Healthy Cities: The Role of Landscape Architecture

Healthy Cities: The Role of Landscape Architecture

Résumé en français

Faragher : Villes saines - l'architecture du paysage est-elle le remèdeaux villes malsaines ?

La pandémie actuelle de COVID-19 a remis au premier plan l'importance de l'infrastructure urbaine, de la planification et du rôle essentiel que joue l'espace public, en plus des services de santé, dans la construction de villes saines. C'est particulièrement important pour l'Afrique du Sud, où l'héritage de l'apartheid en matière de planification affecte la santé de multiples façons. L'émergence de la profession de paysagiste à partir des questions desanté urbaine de la révolution industrielle l'enracine fermement dans la santé publique. Cependant, le discours dominant actuel ne reconnaît pas l'architecture du paysage et continue de considérer les espaces publics verts comme un luxe, ainsi écartant la profession des décisions de planification et de conception.

Par conséquent, le rôle potentiel de l'architecture du paysage dans l'amélioration de la santé urbaine et dans la lutte, l'atténuation et l'adaptation au changement climatique est limité. Cet article explore le concept de villes saines, identifie les principes de conception et de planification quiinfluencent les résultats en matière de santé et de bien-être, situe le rôle de l'architecture du paysage dans la création de villes saines et discute quelques défis liés à la reconnaissance du rôle des architectes-paysagistes.  Il se termine par un appel à l'action.

The ongoing COVID-19 pandemic has re-foregrounded the importance of urban infrastructure, planning and the critical role that public space plays, in addition to health services – towards building healthy cities. This is particularly important for South Africa, where the Apartheid planning legacy affects health in multiple ways. The landscape profession's emergence from the urban health issues of the Industrial Revolution firmly roots it in public health. However, the current dominant narrative does not recognise landscape architecture and continues to view green, public space as a luxury, side-lining the profession from planning and design decisions. Consequently, the potentially impactful role of landscape architecture in improving urban health and combating, mitigating, and adapting to climate change is limited. This article explores the concept of healthy cities; identifies design and planning principles that influence health and wellbeing outcomes; locates the role of landscape architecture in healthy city-making, and discusses some of the challenges in recognising landscape architects' role. It concludes with a call to action.

The call for ‘healthy’ cities is not new. Over millennia, the complexity of growing urban places has resulted in a variety of often health-related crises, keeping city-builders busy. For example, cities built during the Industrial Revolution lacked adequate clean water, sanitation services, sunlight and fresh air, creating the breeding ground for health crises -cholera, tuberculosis, and typhoid. This article will explore the healthy city concept and analyse its applicability to South Africa, before discussing the role of landscape architecture and landscape architects.

City-making at that time changed radically to improve living conditions and included landscape interventions aimed at urban health that are world landmarks to this day. Parks with fresh air offered respite, while innovative suburbs such as Port Sunlight and Bourneville, were planned to enhance residents’ sense of wellbeing. Frederick Law Olmsted’s Emerald Necklace Park (Boston, USA), a water sensitive city project ahead of its time, was designed to improve water quality and reduce the number of cholera deaths (Institute of Landscape Architects, 2013). These projects saw the rise of the landscape architecture profession and established their seminal role in making ‘healthy cities’.

Exposure to green space not only promotes physical health via activity but also improves mental health by providing psychological relaxation, stress alleviation, social cohesion reduced exposure to noise and excessive heat, as well as reduced violence (Kondo, et al., 2018). It follows that landscapes make cities healthier, supporting medical research that health care plays a relatively lesser role in achieving overall health (Berkowitz, et al., 2021). Despite these benefits, green public space is often viewed as a luxury or ‘nice-to-have’.

While the connection between public space and health creates a virtuous cycle supporting individual and community health, the opposite is true for low-quality urban environments (Caroma, 2019). Socio-economic vulnerabilities cause poor health (Braveman & Gottlieb, 2014), lower quality of life - and diminish economic productivity. Consequently, COVID-19 has disproportionately affected the urban poor and heightened global public awareness of the role and importance of public space for our health, while emphasising the widening inequality gap represented by the uneven distribution of public space (Love & Kok, 2021).

This is particularly important for South Africa, the world’s most unequal and unhealthiest country, where according to the Indigo Wellness Index (2019), people are ‘dangerously unhealthy’. Considering the ongoing (and urgent) need for healthy cities, particularly in South Africa, the demand for landscape architects should be a lot higher.

