Kenneth Thompson - Finding hope in the city

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  • Posted:Tuesday 30 July 2019

Hear from Kenneth Thompson how health can be both a mediator for and an outcome of the interaction of people with their urban environment. This session was filmed at our Improving health in urban communities event.


So I’m going to talk about finding hope in the city. These are photographs of Pittsburgh and some of the people who live there. And I want to do my disclosures and my appreciations to start off. I have no disclosures, I’m not making a penny out of any of this and I’ve got no way to make any money out of it, so that’s just the way it is. Appreciations – I’ve got several. One is I’m very pleased and happy, honoured, that you all invited me to come here. Chris, thank you very much. But I have a bigger debt to pay back even further, which is that now almost 40 years ago, I spent some time at the Usher Institute with my wife, Dr Andrea Fox, we were both in medical school. And we came to Edinburgh and to the UK to learn about the National Health Service, because we’d heard a lot about it. Now we wanted to see what was happening and we spent time studying community medicine, took a year off of medical school, went to Scotland for a while, came to London, went to the London School of Tropical Disease, did a clerkship there, and then we went off to revolutionary Nicaragua, which was a fascinating year.

But it all started with the Usher Institute and what we learned about community health when the Black Report came out. Nobody in this audience is old enough to remember the Black Report – maybe one person, that’s good; which was the first time that I had really begun to understand that what made people healthy and what made people ill wasn’t only about their healthcare, which is the common way we think in the United States. And I have to say, I was contaminated at that point, by this UK way of thinking. Because I went back to the States and for the last, almost 35 years, until very recently, if I said things like “health equity”, if I talked about how there was a linear scale of health and wellbeing based on income or social class, people would look at me like, “What are you talking about?” And it has been a long and lonely struggle. However, another appreciation that I want to make – by the way, the Usher Institute did not look like that in 1980, so it’s nice to see some new money went into something around public and community health.

But there is a long, long history of exchange between the United States, the UK, other parts of the countries in Europe, and even as far away as Australasia. And it’s really wonderfully captured in a book that I’m prompting you guys to read, if this is of any interest to you, to think about how we exchange ideas. It’s called Atlantic Crossings, it’s about social politics in a progressive age, it’s about the history of how people were exchanging ideas back from the 1880s, all the way through about 1960. And I think a lot of the themes that we’ve been talking about have come up over and over and over again and I think it’s worth having some sense of how it’s gone. So I recommend this book by Daniel T Rodgers, he’s a Professor at Princeton. So those are my appreciations.

Now I’m supposed to talk a little bit about cities and mental health. There’s been a long, long concern about cities and mental health and a real ambivalence, that’s a very good psychiatric term, and that means you have mixed feelings about something. When we look at mental health issues in the city, what we find is that there are some very clear evidence, that there are pockets in the cities where there are very high rates of psychiatric challenges. And that goes back to work that was done by Faris and Dunham looking in Chicago, they were the first socio ecological view of mental health. There was the mental health in the Metropolis Study, the Midtown Study, done in the 1950s in New York City, which found very high rates of psychiatric challenges. There’s been a long history of studying particularly psychosis in the city. Interestingly enough, a psychiatrist by the name of Lendahl who is an American, got very involved in the war on poverty in the 1960s and started to look at mental health and housing. He worked for something called HUD, the Housing and Urban Development, which is a brand new agency on the war on poverty. He then went on to found something that some of you may be familiar with, the Healthy Cities Movement. So he went on to create that with Trevor Hancock from Toronto.

Healthy Cities never caught on in the United States. We had a brief time we talked about healthy communities, but there was never really the kind of focus that I was aware of when I got to come back to the UK in 1999 during the advent of New Labour. I came here to study Health Action Zones, and to learn about how this notion of how health was determined by the circumstances in the way that people lived, and how they worked and what kind of things happened to them in life, rather than their healthcare. When I came back to study that, you guys had moved along and the United States nothing had happened. So just to say a word about mental health in the city. There’s lots of reasons…and a reason for the ambivalence. There’s lots and lots of stresses and strains in cities that impact on mental health. People get collected there, people end up there, they can’t move out, people are crowded, there’s migrations, very fast pace. I’m trying to talk quickly so I go through all the stuff that I have to say, because I’m in a city. It’s an alienating environment, so there is a lot of oppression and inequality. There’s a lot of conflict and exposures to all kinds of toxic and difficult circumstances.

