Learning Self-Care from Yangzhou: a World Healthy City

What does a healthy city look like?  In the Chinese city of Yangzhou, buildings, public spaces, social programmes and the food sector have been organised to help citizens stay healthy. Urban design expert Graham Marshall and Rhiannon Corcoran, professor of psychology from the University of Liverpool, explain what this means for the citizens of Yangzhour, as part of our Creating Healthy Places programme. 

The International Self-Care Foundation (ISF) presented its first World Healthy City Award to Yangzhou City, China, in 2016, for outstanding achievements in developing an urban living environment conducive to self-care and healthy lifestyles for its citizens.  The ISF is a UK-based charity championing self-care around the world.  

In practical terms this involves helping to develop evidence-based self-care concepts and practices, and helping to promote the role of self-care in health.  We were invited to be part of the accreditation team undertaking the assessment for the designation, which is awarded on merit.  The team also included ISF President Dr David Webber and Prof Debra Moser of the University of Kentucky, USA, and was supported by members of the ISF Hong Kong team.

The award is an important achievement for Yangzhou City at a time of rapid urbanisation across the world, especially set against a backdrop of diverse evidence increasingly telling us that cities can be bad for our health and wellbeing.  

The overall objective of the assessment was to identify and understand the approaches that the Yangzhou City authorities have taken specifically to support and encourage citizens to lead healthy lifestyles and look after themselves through self-care.

The overall objective of the assessment was to identify and understand the approaches that the Yangzhou City authorities have taken specifically to support and encourage citizens to lead healthy lifestyles and look after themselves through self-care. We were looking specifically for policy implementation in health care, education and urban planning.

Beyond Cotswold villages and pastoral golf courses

For an urban designer that identifies city development as a human ecology, the offer to join the accreditation panel of health and wellbeing experts was irresistible; an opportunity to review positive efforts to create a healthy city through the lens of another culture.  The accreditation was undertaken over two full days in Yangzhou, supported with detailed background papers, and concluded with a seminar with senior civic leaders and managers.  We also took the opportunity to spend additional days in the city to take in its cultural history, which reinforced our positive image of Yangzhou.

Prior to this visit, our knowledge of contemporary planning and design in China came from built environment journalists and pundits disseminating bright images of new ‘sustainable’ cities, designed along Western principles.  The mainstream media obliged with stories about the Chinese love of building ‘Cotswold’ villages and pastoral golf courses, replicated ad nausea.  More recently, investigative journalists have ‘uncovered’ a darker side to urban development in China; vast new cities laying empty, banal facsimiles of Paris etc., their developers in jail for corruption; farmers driven from their land, urbanised and ghettoised.  

Thank goodness for an open mind and the background papers.  Putting this in perspective, we have volume housebuilders delivering the same pastiche, Trump golf courses and council estates currently referred to as ‘sink estates’ in government initiatives.

Have you eaten rice today?

Over dinner, we listened to Xie Zhengyi speak of his aspirations for Yangzhou’s citizens and the city region.  He is the Secretary of Yangzhou Communist Party of China Committee and Director of the Standing Committee of Yangzhou People’s Congress.  He explained the Chinese greeting of ‘have you eaten rice today?’ – in short, have you eaten?, undernourishment being a widespread danger to health within living memory.  

The Chinese greeting of ‘have you eaten rice today?’ – in short, have you eaten?, undernourishment being a widespread danger to health within living memory.

In Maslow’s hierarchy, it is a fundamental physiological need, along with clean water and air.  It compares with our greeting of ‘how are you?’ – in short, are you well?, alluding to the diseases of urbanised Britain that led to the establishment of our National Health Service.  

Yangzhou’s contemporary urban planning continues to focus on these baseline needs, with the quality of food high on the agenda.  The local cuisine is about freshness and simplicity which equates to a very healthy diet.  

Yangzhou Food Industrial Park focuses on food growing and processing for the wholesale fresh and prepared food markets – it’s a transformational development that combines ecological science, technology and food security.  

Its first phase covers three square kilometres and drives three economies: food processing, manufacturing and industrial tourism.  It aims to be internationally first-class in these areas and has already won many awards as a demonstration base for the food industry and for experimental agricultural cooperation.  