What is a Healthy City?

The recent UN-Habitat Report on Cities and Pandemics (2021) describes ‘healthy cities’ as being compact and well-planned, combining residential and commercial functions with public spaces and affordable housing that can improve public health, the local economy and the environment. South African cities however exhibit numerous ‘weak areas’.

The ‘healthy city’ concept has evolved from a focus on public health, described as “what we as a society do collectively to assure the conditions in which people can be healthy” (Bloland, et al., 2012). These may include preventing disease and the health consequences of natural or man-made disasters; promoting behaviours that reduce the risk of communicable and non-communicable diseases (NCDs) and injuries; and ensuring the public's access to quality health services.

More recent shifts have seen ‘public health’ co-opted into the sustainable city discourse on urban health with ecological, biological, psychological, behavioural, and economic factors added as health determinants (Ompad, et al., 2007). It follows that a sustainable city is a city that supports good urban health. The proposed solution to urban ills, and mitigation to future pandemics, is urban planning and investment.

Our collective COVID-19 experience supports this view and suggests that city structures and the urban environment, being a web of connections and dependencies that include, but are not limited to, health services, play a significant role in physical wellbeing. Given that half of the world’s population will live in cities by 2050, it follows that cities are central (UN-Habitat WHO, 2016) to achieving healthy people.

Whilst this vision is possibly achievable for cities in the global north, it is less so for those in the poorer global south. UN-Habitat’s city vision not only ignores the gross global inequality (and its impacts), but further draws the eye away from the messy dynamics of rapidly growing cities. It coagulates around intangible future cities at a time when realistic pathways for incremental change that recognise cities’ burgeoning informality and the need to transition existing cities by addressing global inequality, which would perhaps be more helpful and likely to succeed.

The South African Context

Poverty-related issues exacerbated by spatial vulnerability, along with urban and environmental issues, affect South African cities. In a multi-dimensional approach to healthy cities, it is necessary to consider a broad range of factors such as the way that daily activities occur spatially across the city (Berkowitz, et al., 2021). These activities vary across South African cities and are determined by poverty, inequality and unemployment that are oftentimes the remnants of apartheid policy and planning.

A comparative analysis using 2011 data, evaluates the Western Health District (generally wealthy) and Khayelitsha (mostly poor) demonstrating the spatiality of these determinants, where poorer districts had higher air pollution, poorer water quality, and deficient sanitary conditions in addition to sub-optimal mental health services and palliative care (Mumm, et al., 2017). COVID has further highlighted food security and the associated health issues.

The vulnerability of those living in poor areas - characterised by overcrowding, poor housing infrastructure, insufficient basic amenities, inadequate public spaces, overcrowded public transport, environmental degradation and health hazards - increased during the COVID-pandemic because these communities were unable to social distance in the same way as those living in other, better-serviced areas (Berkowitz, et al., 2021). Similarly, these characteristics have contributed towards ongoing issues of HIV and AIDS, tuberculosis, high maternal and child mortality, high levels of violence and injuries and the growing burden of NCDs (e.g. hypertension and cardiovascular diseases, diabetes, cancer and chronic lung diseases) (Maphumulo, W; Bhengu, B, 2019).

Carbon emissions pollute air and affect human and environmental health, playing a role in climate change that in turn affects public health through drought, flooding, heatwaves and environmental degradation. The relationship between climate change and urban health was elevated in a recent media statement made by 200 health journal editors. It states that the science is unequivocal and that aglobal increase of 1.5°C above the pre-industrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse” (PA Media, 2021).

Cape Town’s natural asset base that supplies eco-services necessary to mitigate and adapt to climate change is under significant threat from development and land invasions, limiting its potential to, for example manage floods, placing already vulnerable households at further risk.

Realising Healthy Cities

Nascent City of Cape Town work - consistent with global thinking - recognises that the long-standing divisions and inequalities highlighted by the pandemic, as well as increasing climate change crises, mean that a return to ‘normality’ is no longer enough.

What gives reason for hope is the (re)recognition of design, the public realm and nature in creating healthy cities.

This growing recognition has included an awareness of the role of spatial planning and the need to plan neighbourhoods and communities to be multi-functional and inclusive of formal and informal activities that promote good health; access to goods and services; and alleviate, or in some cases even prevent, poor health.

