingness to work together. There has been opposition from people who saw that these health experts were invading their turf, who ask, "Why should health now become the key criterion."

People are also ambivalent because in Europe there is a tendency that, if doctors are part of a group, they want to take charge. So the people from the Traffic Department, say, often are not at first that convinced. The key thing is to get people motivated to embark on a long-term process - we have defined it as a five year process - in which one will want to change structures, to find new ways of looking at health policy and moving ahead.

There was even opposition within WHO. We had a range of projects, interventions against all the standard kinds of diseases, and people argued that this "Healthy Cities" approach was too soft. It wasn't concrete enough. It didn't come across as something you could measure straight away.

Some people felt that WHO shouldn't be putting its resources into this kind of big enterprise. Some people felt that we should not be working directly with local government, but should stick to the national level. Some people were ambivalent about us going directly to working with other sectors rather than sticking to the health sector that we knew fairly well. They hadn't done it this way before.

Personally, I feel a great sense of success about this. If this had been a private business, with the growth rate it has had, it would get a Fortune 500 prize or something. but, of course, you're always sort of surfing. You can't do anything unless the time is right. The whole idea of health going local again has been very attractive. We caught a social trend, one that was already there, but no one had noticed yet: people are re-discovering cities.

Of course, as in all innovation, first you get opposition, and then when you are successful everyone was part of it, and in fact invented it. That's normal.

Everyone had a part to play in this. there were a number of people out there who could advocate the idea and push it forward. There were people like Len had written about it for years, and Trevor who had turned into something in one city. I had the opportunity of having an organization to turn it into an international project.

Where is health created?

The starting point is: "Where is health actually created?" Health isn't created in hospitals or doctors' offices, so we have to find strategies to help create it. We believe that projects such as Healthy Cities and Health Promoting Schools can help focus our thinking on creating health. We can create health by actually changing the institutions and environments in which people spend a major part of their day, and by enabling people to participate in that change.

We know from health research that one of the most significant things in health is people's self esteem and sense of coherence. Modern society doesn't seem to be giving people a lot of that. So the challenge is to find projects where, by involving people, we can help give them that self esteem, that sense of coherence, at the same time that they improve their environment in a way that contributes to their health.

You can't force health on people. If you don't involve communities, if you don't allow for process, it doesn't work. It doesn't work if you don't go intersectoral. It doesn't work if the health people want to stay in charge. It doesn't work if you approach it professionally only. It's got to have a broad scope, it's got to have a bit of zoom to it for people to want to be involved. It's got to be a positive health concept, not just a concept about what people shouldn't do. It's got to be about how they can contribute to their city.

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