Equally important is water quality, something we take for granted in Britain.  The first water plant in Yangzhou was founded in 1960, and its expansion completed in 2014 includes the most advanced treatment processes available.  These are important State sponsored infrastructure projects that provide the basis for health.  

Helping people to look after themselves 

In terms of healthcare, the State provides free Western and Traditional Chinese Medicine at the secondary and tertiary levels – hospitals and specialist centres - with subsidised prescriptions for medicines.  However, there is no primary care - GP surgeries - as the cost is prohibitive to the State.  This creates a significant health and economic issue.  

If preventable diseases are not identified or treated early enough, there is an increased economic impact on the health and social care systems further down the line, not to mention the impact on the individual, family, community and wider economy.  This Catch 22 is an unsustainable scenario and well represented in the United States where without a welfare system, people without insurance often defer addressing minor problems until they become chronic.

If preventable diseases are not identified or treated early enough, there is an increased economic impact on the health and social care systems further down the line, not to mention the impact on the individual, family, community and wider economy.

In Britain, our National Health Service is widely described as being in crisis, with increasing privatisation, and sometimes a lottery in the quality of or access to health care, depending on your post code and the services you require.  In short, it is looking unsustainable in terms of the demands we have of it.  In 2013, responsibility for public health was transferred from the NHS to local councils.  Whilst this may have led to a lack of coordination between different services and continuity of care for the patient, it also prompts us to think differently about health.  

In 2016, the Local Government Association published a guide on self-care - Helping People Look After Themselves.  As Simon Stevens, Chief Executive NHS England puts it, “At a time when resources are tight, we’re going to have to find new ways of…boosting the critical role that patients play in their own health and care”.

What can we learn from Yangzhou?

Self-care is central to the development of Yangzhou.  Mr Xie Zhengyi continued his conversation with a reflection on the history of the city.  Yangzhou is 2,500 years old with a population over 4.6 million and sited at the confluence of two great river systems that create an environmentally rich landscape. 

 It is also the beneficiary of historic decisions to build major canals over the millennia to capitalise on these natural assets and cement Yangzhou’s place in China’s trade network.  The long-term benefit of these projects (regardless of their original purpose) is not lost on the leadership.  The ecological value of the inherited water system, and its ‘flow’ through the city, provides a unique public realm, free and accessible to its citizens.  Yangzhou’s management of its green and blue infrastructure has won many international awards. 

To capitalise upon this, and forming this generation’s contribution to the future, sixty new parks and several million semi-mature trees are being planted as part of a five-year plan.  Symbolically, six million Gingko biloba trees have been planted.  Native to China, they are one of the oldest living trees species on earth, extremely long lived, virtually indestructible (six survived the atomic bombing of Hiroshima), and are a source of food and medicine.  

The purpose of the public realm 

The great avenues through the city are a statement of the future linking to the past, connecting every neighbourhood.  Whilst cleaner air from this landscape is a benefit for health, the strategy behind it is to achieve a hierarchy of park provision within the city, with every citizen being no more than a ten-minute walk from a local park. The purpose is to encourage active lifestyles for people at all stages of life in a healthy ecological landscape.  There is provision for sports, games, dancing, walking, running, tai chi and facilities for watching, along with celebrations of the history and culture of the province.  What is created is an inclusive outdoor environment, delivering intergenerational mental wellbeing. 

In areas of residential regeneration and development, the foundations of good health are delivered ahead of homes to bring immediate benefit: clean water, medical centres and active environments.

The quality and purpose of this public realm is consistent across the city.  In areas of residential regeneration and development, the foundations of good health are delivered ahead of homes to bring immediate benefit: clean water, medical centres and active environments.  The driver of this city is the living environment, not the built environment - a different way of valuing place.  There is a consistent impression of public space being an inclusive resource, which is much more important to mental wellbeing than merely ‘greening’. 

Like anywhere else, there is a hierarchy in Chinese society reflected in the urban form, but here it is modified by certain physical features that serve as levellers.  Residential development is of a predominantly dense, city scale within a positive public realm, rather than taking the form of suburban sprawl.  All residents have access to the same range of facilities within each neighbourhood, complex and building. 

In some complexes, where doctors are residents, they volunteer time to advise their neighbours on self-care.