Figure 1 illustrates that health facilities are part of a bigger health’ picture’ that includes the natural environment, food environment, recreational facilities, walkability, safe spaces, social cohesion and community culture, (Weimann, 2020).

Figure 1: Direct and indirect health impact and scales of geography (adapted from Weimann et al, 2020)

Figure 2 further illustrates and confirms that neighbourhood characteristics influence health and wellbeing outcomes. It indicates possible design and planning principles for neighbourhoods, suggesting that health outcomes can be affected through planning and design (Public Health England, 2017). Evidently, where we live affects our health, and that premature death and disease can be prevented through healthier environments (Connolly, 2017).

Figure 2: Association between planning principles and health (adapted from Public Health England, 2017)

This framework highlights a useful entry point for landscape architects. Emphasis on urban planning suggests a narrow understanding of the roles and responsibilities across the planning and design scales. Although neighbourhood and community-scaled interventions are critical, they exclude broader geo-political and city-scaled issues of inequality in addition to the impact of urban systems on climate change and health that occur across scales.

Landscape architects, responsible for designing the natural environment, public space networks and public spaces, should drive the environmental planning and public space agenda across these scales. Professional pedantry needs to be put aside given the urgent need to put human and environmental health back at the core of all planning and design processes.

Role for Landscape Architecture in building Healthy Cities

The Institute of Landscape Architects describes the work of the landscape architecture profession as the preparation of plans and designs that manage our land resources in order to secure the best possible outcomes for people, the environment and the economy. It includes the consideration and understanding of a complex set of natural and man-made factors, which contribute towards both aesthetic and functional qualities to achieve positive outcomes for people’s health and wellbeing at all scales and all stages of development. Landscape architects understand how the aesthetic and functional qualities of a place can enhance the quality of life (Landscape Institute, 2013).

Figure 3: Merriman Square, Cape Town, treats stormwater on site using a constructed wetland in an urban area (Square One, Landscape Architects)

The following healthy ‘places’ principles are adapted from those defined by the Landscape Institute and consider how healthy city principles could be implemented by particular landscape interventions. The principles are significantly applicable across city, district, neighbourhood and site scales, indicating an inter-scalar role for landscape architects commencing at the natural systems scale, through to park, garden, green wall and green roof design.

These principles are applicable for even the smallest green spaces, given the pressure on space within urban areas and considering the health, environmental and economic benefits of well-designed landscapes (ARUP, n.d.).

An example of this approach is Cape Town’s Green Point Urban Park (by OvP Landscape Architects), developed as part of the 2010 Soccer World Cup infrastructure. Popular across the city, it offers urban cooling, amenity, play areas for children, picnic areas, a biodiversity garden for teaching and learning, increased area for stormwater management, additional biodiversity, in addition to enhancing property values. The Green Point Urban Park has succeeded on many levels, most notably because of active management that ensures safety, attractiveness and usability.

Figure 4: Green Point Urban Park exhibits healthy city planning principles

Not all areas are similarly serviced and managed. People living in overcrowded conditions use the public realm for family activities because of insufficient indoor living space. It is also where many shop. The significance of public space as a food environment that impacts nutrition should not be underestimated, nor should the need to provide dignity. South African cities need to ‘think big’ and adopt an infrastructure approach to public space supported by investment and long-term management and activation in vulnerable areas, as a first step towards a healthy city.

Figure 5: Masiphumelele street food


The literature and professional discussions related to healthy cities and the built environment do not adequately recognise landscape architects as key role players. A review is therefore necessary to enable a more co-ordinated approach that recognises the vital role of landscape architects.

Besides public green spaces, urban agriculture, green walls, green roofs, along with nature reserves, floodplains, river corridors and biodiversity areas play an important role in creating a healthy, resilient, natural environment. Besides design, management is critical for supporting the urban environment, improving environmental health and mitigating and adapting to climate change by for example, providing flood mitigation. A multi-scaled view must therefore be taken to ensure that planning, design, implementation and management is integrated, co-ordinated and funded across departments.

The literature offers little insights into the issues that affect Cape Town’s public spaces, beyond suggesting investment and ‘good design’. The reality is that public space ‘design’ is an activity within a continuum affected by a variety of issues within a city divided racially, socially and economically.

