This new definition is steeped in Dr Zeisel’s own experiences in dementia care and research, as well as offering a progression from historic interpretations of what a healthy city represents. The answer to the question “what is a healthy city?” has continually shifted depending on the public narrative of the times, explained Dr Zeisel. The first, which followed the Industrial Revolution and rapid growth of cities, was the idea of urban renewal – a theory seen as a solution to the societal blight of slums but which forced those living in them out of the city.

The approach, described by Dr Zeisel as a form of “healthful” urban cleansing, was embraced by famous architects and urban planners such as Mies van der Rohe, whose clean and straight-lined Illinois Institute of Technology, in Chicago, reflected these principles. A new urban design movement, led by planner Jane Jacobs, criticised urban renewal for destroying healthy urban neighbourhoods, and her efforts to restore them became labelled ‘urban villages’ – a term that shifted urban planning towards a social definition of healthy cities rather than one founded purely in the built environment. 

In the 1950s and 60s, architect Bertrand Goldberg promoted high-rise urban buildings, such as his Marina Towers, also in Chicago, which, in addition to apartments, included day care centres, supermarkets, parks, and other urban neighbourhood amenities. But his proposals for more such schemes were blocked and opposed by the city planners of the time.

Today, the ‘engaging city’ offers a new interpretation of the healthy city – an idea built on neuroscience and genetics evidence, and which points to five necessary components to collective human health: exercise, diet, sleep, reduced stress, and meaningful engagement, value or purpose. 

The engaging city concept, stressed Dr Zeisel, needs to be approached from a model of hope rather than despair. He explained the two models in broad terms, but with a focus, too, on people suffering from dementia.

“Many situations are ambiguous and if you face them with despair, you get angry and afraid,” he said. “Fear and anger are not what’s going to lead to better cities, and they’re definitely not what’s going to lead to better care for people with dementia.

“The one group who don’t use the city at all is people with cognitive issues because they’re so afraid of going out they don’t use parks, restaurants or streets. Unless there is more to the process or product it’s not going to happen. In fact, no one is going to use the street if we have a despair model.”

The despair model, he elaborated, is a self-fulfilling prophecy, whereby fear about thinking about what won’t exist leads people to experience sadness and the four ‘As’ of Alzheimer’s – also the four ‘As’ of ill health in cities – anxiety, agitation, aggression and apathy.

“As these things increase, people look for a quick fix and they look for drugs: a pill that will solve the problem,” said Dr Zeisel. “The despair model not only leads to a lack of progress in individuals but also in organisations and in cities. The hope model is the exact opposite. There are still the problems, the challenges, and the diagnosis of dementia, but we grieve about them and move on. In dementia, we see the person. We see what that person can do and we see the positives. We keep engaging them and us in some purposeful activities.

“So the future of dementia care – and I use that as an example for cities as well – is engagement. Because if someone is engaged in something that’s interesting and purposeful, they can’t also be angry, agitated and all those other things.”

Having established the principles of the ‘engaging city’, Dr Zeisel went on to describe two urban programmes demonstrating how the city can engage and thus provide health, meaning and quality of life for persons with dementia.

The first, Riverside Hope and Memory Park in Manhattan, is focused more on the physical environment. Problems that people with cognitive challenges face in their daily lives include difficulty in walking down the street if they can’t see their destination. Another is that if they are faced with a fork in the road, and no reason to go down one or the other, then they become confused, upset and anxious.

Design solutions to address these challenges include providing a place that’s enclosed and safe, where care partners can also sit but allow people with dementia to feel free and independent. Linking a narrative of places is another design device – where place is designed around ‘beats’ that are linked so people with dementia can see and navigate them using landmarks along the way. Designed around two zones, the park in Manhattan follows these principles and others, which help people with dementia to avoid the conflict that such urban environments can bring.

The second city programme is focused more on social interaction and the management of creative programmes. The ‘It Takes a Village’ programme uses underused urban resources to regularly engage persons living with dementia. One of the first, developed in Brookline, Massachusetts, involves the local museum, theatre and arts centre opening their doors and running weekly dementia-friendly programmes. 

“The biggest problem is getting people to cross the threshold because they’re so frightened of our cities,” commented Dr Zeisel. “They’re not frightened of the people, they’re frightened of being out of place, and it’s not only people with dementia; it’s also their care partners.

“We learn two ways: episodically and procedurally – people never lose the ability to learn procedurally. So, in order to make cities healthy for people who are really ill, we have to break down the barriers both inside and outside.

“Healthy cities needs both of these things to take off. And if we don’t do evaluations and measure the impact, we can’t really serve our purposes.”

Dr Zeisel’s own research into the programmes he describes above has shown several important outcomes, including: increased quality of life; reduced stigma towards people with dementia; reduced falls; increased engagement; and lower depression and stress.

He concluded: “If we build cities that are healthy, healing and support exercise, reduce stress, provide purpose, and support diet and sleep – and we can get the money to make not only the physical changes but also the management changes – then we can make a difference.”

The inaugural Healthy City Design 2017 International Congress was organised by SALUS in collaboration with the Helen Hamlyn Centre for Design, Royal College of Art at the Royal College of Physicians, from 16-17th October.