So these are all challenges to mental health, they’re all challenges to recovering from a mental health problem, and they are rife in cities. However, what else is in the cities? Opportunities. Potentially lots of support. All kinds of resources. Culture. And a great deal of knowledge accumulated. So cities balance one way or the other in how they’re impacting on the health and mental wellbeing of the people in the city and they do it perhaps in pockets. Some places get more, some places get less. 

So the city is really the cause and the solution of the mentally healthy city. Now, in this moment in history, we have had, I hope, a resurgence of international interest in mental health in cities, and I just want to speak very briefly about this. There’s an entity called the International Initiative for Mental Health Leadership, how many people in this audience have ever heard of this? Jacqui, I know, because we’ve been involved with her through that. So the International Initiative for Mental Health Leadership is actually a partnership of nine countries, including England, the US, Canada, just recently Holland, Sweden, Australia, New Zealand and Canada. And they have been working together for 20 years to encourage leadership around mental health issues and sharing that across boundaries. So they’ve been doing this kind of Atlantic and Pacific crossings that I was talking about before.

About three years ago, we had a presentation at one of our sessions by a guy from Philadelphia, whose name of course went right through my head – Arthur Evans – I’ve only known for 40 years myself. Arthur gave a talk particularly focusing on the use of murals in Philadelphia and I don’t know if any of you have been to Philadelphia, if you’ve not? They have done a huge programme around beautifying the city, but also using the murals as a way to help people get past stigma, have community conversations and to use public art, a particular kind of public art, in a way that defines what Philadelphia is about. He gave a talk about his work in that area in particular, but the notion that cities could do something and address things in mental health concerns, that were beyond just doing services. We’ve been doing services and we have not gotten better at what we’re doing, so how do we get out of that circumstance?

As a result of that, we’ve recently formed International City and Urban Regional Collaborative, I-CIRCLE. They have been promulgating the thrive principles. These are ideas that came out of work in New York City, where about 800 million dollars was gotten out of the city budget to do a complete revamp of how they think about mental health beyond just providing psychiatric services, which New York provides quite a lot of. And they came up with a number of principles that I’m just going to go through very quickly – Change the culture, so make mental health everybody’s business. Use data better, build new ways to get the kind of information needed for a public health approach.  Act early, so invest in prevention and early recognition and help for people with various kinds of psychiatric challenges. Close treatment gaps, so they’ve been particularly active in getting folks into primary health settings. Partner with communities, work very closely with communities, a lot of the themes that we’ve talked about before. And importantly, position Governments to lead. Government has, in the United States, been kind of on its back heels when it comes to organising and pulling together multiple sectors together. We are pretty good at working in silos, but we have not been a place that has really been able to pull, say housing, work opportunities, education and health services all together in a pod, which you guys have been talking about all day long.

So this is stuff that’s going on with Thrive and these principles are now being generalised now through I-CIRCLE, they’re about somewhere between 10 and 15 cities involved with it, to create a playbook. So I wanted to make sure if people just got an awareness of this, this is something that if you go to the I-CIRCLE website, you will see eventually, I don’t know if it’s been downloaded yet, because we’re still constructing it, but it goes through all of those six principles and gives examples of places around the world that are addressing some kind of element of those principles in projects and activities that they’re doing. So what we’re hoping is that at the end of this, if you’re somebody in London or if you’re somebody in Manchester or Birmingham, wherever, if you want to get some ideas about how to really bump up the work that you’re doing around mental health and addressing issues in the city, that you can go to the I-CIRCLE playbook and pull it up and see things that are being done elsewhere, get in touch with people, get materials that you need so that you can move forward.

So that’s one thing I wanted to present. The second thing I want to present very quickly, I want to just talk about Pittsburgh which is an old industrial town, now post-industrial, and pre-something else. It’s a city where we lost over 150 thousand jobs, it’s a neoliberal divided city and individual risk society where there’s been essentially austerity for a long time, where we’ve had real difficulties with social exclusion both on race and class. The notion of the diseases of despair, which we’ve talked a little bit about, really kind of has come to the forefront. So we’ve had a burgeoning epidemic of people dying from opiates, the suicide rate has been increasing, deaths from alcohol and violence increasing, and there’s just an ongoing burden of chronic illness and disability in the neighbourhoods that carry the burden of having been deindustrialised and losing resources. When I say something new though, I want you to just take a look at this picture. This is a photograph of what’s called the Carrie Furnace. Anybody see anything in it that looks a little bit unusual?  