Developers must provide internal space where neighbours can meet; the use of these spaces depends on the community, but central to all of them are health and self-care.  In some, equipment is provided where people can check their own blood pressure etc. and access health information via computers.  In some complexes, where doctors are residents, they volunteer time to advise their neighbours on self-care.  In other neighbourhoods, professionals in local health centres volunteer with the local community. 

 Many other members of the community (such as teachers, musicians and gardeners) also volunteer their time and expertise, enhancing wellbeing for all.  This resonates with our Five Ways to Wellbeing (New Economics Foundation 2008) which is embedded in the UK government’s health policies. 

We witnessed these physical and social approaches to self-care in Wenchang Garden Community, the largest ‘resettlement community’ in Yangzhou, home to 12,608 people in 4,220 households on a 13-hectare site.  The programme that has created this new neighbourhood aims to lift people out of poverty and to support individuals and families in the transition from rural subsistence farming to urban living.  Many, but not all, the people here are from former rural communities displaced by the expanding city.  

The urban fringe

In the many areas on the urban fringe that we visited, there were still farmers living in unsanitary conditions, housed in makeshift tarpaulin shelters amongst ‘food gardens’ – we might recognise them as allotments.  They are precarious places where you would still ask, “have you eaten rice today?”  The shift from this lifestyle to a dense urban one where you have few skills on offer,  is why new and emerging neighbourhoods like Wenchang Garden Community are so important for nurturing behaviour change, helping to apply skills in a new environment and integrating with a new way of life.   

It is a mixed neighbourhood, where welfare and support systems have been established and are managed by the community, covering social services, employment and training.

The support structure in Wenchang Garden Community includes 2,000m2 of office space plus extensive community rooms that contain libraries, museums, arts, crafts and activity spaces.  It is a mixed neighbourhood, where welfare and support systems have been established and are managed by the community, covering social services, employment and training.  To prevent isolation, ‘caring cards’ are distributed to residents, aimed particularly at vulnerable groups.  Thirty-five social organisations have been established within this community, with 1,372 volunteers registered on a time-banking scheme.  A community work exchange centre and a ‘community doctor workstation’ have been established, the latter operating as an educational practice base for the local hospital and university.  The workstation enables a mixture of hands on work and theoretical research into community building and management.  There is a lot to learn here in terms of how universities and communities could work together in the UK.   

At a policy level, Yangzhou City has implemented a “10 Themes (of) Health Promotion” programme, covering hospitals, schools, health providers, companies, communities and families.  The city authorities indicate that there are already demonstrable positive benefits from this work in progress.  The average life expectancy of Yangzhou City residents is 79 years, three years higher than the national average, and with lower levels of hospitalisation and chronic disease.  This has resulted in a surplus in Yangzhou’s health insurance scheme and its wider recognition as a city of choice, attracting new residents, business and responsible high quality inward investment. 

What of the challenges?

Whilst the shape and form of developments and infrastructure can be planned, taxation policies put in place to cross fund public works, and volunteer schemes facilitated to nurture a sense of citizenship, stewardship of the future city is a potent issue.  Yangzhou city planners were open about the threats inherent in the success of the city, demonstrating a preparedness as paraphrased below: 

• The growth of motor vehicles is rapidly creating pedestrian conflicts, with environmental and health problems for the city at large.
• The city layout is loose and not conducive to walking, while the cost of private transport is high for most residents, creating inequity within the city.
• Greater provision for an ageing population is required to overcome a serious lack of health care institutions and a good building mechanism (we interpreted this as lifetime homes, though the extra-care facilities we saw were excellent).
• The environmental situation remains challenging, with air and water pollution continuing to hamper urban development.

Movement is a big issue.  Whilst neighbourhoods are walkable, getting around the city on foot is challenging.  Cycle infrastructure is established at a significant level across the city, with 2,000 bicycle hire stations supplying 20,000 cycles for public use.  There is extensive use of electric mopeds and scooters, but near misses with cars are everywhere to be seen.  The highway network is generous, and attractively designed from a pedestrian and cycling perspective.  Whilst there is time, it will be crucial to capitalise on this positive environment with public transport infrastructure that reduces the space available for private motor transport, moderating its dangerous influence.

The cooperative city leadership, working with concerted coordination between departments, is implementing a thoughtful and consistent people-oriented philosophy, allowing a resilient environment to emerge from a healthy, sustainable community.