triangles of health

Charles-Antoine Rouyer on urban health.

It all started back in the early 1960s. Dr. Len Duhl, a psychiatrist in San Francisco, wondered what was the point in treating patients, helping them to a healthier mental state, only to send them back into a “sick environment” – often their own family environments.

Duhl continued brainstorming: to restore mental health, how many levels of social environments do we need to consider? The circle of friends around the patient? The neighbourhood, the work environment? The state or province? How about the nation, the continent, the planet, the universe? Duhl settled on the city – the level of government closest to people – and wrote a book, Urban Condition, a holistic approach to cities and health issues.

Much like yoga practitioners, Dulh realized that many interrelated factors influence health. So in order to heal and maintain a state of well-being, why focus on one single isolated element, such as the body, while ignoring other key factors in the health equation?

Indeed, many of us yogis have ended up with a muscle tear by pushing too hard in an asana because of the wrong attitude or simply to show off in a class. Injury is the price to pay for ignoring mental or spiritual health and focusing only on the physical.

Conversely, some practioners may have felt a connection between the physical and mental levels when emotions or memories surface during an asana or in meditation. This reminds us of the ultimate reason to practise yoga: to achieve health and balance in the yogic trilogy of body, mind and spirit.

In urban centres, well-being also comes in threes. Urban health emerges out of balancing the environment, the community and the economy. If people can practise yoga to nurture or rebalance their trilogy of health, how can an entire city do that?


After Duhl’s book came out in 1964, it took another twenty years before the healthy city concept took hold in North America. At that time another set of threes – this time three people – crossed paths in Toronto.

In the early 1980s, Toronto decided to become “the healthiest city in North America.” Dr. Trevor Hancock, a key actor in getting the city to adopt this mission, had read Duhl’s writings. In 1984, Hancock flew in Duhl for a Healthy Toronto 2000 workshop, to help Toronto figure out what being a healthy city meant.

Hancock also organized an international conference on public health, Beyond Health Care, to get a global point of view on health. A young World Health Organization (WHO) executive, Ilona Kickbush, attended and heard of the workshop.

Kickbush liked the vision of a healthy city, and hired Duhl, Hancock and other specialists to refine it. Within ten years, the concept had taken hold throughout Europe. Today, WHO Healthy City projects are present on every continent.


From a concept, the idea of a healthy city became a model, a set of practical steps for cities to follow to balance their natural, social and economic environments.

So what can an urban centre do to nurture urban health?

Simply put, every decision by a city government should take into account the health impacts of its actions on the municipality as a whole. Municipal policies should embrace bottom-up decision-making processes that allow citizens to voice their needs and wishes to the municipal administration. Cities should also adopt multi-sectoral approaches with collaboration between administrative units. Multi-sectoral also means public sector, private sector and community collaboration.

Just as the silhouettes of yoga postures on a page can prove difficult to perform on a yoga mat, the Healthy City theory may look great on paper, but what about in real life? What about Toronto, the Healthy City shrine for many throughout the world? Twenty years after the 1984 workshop, has the Canadian city become an urban nirvana?

Nowadays, we are actually more familiar with a state of urban imbalance than balance. For example, in 1999, the Ontario Medical Association (OMA) calculated that in 2000, the cost of illness in Ontario caused by air pollution would reach $1 billion and result in 1900 premature deaths from smog. The urban health trilogy can be clearly seen at play in this example: natural environment ill-health translates physically as lung diseases; it manifests socially in lost working days for the sick and in the pain of losing a friend or relative to illness; and economically, in the cost of health-care expenses and lost productivity at work.

However, the reality of Ontario’s urban life is that a large share of the province’s economy relies on car production. So while transportation is a leading contributor to smog in the province, curbing car transportation would mean serious cuts to the province’s income as well as jobs. And so the cycle is difficult to break.


On a more personal level, I just returned from a journey into the trenches of urban health in Toronto. In an almost comical twist of fate, I, an urban health journalist, became part of the stats the media are usually reporting.

In 2001, the Healthy Cities Concept I had studied in graduate school became blatantly tangible: I was forced from my downtown Toronto apartment of nine years.

In a red-hot Toronto housing market, my landlord evicted me in favour of a higher paying tenant, thanks to a new provincial law, ironically called the “1997 Tenant Protection Act.”

The eviction triggered a domino effect in my life, a downward spiral into ill health. Economic health problems (60 percent higher rent) led to social ill health (near bankruptcy of my freelance media home business), which spread to my physical and mental well-being. Short of time and money during that whole transition, I cancelled my swimming routine as well as my yoga practice. I put on weight, my overall energy level and mood dropped and I became mildly depressed.

Like many of us, in a time of stress, I ended up cutting out of my life some of the very support systems that actually help balance the negative pressures.


At that point, theory came to inspire my practice. Standing back, I realized how the overall urban health equation in Toronto (housing market and public policies) directly impacted on my personal health balance – a mild ordeal compared to what might happen to an entire family thrown out on the street.

It was actually an unhealthy policy at the provincial level, compounded by federal deficit cutting, that had influenced the lower-level municipal government and me – highlighting the connections between local, provincial, national and global health.

Piecing together our national and provincial context with my personal struggle, I remembered how housing (shelter) was actually one of the main determinants of health outlined by the WHO: “the fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Improvement in health requires a secure foundation in these basic prerequisites.” Yogis may well picture this string of health determinants as the “many limbs” of health. I also recalled reading Ilona Kickbush, stressing that having a sense of control over one’s life was probably the key health determinant.

I finally came back to my senses. If I were going to get better I had to first get back in physical shape, regain some mental strength, then rebuild social comfort. I resumed swimming and started my yoga practice and slowly rose above the clouds in my life.


In my case, it was a sick environment that started my downward spiral, very much like Duhl’s original patient. Once I realized that my experience was an example of the theories I’d studied, the self-doubt instilled in me by the eviction began to dissipate and I could move forward in my life. I realized first-hand that Toronto is far from being an urban nirvana. But that awareness made me appreciate the necessity of the urban health theory, the same way I appreciate the eight limbs of yoga: as a road map to a healthier and more fulfilling life. And led me to reflect more deeply on two basic healthy theory mantras: “Our health-care system is actually a sick-care system” and (in the WHO own words) “Health is a state of complete physical, mental and social well-being.”

Like all theories, the healthy city model is not foolproof, but it can offer a roadmap of a “middle way” between natural, social and economic health. As we all know from practising yoga, the difficult part is the transition, moving from old habits to a new way of being, the journey to the ever elusive and constantly evolving state of balance. Healthy city philosophy is a process, a frame of mind and way of life. Like yoga, it requires discipline, dedication and consistency to move upstream from disease and closer to a healthier quality of life.

Charles-Antoine Rouyer is a Toronto-based freelance journalist specialized in urban health and urban ecology. He contributes to several local and national media outlets and teaches “Communication, Health & Environment” at Glendon College, York University.

Copyright ©2007 ascent magazine, first Canadian yoga magazine, yoga for an inspired life