Many of the unspoken issues are institutional such as maintenance, poor governance and management integration, in addition to insufficient supply. Comparatively, design issues are easier to resolve than high levels of unemployment, crime, poverty and illegal land occupation that make public spaces unsafe and unusable. It is unlikely landscape architects will resolve poverty and overcrowding arising from unemployment and low incomes that are the cause of a substantial part of Cape Town’s poor health. But they can make a significant contribution to the connection between public space and health to reinforce individual and community health.


COVID-19 has been deeply damaging on many levels. But it has also shone light on the urban poor and raised the global public awareness of the role and importance of public space for our health. It follows that the need for landscape architects to collaborate with planners and other built environment professionals to build healthy, liveable, climate adaptive cities has never been greater - particularly in South Africa.


ARUP, n.d. Landscape essential for healthier cities. [Online]
Available at:
[Accessed 20 September 2021].

Berkowitz, N., Faragher, T. &Ferreira, A., 2021. IDP DiscussionPaper - From Pandemic to an integrated health (and wellbeing) approach, Cape Town: Unpublished.

Bloland, P. et al., 2012. The Role of Public Health Institutions inGlobal Health System Strengthening Efforts: The US CDC's Perspective

Braveman, P. & Gottlieb, M., 2014. The Social Determinants of Health:It's Time to Consider the Causes of the Causes Jan-Feb;. Public Health Rep, p.19–31.

Caroma, M., 2019. Place value: place quality and its impact on health, social, economic and environmental outcomes. Journal of Urban Design, 24(1),pp. 1-48.

Chopra, M., Steyn, N. & Lambert, V., 2007. Decreasing the Burden of Cardiovascular

City of Cape Town, 2019 (a). Resilience Strategy

City of Cape Town, 2019 (b). Food Systems Programme Pilot, CapeTown.

Connolly, A., 2017. UK Health Security Agency. [Online]
Available at: [Accessed20 September 2021].

Green, J., 2021.[Online]
Available at:

IPC, 2021. Integrated Food Security Phase Classification. [Online]
Available at: [Accessed20 September 2021].

Kondo, M., Fluehr, J., McKeon, T. & Branas, C., 2018. Urban green space interventions and health: A review of impacts and effectiveness.. International Journal of Environmental Research and Public Health , 3 March.15(3).

Landscape Institute, 2013. Public Health and Landscape: Creating healthy places - Landscape Institute Position Statement

Love, H. & Kok, C., 2021. Beyond traditional measures: Examining the holistic impacts of public space investments in three cities. [Online]
Available at:
[Accessed 19 September 2021].

Maphumulo, W; Bhengu, B, 2019. Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review. Curotonis, Volume42(1).

Metropolis, 2021. Public space for all: transforming society from the ground up. [Online]
Available at:
[Accessed 19 September 2021].

Mumm, R. et al., 2017. Exploring urban health in Cape Town, South Africa:an interdisciplinary analysis of secondary data.. Pathog Glob Health, 17January, 111(1), pp. 7-22.

Ompad, D., Galea, S., Caiaffa, W. & Vlahov, D., 2007. Social determinants of the health of urban populations: methodologic considerations. J. Urban Health, Volume 84, pp. 42-53.

PA Media, 2021. More than 200 health journals call for urgent action on climate crisis. 6 September.

Public Health England, 2017. Spatial Planning for Health - An evidence resource for planning and designing healthier places, s.l.: PHEPublications.

UN Habitat, 2021. Cities and pandemics towards a more just green and healthy future

UN-Habitat | WHO, 2016. Global Report on Urban Health; Equitable, Healthier Cities for Sustainable Development

Weimann, A. et al.,2020. Health through human settlements: Investigating policymakers’ perceptionsof human settlement action for population health improvement in urban SouthAfrica. Habitat International, September.Volume 103.

Western Cape Govenment, 2018. WCG International Futures Modelling System

Western Cape Government, 2016. Western Cape Government Household Food and Nutrition Security Strategic Framework

Western Cape Government, 2017. State of Environment Outlook Report -Air Quality

WHO, n.d. The Global Health Observatory. [Online]
Available at:
[Accessed 20 September 2021].


Photographic sources:

Main photo: Green Point Urban Park. City of Cape Town, Bruce Sutherland

Figure 3: Merriman Square, Square One Landscape Architects

Figure 4: Green Point Urban Park. City of Cape Town, Bruce Sutherland

Figure 5: Masiphumelele street food. Samantha Reinders