So that’s a piece of art and what we’re now trying to do is to really imagine what Pittsburgh is about by reconceptualising it and this kind of captures some of that. These are maps of Allegany County, Alonzo Plough already gave that a shout out and some of this work is probably based on the data that you guys helped fund. The only reason I put this up here is to show you that if you look at it, there are different colours but the different colours group together and these maps are of poverty in the upper left, of the median age of death, the number of opiate cases of overdoses, and the number of suicides.  And what you’ll see is, there’s three rivers that make up Pittsburgh. This is the Allegany, this is the Monongahela and this is the Ohio – all the steel mills were along these rivers here. The poor folks essentially live in those neighbourhoods. So what you’ll see is that for the most part, the burdens of illness, particularly ODs, particularly early death and suicide, tends to track along with the neighbourhoods – with one exception and that is the opiates have actually started to show up particularly in this area here. That’s working class white folks whose neighbourhoods are actually going down. They are really struggling and suffering.

So we’re seeing an increase at that place in those folks. We got involved with a project with the Robert Wood Johnson Foundation to learn from Glasgow about what Glasgow was doing to address their health equity issues. You all are probably familiar that Glasgow has a history and a reputation as having very significant health equity issues. So we went to them because of work that the Glasgow Centre for Population Health had been doing and because we were very much connected into Resilient Pittsburgh and Resilient Pittsburgh was very much connected into Resilient Glasgow. So these are the Hundred Resilient City Initiative. Glasgow and Pittsburgh were the two post industrial cities in that Hundred City collection. We went to them and said “What are you guys doing to address this stuff?” And this is what they said. They said, “People make Glasgow.  If you want a resilient city, then you have to make it possible for people to thrive and to flourish – everybody.  And if you’re going to do that, you have to recognise that it’s the people who are going to make your city and make your city the health resilient and equitable.”

So we’ve learned from that. We had three major themes – one was working together to make places that support people thriving, we worked on creating health services that build on the power of community and we kept in mind the fact because we both as cities know that things don’t stay the same, that we wanted to look to the future and to begin to anticipate things like the neighbourhood that I live in is filled with automated cars. So we’re looking at robotics, we’re looking at automation, we’re looking at major job loss potentially in the future, so we wanted to start to think about what will happen to our cities in the future. Not just what’s happening today, but where are we going to be in 10 years and what are the issues that we need to be thinking about?

The things that we’ve established and I’ll just give an example of some things we accomplished. One is this is a list of the values of what’s called One Pittsburgh, that is the mayor’s initiative to become a resilient city. When we started, people was not on the top, when we started planet, place and performance were above people. Because the notion was, that if you built the infrastructure right, the people would be okay. And what we’ve been saying to folks is based on the Glasgow input is, you have to attend to the people first and the other stuff is very important, don’t neglect it, but it’s really going to be based on what your people are capable of doing and what kind of resources they have to do it. So that was a change. Through that work, the mayor is now calling for a three billion dollar social investment fund to help us do a better job in terms of getting affordable housing. All day, free P.K. for kids and a variety of other activities to ensure that people have opportunities to make their lives move forward. That is a whole new thing – the notion of the three billion dollar social investment fund is something that we are really hoping can happen.

We also, because the Scots came, we brought some folks from Glasgow who have been working – Sonia Scott is in here some place, maybe, have been working on the ending child poverty initiative that’s going on in Scotland, and I know happened in England previously. They came and held a forum and we have now put child poverty on the agenda in the United States in Pittsburgh in a way that it was never ever discussed before. What we’ve been learning is that in a place like Pittsburgh and Glasgow, there’s a tremendous pressure to redevelop, the city’s almost died, what are you going to do to bring it back? And there’s a focus on economic development, community development and that context, let’s build the environment, let’s build the opportunities. The challenge with that is, that it isn’t just about that, it’s also about developing the community, putting people in connection with each other, putting resources in their hands and making sure that they have an opportunity to go forward.

This is what our mayor says – if it’s not for all of us, it’s not for us. About nine months ago, we had a tragedy in Pittsburgh where 11 people were murdered – one of them was a colleague of mine, a worker, who actually also was my dentist. The picture on the left is a photograph of the vigil that was held that pulled people together, that created this sense of community. This is not going away. To the right, there’s the challenge that we have of young black men being shot by the Police, a guy named Anton Rose. A real shard in that collective community. So we are still struggling, we’ve got the basis, but we don’t have all of the pieces pulled together to have that community really develop, and that’s where we are working and that’s where we look to solidarity with other places around the world, including Glasgow, to begin to think about how we build cities that are going to be open, that are going to be inclusive, that are going to be places where people can thrive.

Of course we have our Steelers, which if I don’t put this up I can’t come back to Pittsburgh. Thank you very much.